Safety food control is a constitutional competence of the Brazilian Unified National Health System (SUS), exercised by health surveillance actions. Law n. 8,080/1990¹1. Ministério da Saúde. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set., which institutes the SUS, defines sanitary surveillance as “a set of actions capable of eliminating, reducing or preventing health risks and intervening in sanitary problems arising from the environment, the production, and circulation of goods and the provision of services of interest to health”.

Thus, every food consumed in Brazil and its ingredients are controlled to a greater or lesser degree by health surveillance. It also controls the services that produce them, from the small bakery on a simple neighborhood to the large transnational companies installed in the country. Packaging materials and utensils are also regulated and inspected. And, food advertising is also under control and inspection ²2. Brasil. Lei nº 9.782, de 26 de janeiro de 1999. Define o Sistema Nacional de Vigilância Sanitária, cria a Agência Nacional de Vigilância Sanitária, e dá outras providências. Diário Oficial da União 1999; 27 jan..

The scope of the Brazilian Health Surveillance System (SNVS) is also considerable. As it is an integral part of SUS, practically all Brazilian states and municipalities have a health surveillance structure to carry out this list of actions, under the coordination of the Brazilian Health Regulatory Agency (ANVISA).

With such an ambitious task and such a wide reach, health surveillance has a prominent role in the Brazilian National Food and Nutrition Policy (PNAN) ³3. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2012., being a key element for the prevention and control of diseases related to food and nutrition. The policy has a specific chapter to deal with the control and regulation of food, aspects that are addressed based on an integral perspective, so that the health risks and nutritional risks arising from a scenario of increased supply and variety of ultra-processed foods are discussed together.

And it is at this point that some obstacles in the dialogue between PNAN and the health surveillance are seen. The publication of the Food Guide for the Brazilian Population⁴4. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para população brasileira. Brasília: Ministério da Saúde; 2014. in 2014, a significant milestone for the consolidation of the policy in the country, contributed to expose some inconsistencies related to the understanding of health risk adopted by the food health surveillance in some of its activities, indicating relevant aspects that need to be reconsidered.

The use of food additives and the approval process by ANVISA illustrates this situation. The food guide presents an emphatic recommendation for the population to avoid consuming ultra-processed foods, characterized by a high degree of processing and wide use of food additives. Since the publication of the guide and the NOVA classification ⁵5. Monteiro CA, Cannon G, Levy R, Moubarac JC, Jaime P, Martins AP, et al. NOVA: the star shines bright. World Nutr 2016; 7:28-38., which describes food groups according to the levels of processing and treatment to which they are submitted, robust scientific evidence has demonstrated the health risk related to the consumption of ultra-processed products ⁶6. Pagliai G, Dinu M, Madarena MP, Bonaccio M, Iacoviello L, Sofi F. Consumption of ultra-processed foods and health status: a systematic review and meta-analysis. Br J Nutr 2021; 125:308-18..

However, the health regulation does not consider the classification used by the Guide in its actions, and so far, Anvisa has not promoted a broad and participatory debate on the possibilities of its use. Thus, although the approval of the use of food additives is based on the risk assessment methodology adopted internationally by other regulatory bodies and by the Codex Alimentarius⁷7. Food and Agriculture Organization of the United Nations; World Health Organization. Codex Alimentarius Commission: procedural manual. 27th Ed. Rome: Food and Agriculture Organization of the United Nations/Geneva: World Health Organization; 2019., it is impossible to ignore that the method adopted disregards relevant aspects from the point of view of risk to health, such as not to assess the impact of greater availability of ultra-processed foods on the health of the population.

It cannot be ignored that the wider the use of food additives, the greater the amount of ultra-processed products. Foods that could be available in less processed versions, such as dairy and meat products, are elevated to the ultra-processed category due to the use of food additives by the food industries, all approved by ANVISA. Thus, a major challenge for sanitary surveillance is to consider in the approval process of these substances, in addition to the traditional identification of toxicological hazards, issues that assess how the claimed use can increase the amount of ultra-processed products on the market and contribute to a decline in minimally or unprocessed food supply and culinary preparations.

Designing mechanisms to monitor the health effects of already approved additives, based on findings from observational scientific studies free of conflicts of interest, can also be a relevant strategy to ensure greater safety in the use of these substances after they enter the market. An example that illustrates the need to adopt this strategy is the uncertainty about the influence of sweeteners already approved by various regulatory authorities on health indicators, such as body weight ⁸8. Toews I, Lohner S, Gaudry DK, Sommer H, Meerpohl JJ. Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies. BMJ 2019; 364:k4718..

Another aspect that deserves to be discussed is how the process of deregulation of the identity and quality standards of foods may have contributed to the greater availability of ultra-processed foods in the country. A large part of the technical regulations of product standards currently in force were published by ANVISA in 2005 and do not cover quality requirements for various product categories. Thus, the food industry has come to have greater freedom to replace fresh or minimally processed ingredients with food additives and other more processed components, simulating the colors, aromas and textures originally conferred by less processed ingredients and enabling larger scale production and cost reduction.

From this perspective, it is also important to consider that a large part of the food identity and quality standards is not under the responsibility of the health sector. The regulation of minimally processed foods of animal and vegetable origin and relevant beverages for the Brazilian population (such as meat, rice and beans) are under the scope of the Brazilian Ministry of Agriculture, Livestock and Supply (MAPA). Thus, strategies must be evaluated and implemented to align, as much as possible, the interests of the agricultural sector with the comprehensive approach to health control proposed by PNAN.

The Technical Note prepared in September 2020 by MAPA (Technical Note n. 42/2020) ⁹9. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. Manifestação do Nupens/USP sobre a Nota Técnica nº 42/2020 do Ministério da Agricultura com descabidos ataques ao Guia Alimentar para a População Brasileira. https://www.fsp.usp.br/nupens/nota-oficial/ (acessado em 10/Fev/2021).
https://www.fsp.usp.br/nupens/nota-ofici... , which states that “the NOVA classification is confusing, inconsistent and hinders the implementation of adequate guidelines to promote adequate and adequate and healthy nutrition for the Brazilian population”, which criticizes the concept of ultra-processed food and asks the Brazilian Ministry of Health to revise the food guide, is an indication that this task may not be so simple. Fortunately, motivated by pressure from the organized society and the scientific community, the note was not sent to the Brazilian Ministry of Health ¹⁰10. Agricultura quer retirar crítica à comida industrializada de guia. A Gazeta 2020; 18 set. https://www.agazeta.com.br/economia/agricultura-quer-retirar-critica-a-comida-industrializada-de-guia-0920.
https://www.agazeta.com.br/economia/agri... . But this fact has become emblematic and illustrates the need to discuss and create strategies to integrate the various sectors responsible for food control in the discussion and implementation of the PNAN.

In addition to these issues, there are still several other issues that need to be advanced. Ensuring adequate compliance with the Brazilian Standard for the Marketing of Food for Infants and Early Childhood Children (NBCAL) is crucial for improving breastfeeding and complementary feeding indicators in Brazil. Advancing in the control of the profile of some nutrients related to chronic non-communicable diseases (NCDs), such as sugar and sodium, is another important point. And designing mechanisms to control the advertising of ultra-processed foods as well, although the performance of ANVISA in this matter has been weakened after the judicialization ¹¹11. Fragano Baird M. O lobby na regulação da publicidade de alimentos da Agência Nacional de Vigilância Sanitária. Revista de Sociologia e Política 2016; 24:67-91. of the attempt to regulate food advertising aimed at children ¹²12. Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada nº 24, de 15 de junho de 2010. Dispõe sobre a regulação da publicidade de alimentos. Diário Oficial da União 2010; 29 jun..

Even with all these challenges, the great contributions of health surveillance in the implementation of PNAN that have taken place in recent years cannot be underestimated. Examples of relevant actions are the regulation of salt iodination ¹³13. Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada nº 23, de 24 de abril de 2013. Dispõe sobre o teor de iodo no sal destinado ao consumo humano e dá outras providências. Diário Oficial da União 2013; 25 abr., the fortification of wheat and corn flour with iron and folic acid ¹⁴14. Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada nº 150, de 13 de abril de 2017. Dispõe sobre o enriquecimento das farinhas de trigo e de milho com ferro e ácido fólico. Diário Oficial da União 2017; 17 abr., the ban on industrial trans fat in foods ¹⁵15. Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada nº 332, de 23 de dezembro de 2019. Define os requisitos para uso de gorduras trans industriais em alimentos. Diário Oficial da União 2019; 26 dez. and the new rules on nutritional labeling, which brought considerable advances (although not unanimous), such as the implementation of frontal nutrition labeling ¹⁶16. Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada nº 429, de 8 de outubro de 2020. Dispõe sobre a rotulagem nutricional dos alimentos embalados. Diário Oficial da União 2020; 9 out.^,1717. Agência Nacional de Vigilância Sanitária. Instrução Normativa nº 75, de 8 de outubro de 2020. Dispõe sobre a rotulagem nutricional dos alimentos embalados. Diário Oficial da União 2020; 9 out..

About this last experience, even though frontal nutritional labeling was instituted with a warning model about the presence of sugar, saturated fat and sodium in the shape of a magnifying glass, Anvisa’s choice to adopt a different model from that submitted to Public Consultation and scientifically tested ¹⁸18. Deliza R, Alcantara M, Pereira R, Ares G. How do different warning signs compare with the guideline daily amount and traffic-light system? Food Qual Prefer 2020; 80:103821.^,1919. Bandeira LM, Pedroso J, Toral N, Gubert MB. Desempenho e percepção sobre modelos de rotulagem nutricional frontal no Brasil. Rev Saúde Pública 2021; 55:19. generated criticism from organized civil society ²⁰20. Instituto de Defesa do Consumidor. Idec reprova decisão sobre rotulagem nutricional de alimentos. https://idec.org.br/noticia/idec-reprova-decisao-sobre-rotulagem-nutricional-de-alimentos (acessado em 14/Mai/2021).
https://idec.org.br/noticia/idec-reprova... .

Finally, for the integration between health surveillance and the PNAN to become more feasible and strengthened, it is important to educate and train public health professionals and managers in this complex field of action. Fostering the production of scientific knowledge in the area is also fundamental. The food industry works tirelessly to master the language and working mechanisms of sanitary surveillance, aiming to expand its participation in public debates promoted by ANVISA, such as Public Consultations and Hearings. Thus, health managers, the scientific community and civil society also need to appropriate the theme and play the leading role that is theirs. In addition, the Agency must make an ever-increasing effort to include and ensure effective social participation in its initiatives. Only then, sanitary surveillance and public health policies, including the PNAN, will act synergistically, promoting an improvement in the health of the population and ensuring greater food and nutritional security in the country.

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