Abstract

Introduction

The concept of healthy eating has been problematized by the academic literature ¹1. Azevedo E. Alimentação saudável: uma construção histórica. Revista Simbiótica 2014; 7:83-111.^,22. Martinelli SS, Cavalli SB. Alimentação saudável e sustentável: uma revisão narrativa sobre desafios e perspectivas. Ciênc Saúde Colet 2019; 24:4251-61.^,33. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318.^,44. Kramer FB, Prado SD, Ferreira FR, Carvalho MCVS. O discurso sobre alimentação saudável como estratégia de biopoder. Physis (Rio J.) 2014; 24:1337-59.^,55. Soares S. Kant em defesa da alimentação saudável. Princípios: Revista de Filosofia 2016; 23:105-23. and has driven public actions in Brazil, especially since the Brazilian National Food and Nutrition Policy (PNAN) of 1999 ⁶6. Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 1999., which was the first to link the promotion of healthy eating to the food and nutrition agenda.

The coexistence of multiple meanings assigned to foods and eating ¹1. Azevedo E. Alimentação saudável: uma construção histórica. Revista Simbiótica 2014; 7:83-111.^,22. Martinelli SS, Cavalli SB. Alimentação saudável e sustentável: uma revisão narrativa sobre desafios e perspectivas. Ciênc Saúde Colet 2019; 24:4251-61.^,33. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318.^,77. Vivero-Pol JL. The idea of food as commons or commodity in academia: a systematic review of English scholarly texts. J Rural Stud 2017; 53:182-201. indicates the heterogeneity and contradictions of prevailing social practices, potentially mobilizing public policies towards different proposals for action in the promotion of healthy eating, considering the interests at stake. The dispute between ideas also influences the debate on governments’ attributions, especially on the forms and “limits” of regulation of markets and food marketing practices.

Given the relevance of this process for the public agenda in nutrition, this article analyzes the disputes over ideas that comprise the different discursive repertoires on healthy eating in Brazil’s national policies in the last 20 years, considering the PNAN 1999 as the initial framework. Based on analysis of the ideas, the article indicates possible correlations with the actions proposed in the policies and with the debate on the State’s attributions.

Methods

The study was based on the document analysis method and adopted a definition of document as a discursive practice, where “discourse” and “practice” are indissociable dimensions of political action. The ideas conveyed in the documents constitute the central focus of analysis, considering that they produce meanings, establish processes, shape reality itself, and back political action when they are appropriated differently by the various actors ⁸8. Griggs S, Howarth D. Discourse and practice: using the power of well-being. EvidPolicy 2011; 7:213-26.^,99. Spink MJ, Menegon VM. Práticas discursivas como estratégia de governamentalidade: a linguagem dos riscos em documentos de domínio público. In: Iniguez L, organizador. Manual de análise do discurso em ciências sociais. Petrópolis: Vozes; 2005. p. 258-303.^,1010. Cellard A. Análise documental. In: Poupart J, Deslauriers J-P, Groulx L-H, Laperrière A, Mayer R, Pires AP, et al. A pesquisa qualitativa: enfoques epistemológicos e metodológicos. Petrópolis: Vozes; 2008. p. 295-316..

We analyzed documents produced by government policies, multilateral agencies, and the private commercial sector since 1999, the year the first PNAN was published. The selection criteria were policies, plans, and instruments in national policies that present proposals for the promotion of healthy eating, whether implemented or not, aiming to identify ideas, guidelines, and negotiated actions. National policies are part of a globalized dynamic. We thus analyzed international documents that were selected according to two criteria: having been cited in the government documents and/or problematized by civil society and academia ¹¹11. World Health Organization. Global strategy on diet, physical activity and health. Fifty-seventh World Health Assembly 2004. Geneva: World Health Organization; 2004. (WHA57.17).^,1212. World Health Organization. Global status report on noncommunicable diseases 2010.Geneva: World Health Organization; 2011.^,1313. Organização Pan-Americana da Saúde. Plano de ação para prevenção da obesidade em crianças e adolescentes. Brasília: Organização Pan-Americana da Saúde; 2015.^,1414. Organização Pan-Americana da Saúde. Modelo de perfil nutricional da Organização Pan-Americana da Saúde. Brasília: Organização Pan-Americana da Saúde; 2016.^,1515. International Panel of Experts on Sustainable Food Systems. Unravelling the Food-Health Nexus: addressing practices, political economy, and power relations to build healthier food systems. Brussels: International Panel of Experts on Sustainable Food Systems; 2017.^,1616. High Level Panel of Experts on Food Security and Nutrition. Nutrition and food systems: a report by the HLPE of the Committee on World Food Security. Rome: High Level Panel of Experts on Food Security and Nutrition; 2017.^,1717. World Cancer Research Fund International. Driving action to prevent cancer and other non-communicable diseases: a new policy framework for promoting healthy diets, physical activity, breastfeeding and reducing alcohol consumption. London: World Cancer Research Fund International; 2018.. The private commercial sector’s discursive repertoires were identified in the annual reports and public documents by the principal business association of the Brazilian food industry or elaborated in partnership, besides documents cited in these reports, in dialogue with the government documents analyzed and that were available on the official websites of these associations at the time the study was performed ¹⁸18. Associação Brasileira da Indústria de Alimentos. Relatório anual 2015. https://www.abia.org.br/vsn/anexos/ABIARelatorioAnual2015.pdf (acessado em 20/Jun/2020).
https://www.abia.org.br/vsn/anexos/ABIAR... ^,1919. Associação Brasileira da Indústria de Alimentos. Relatório anual 2016. https://www.abia.org.br/vsn/temp/z2017417RELATORIOANUAL2016.pdf (acessado em 20/Jun/2020).
https://www.abia.org.br/vsn/temp/z201741... ^,2020. Associação Brasileira da Indústria de Alimentos. Documento submetido à Agência Nacional de Vigilância Sanitária (Maio 15 2018). https://pt.scribd.com/document/382022379/Abia-apresenta-documento-a-Anvisa#from_embed (acessado em 20/Jun/2020).
https://pt.scribd.com/document/382022379... ^,2121. Associação Brasileira da Indústria de Alimentos. Alimentos e ciência. São Paulo: Associação Brasileira da Indústria de Alimentos; 2019.^,2222. Associação Brasileira das Indústrias de Refrigerantes e de Bebidas não Alcoólicas. Revista ABIR 2019; 2018/2019. https://abir.org.br/abir/wp-content/uploads/2019/01/REVISTA-ABIR-2019.pdf.
https://abir.org.br/abir/wp-content/uplo... ^,2323. Associação Brasileira das Indústrias de Refrigerantes e de Bebidas não Alcoólicas. Revista ABIR 2020; 2019/2020. https://abir.org.br/abir/wp-content/uploads/2020/03/revista-abir-2020.pdf.
https://abir.org.br/abir/wp-content/uplo... ^,2424. Associação Brasileira da Indústria de Alimentos. Relatório anual 2012: desafios e superações da indústria da alimentação. https://www.abia.org.br/vsn/anexos/relatorio_anual_abia_2012.pdf (acessado em 20/Jun/2020).
https://www.abia.org.br/vsn/anexos/relat... .

The analysis considered the documents’ historical and political-institutional contexts and specificities. The “official” discourse, the result of negotiations permeated by multiple conflicts, does not express all the connections established between the actors in the “political backstage”. Government documents formalize possible agreements in a certain conjuncture and are part of a process aimed at reducing the level of tension and confrontation between the stakeholders. Policies present broad guidelines, plans provide details on targets and actions, and instruments give greater depth in operational indications. The script for document analysis was developed to encompass the central analytical dimensions of ideas, actions, and historical and political-institutional contexts, namely: conceptions of healthy eating; actions in the promotion of healthy eating; home institution; and year of publication. The policy documents were analyzed in full, identifying the degree and centrality of the theme of healthy eating in the narratives and the elements associated with eating throughout the text. The texts were interpreted in dialogue with academic articles, identified with the descriptor “healthy eating”, selected according to their focus in the conceptual debate and used as the source for identification of repertoires and references to distinguish between various healthy eating perspectives ¹1. Azevedo E. Alimentação saudável: uma construção histórica. Revista Simbiótica 2014; 7:83-111.^,22. Martinelli SS, Cavalli SB. Alimentação saudável e sustentável: uma revisão narrativa sobre desafios e perspectivas. Ciênc Saúde Colet 2019; 24:4251-61.^,33. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318.^,44. Kramer FB, Prado SD, Ferreira FR, Carvalho MCVS. O discurso sobre alimentação saudável como estratégia de biopoder. Physis (Rio J.) 2014; 24:1337-59.^,55. Soares S. Kant em defesa da alimentação saudável. Princípios: Revista de Filosofia 2016; 23:105-23..

The study was based on references for cognitive analysis of policies, featuring the dimension of ideas (distinctions and tensions between the ideas in dispute) and the weight of their influence on the configuration of policy processes, conceiving them as: interpretative schemes shared by the actors; structures of meaning that allow specific understandings of the public issues and the ways of dealing with them, linked to interests and conditioned by institutions. The policies were analyzed as cognitive matrices and systems for interpretation of the reality that demarcated actions by the various actors. Certain ideas can drive specific actions according to the interest in dispute, shaped in distinct historical and political-institutional contexts ²⁵25. Grisa C. As ideias na produção de políticas públicas: contribuições da abordagem cognitiva. In: Bonnal P, Leite S, organizadores. Análise comparada de políticas agrícolas. Rio de Janeiro: MANAUD; 2011. p. 93-137.^,2626. Muller P, Surel Y. A análise das políticas públicas. Pelotas: EDUCAT; 2002.. Thus, the institutions - defined as forms of social organization - were analyzed as elements in the context of building ideas, highlighting the State’s institutional role, considering the objective of analyzing the public policies’ discursive repertoires. We analyzed how the distinctions between the health sector’s institutional role and the inter-sector role of food and nutritional security affected the development of different ideas on healthy eating and promoted different interactions between the actors and their interests. Actors situated in different institutional contexts (State, society, and market) appropriate the ideas over the course of their political action and disseminate distinct conceptions on the attributions of public institutions that situate the policies in question. The theoretical perspective of adequate and health eating, inscribed in the interdisciplinary and systemic cognitive matrix of food and nutritional security, was used as the reference for analysis of ideas, as the one that integrates the various dimensions of eating identified by the literature ³3. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318..

Supplementary Material (http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf) presents the set of documents analyzed and the explicit or implicit conceptions of healthy eating in the proposed actions. Based on this mapping, Box 1 indicates relations between discursive repertoires and public policies based on: demarcation of different perspectives of healthy eating and their constitutive elements and ideas; identification of actions driven by each of them and exemplification of mixed authorship and ideas in the documents. The process of demarcating these perspectives of healthy eating aimed to organize and highlight elements that distinguish them, identified according to the central underlying principles. As such, we compared principles and distinctions already indicated in the academic literature to the explicit and implicit definitions in the government documents. The terms used to distinguish between them - “biological”, “culturalist”, “medicalizing”, etc. - intersect with the concepts referenced in the academic literature and were chosen because they display striking characteristics in each of them, aimed at distinguishing between them, although with combinations and intersections. This process was shared by five researchers and verified by one of them. Four of these researchers were nutritionists specialized in public health and public policies and one was a journalist.

Results

In the last twenty years, Brazil consolidated two major policy lines related to food and nutrition: the PNAN ⁶6. Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 1999.^,2727. Ministério da Saúde. Portaria nº 2.715, de 17 de novembro de 2011. Atualiza a Política Nacional de Alimentação e Nutrição. Diário Oficial da União 2011; 18 nov., under the health sector, and the Brazilian National Policy on Food and Nutrition Security (PNSAN), which involves more than 20 government ministries ²⁸28. Brasil. Decreto nº 7.272, de 25 de agosto de 2010. Regulamenta a Lei nº 11.346, de 15 de setembro de 2006, que cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas a assegurar o direito humano à alimentação adequada, institui a Política Nacional de Segurança Alimentar e Nutricional - PNSAN, estabelece os parâmetros para a elaboração do Plano Nacional de Segurança Alimentar e Nutricional, e dá outras providências. Diário Oficial da União 2010; 26 ago..

Health sector policies

The PNAN 1999 adopts the guideline of “promotion of health eating practices and lifestyles” and employs the concept of healthy eating, but not explicitly. The policy highlights the need to regulate advertising of foods targeted to children and other marketing practices, besides monitoring the industrialization and marketing of pharmaceutical and diet products presented commercially as therapeutic or prophylactic solutions to nutritional problems (sometimes debatable and/or without evidence) (Supplementary Material: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf). The policy acknowledges that the promotion of healthy eating serves the national priorities in food and nutrition by responding simultaneously to obesity and undernutrition, a perspective that was not obvious at that time, when the approach to these topics was not linked and the concept of “double burden of diseases” was still not widely adopted ²⁹29. Ministério da Saúde . Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2006.. According to Paiva et al. ³3. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318., this policy intersects with the broader concept of eating practices and evokes the adjective “healthy” to also describe the notions of diet and lifestyle and “nutritionally balanced and healthy eating”. Some proposed actions transcend the biological perspective, such as reclaiming regional food and farming practices and encouragement of local consumption of low-cost foods with high nutritional value ⁶6. Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 1999. (Box 1 and Supplementary Material: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf). In addition, the policy innovates by proposing to “contribute to the guarantee of Food and Nutritional Security and the human right to adequate food” ⁶6. Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 1999. (p. 29), themes that had received little attention in the Brazilian literature at that stage. That same year, the United Nations explicitly adopted the concept of human right to adequate food, assuming that “adequate” food is not limited to a minimum package of specific nutrients, rather encompassing social, economic, cultural, climatic, and technological conditions and sustainability. Subsequently, the concept of adequate and healthy eating elaborated by the Brazilian National Council on Food and Nutrition Security (CONSEA) ³⁰30. Conselho Nacional de Segurança Alimentar e Nutricional. Grupo de Trabalho Alimentação Adequada e Saudável: relatório final. Brasília: Conselho Nacional de Segurança Alimentar e Nutricional; 2007. (included in the interdisciplinary and systemic cognitive matrix of food and nutritional security) consolidates the convergence between the terms “adequate” and “healthy”, based on the concept of adequacy according to the human right to adequate food ³3. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318..

Food and nutritional security and human right to adequate food are not fully reflected in the perspective of healthy eating in the PNAN 1999, since this policy emphasizes the nutritional aspect disconnected from a systemic matrix. Even so, the policy expands a limited conception of healthy eating that originated with nutrition science, based on “nutritional reductionism” ³3. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318. (Box 1).

This expansion gained new characteristics with the first edition of the Dietary Guidelines for the Brazilian Population (Guidelines 2006) ²⁹29. Ministério da Saúde . Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2006., orienting other policies outside the health sector, acknowledging that the promotion of healthy eating addresses the challenges of the double burden of diseases and indicates that healthy eating should be based on environmentally sustainable eating practices with social, affective, and cultural meaning, since foods are not merely vehicles for nutrients. However, the biological dimension prevails in the guidelines, organized by food groups according to nutritional composition, as well as recommendations on the number of daily servings according to energy value. The foods’ processing is only cited as a stage in their production. Nonbiological aspects of food are valued in the document - in a step ahead of the debates at the time - but they were not turned into actual guidelines. The notion of human right to adequate food itself is only mentioned in reference to the PNAN 1999.

Meanwhile, PNAN 2011 explicitly addresses a concept of adequate and healthy eating (Supplementary Material: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf) that incorporates the dimension of environmental sustainability but mentions that adequate and sustainable production practices are those “with minimal amounts of physical, chemical, and biological contaminants” ²⁷27. Ministério da Saúde. Portaria nº 2.715, de 17 de novembro de 2011. Atualiza a Política Nacional de Alimentação e Nutrição. Diário Oficial da União 2011; 18 nov. (p. 32). The Brazilian National Policy on Health Promotion (PNPS) of 2006 ³¹31. Ministério da Saúde. Política Nacional de Promoção da Saúde. Brasília: Ministério da Saúde; 2006. also recommends the “reduction” in the use of pesticides. These policies thus provide for the use of these contaminants, overlooking the Guidelines 2006 ²⁹29. Ministério da Saúde . Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2006., which problematize their use due to their toxicity, and the CONSEA document ³⁰30. Conselho Nacional de Segurança Alimentar e Nutricional. Grupo de Trabalho Alimentação Adequada e Saudável: relatório final. Brasília: Conselho Nacional de Segurança Alimentar e Nutricional; 2007., which defines adequate and healthy eating as free from physical and chemical contaminants and genetically modified organisms. Although the impacts of pesticides had already been problematized by the health sector by this time, the link between this issue and the healthy eating agenda did not gain centrality in these documents. The hypothesis is that in the national and international institutional context of the fields of nutrition and noncommunicable diseases (NCDs), this link had still not been incorporated centrally, thereby favoring a superficial approach to it in the documents. This distinction between approaches reiterates the current study’s assumptions that the official discourse expresses possible pacts at a certain conjuncture, conditioned by heterogeneous institutionality, even within the same sectorial policy (in this case the Health sector).

In the concept of adequate and healthy eating, the second edition of the Dietary Guidelines for the Brazilian Population (Guidelines 2014) ³²32. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014. adopts the reference that food production practices should be adequate and sustainable. As in the Guidelines 2006, the second edition affirms the importance of transcending the nutritional aspect of eating and elaborates further on this meaning. The Guidelines 2014 adopt a categorization of foods based on the NOVA classification ³³33. Monteiro CA, Cannon G, Levy RB, Moubarac J-C, Jaime P, Martins AP, et al. NOVA. The star shines bright. World Nutr 2016; 7:28-38.^,3434. Monteiro CA, Cannon G, Levy RB, Moubarac J-C, Louzada ML, Rauber F, et al. Ultra-processed foods: what they are and how to identify them. Public Health Nutr 2019; 22:936-41., in which nutritional and other characteristics of foods are examined according to the extent and purpose of their processing. The document received international interest because it recommends that the consumption of ultra-processed foods should be avoided, considering the harms to health and the risks for traditional food cultures, besides expressing (and contributing to) socially, economically, and environmentally unsustainable food systems ³⁵35. Fischer CG, Garnett T. Plates, pyramids, planet. Developments in national healthy and sustainable dietary guidelines: a state of play assessment. Rome: Food and Agriculture Organization of the United Nations/Oxford: Food Climate Research Network, University of Oxford; 2016..

Based on the NOVA classification ³³33. Monteiro CA, Cannon G, Levy RB, Moubarac J-C, Jaime P, Martins AP, et al. NOVA. The star shines bright. World Nutr 2016; 7:28-38.^,3434. Monteiro CA, Cannon G, Levy RB, Moubarac J-C, Louzada ML, Rauber F, et al. Ultra-processed foods: what they are and how to identify them. Public Health Nutr 2019; 22:936-41., healthy eating requires avoiding ultra-processed foods and making natural or minimally processed foods the basis for eating. The Guidelines 2014 are oriented by this approach and cover aspects related to culture, cooking, regional practices, diversity, commensality, and sustainability, among others.

A similar trend was seen in the Dietary Guidelines for Brazilian Children Under Two Years of Age³⁶36. Departamento de Promoção da Saúde, Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Guia alimentar para crianças brasileiras menores de dois anos. 2ª Ed. Brasília: Ministério da Saúde; 2019. of 2019, which updated the guidelines from 2002 ³⁷37. Secretaria de Política de Saúde, Ministério da Saúde; Organização Pan-Americana da Saúde. Guia alimentar para crianças menores de dois anos. Brasília: Ministério da Saúde; 2002.. The new guidelines valued foods’ nutritional balance and aspects related to early childhood development. Aligned with the Guidelines 2014, the new edition is based on the NOVA classification and adopts the definition of adequate and healthy eating that incorporates sustainability, considering it as an element that strengthens sustainable food systems ³⁶36. Departamento de Promoção da Saúde, Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Guia alimentar para crianças brasileiras menores de dois anos. 2ª Ed. Brasília: Ministério da Saúde; 2019., intersects with the sociocultural dimension of eating, expands topics such as cooking and sharing household chores, and identifies challenges for the daily practice of adequate and healthy eating (Supplementary Material: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf).

This perspective of adequate and healthy eating and the NOVA classification clash with the approaches by the private commercial sector developed as part of corporate policy action aimed at influencing policies and public opinion to favor the sector ³⁸38. Mialon M, Julia C, Hercberg S. The policy dystopia model adapted to the food industry: the example of the Nutri-Score saga in France. World Nutr 2018; 9:109-20.. A recurrent discursive strategy is distortion of the debate on food and public health ³⁸38. Mialon M, Julia C, Hercberg S. The policy dystopia model adapted to the food industry: the example of the Nutri-Score saga in France. World Nutr 2018; 9:109-20., ruling out the responsibility of the private commercial sector and its products for negative health impacts, irreconcilable with approaches to eating as a public good and human right to adequate food ³⁹39. Burlandy L, Gomes FS, Carvalho CMP, Dias PC, Henriques P. Intersetorialidade e potenciais conflitos de interesse entre governos e setor privado comercial no âmbito das ações de alimentação e nutrição para o enfrentamento de doenças crônicas não transmissíveis. Vigil Sanit Debate 2014; 2:124-9.. The arguments’ focus is shifted to individual responsibility, translated in the use of such expressions as freedom of choice, right to information, “consumer empowerment” ²⁰20. Associação Brasileira da Indústria de Alimentos. Documento submetido à Agência Nacional de Vigilância Sanitária (Maio 15 2018). https://pt.scribd.com/document/382022379/Abia-apresenta-documento-a-Anvisa#from_embed (acessado em 20/Jun/2020).
https://pt.scribd.com/document/382022379... , and physical inactivity. Educational actions are cited as a “solution” ³⁸38. Mialon M, Julia C, Hercberg S. The policy dystopia model adapted to the food industry: the example of the Nutri-Score saga in France. World Nutr 2018; 9:109-20.^,4040. Mialon M, Swinburn B, Sacks G. A proposed approach to systematically identify and monitor the corporate political activity of the food industry with respect to public health using publicly available information. Obes Rev 2015; 16:519-30.^,4141. Mialon M, Gomes F. Public health and the ultra-processed food and drink products industry: corporate political activity of major transnationals in Latin America and the Caribbean. Public Health Nutr 2019; 22:1898-908.. The narrative’s repertoires on healthy eating mobilize arguments and ideas that aim to downplay and counteract the conception based on national policies and instruments such as the new dietary guidelines, considering the conflicting interests ³²32. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014.^,3636. Departamento de Promoção da Saúde, Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Guia alimentar para crianças brasileiras menores de dois anos. 2ª Ed. Brasília: Ministério da Saúde; 2019..

Some elements from the concept of adequate and healthy eating are appropriated in commercial promotion strategies by the private sector in less conflictive terms, superficially, and without problematizing such determinants as culture and commensality. In the case of commensality, the strategies refute the argument that ultra-processed foods are “socially destructive”, indicating the possibility that they can be consumed “as an accompaniment to home-cooked and restaurant meals” ⁴²42. Instituto de Tecnologia de Alimentos. Mitos e fatos. MITO: alimento processado com aditivos químicos é comida de mentira. https://alimentosprocessados.com.br/ingredientes-alimentares-mitos-fatos-comida-mentira.php (acessado em 20/Jun/2020).
https://alimentosprocessados.com.br/ingr... (p. 33).

The discourse that there are no good or bad foods, long reiterated by the private commercial sector ⁴³43. Associação Brasileira das Indústrias de Alimentos para Fins Especiais e Congêneres. Contribuição à Consulta Pública nº 71, de 2006. Brasília: Agência Nacional de Vigilância Sanitária; 2006.^,4444. Zocchio G. Tem que mudar 'isso daí'? Representante da indústria fala em alterar o guia alimentar. O Joio e O Trigo 2019; 2 jul. https://outraspalavras.net/ojoioeotrigo/2019/07/representante-da-industria-de-comida-porcaria-fala-em-mudar-o-guia-alimentar/.
https://outraspalavras.net/ojoioeotrigo/... , gains centrality when the Guidelines 2014 and the NOVA classification explicitly name a group of foods that should be avoided (ultra-processed foods). The confrontation becomes explicit with the NOVA classification. Since the document’s public consultation phase, business associations and corporations (and organizations financed by them) tried to prevent the text from including the expression “ultra-processed foods” and the recommendation of avoiding their consumption ⁴⁵45. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Relatório final da consulta pública: Guia Alimentar para a População Brasileira. Brasília: Ministério da Saúde; 2014.. Among the arguments, they pointed to “equivocation in relation to the chosen approach” and the “adoption of a nonexistent classification without scientific evidence for ready-to-eat and ultra-processed products, dissociated from the concept of food; ideological and impractical content, out of step with the Brazilian population’s social and cultural stage” ⁴⁵45. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Relatório final da consulta pública: Guia Alimentar para a População Brasileira. Brasília: Ministério da Saúde; 2014. (p. 160).

Another example of corporate policy action that aims to shape or influence the debate on food and government action ³⁸38. Mialon M, Julia C, Hercberg S. The policy dystopia model adapted to the food industry: the example of the Nutri-Score saga in France. World Nutr 2018; 9:109-20.^,4040. Mialon M, Swinburn B, Sacks G. A proposed approach to systematically identify and monitor the corporate political activity of the food industry with respect to public health using publicly available information. Obes Rev 2015; 16:519-30. is the agreement between the Brazilian Ministry of Health and the Brazilian Food Industry Association (ABIA) that frames healthy eating as merely one aspect in building a National Plan for Healthy Living, alongside physical activity and nutrition education ⁴⁶46. Ministério da Saúde. Acordo de cooperação técnica para a execução do Plano Nacional de Vida Saudável. Brasília: Ministério da Saúde; 2007..

The discourse on healthy eating expresses a dichotomy in the organizations representing ultra-processed foods. On the one hand, they maintain the position that there are no good or bad foods ²⁰20. Associação Brasileira da Indústria de Alimentos. Documento submetido à Agência Nacional de Vigilância Sanitária (Maio 15 2018). https://pt.scribd.com/document/382022379/Abia-apresenta-documento-a-Anvisa#from_embed (acessado em 20/Jun/2020).
https://pt.scribd.com/document/382022379... . On the other, advertisements and products begin to incorporate the idea of “clean label”, from a perspective of product lines without artificial additives and with few ingredients, coopting one of the aspects of the NOVA classification and even incorporating the expression “minimally processed foods” as a motto for the products’ promotion ⁴⁷47. Peres J. Indústria escancara tensão entre aposta na comida de verdade e fidelidade à comida-porcaria. O Joio e O Trigo 2019; 5 set. https://outraspalavras.net/ojoioeotrigo/2019/09/industria-escancara-tensao-entre-aposta-na-comida-de-verdade-e-fidelidade-a-comida-porcaria/.
https://outraspalavras.net/ojoioeotrigo/... . In the area of the Brazilian Health Regulatory Agency (ANVISA), in the discussion on the adoption of a front-of-package labeling system that better informs consumers, the private sector takes a clear position in the first line of argument, claiming that warning signs trigger “fear” and are not educational ²¹21. Associação Brasileira da Indústria de Alimentos. Alimentos e ciência. São Paulo: Associação Brasileira da Indústria de Alimentos; 2019..

The private commercial sector’s reaction to the ideas defended in the government documents indicates the terms in the policy disputes and the conflicting interests, reiterating the analytical assumption adopted here that discourse establishes realities and is not dissociated from practices. The idea of “unhealthy” ⁴⁸48. Departamento de Análise de Situação de Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: Ministério da Saúde; 2011. or “nonnutritive” foods ¹¹11. World Health Organization. Global strategy on diet, physical activity and health. Fifty-seventh World Health Assembly 2004. Geneva: World Health Organization; 2004. (WHA57.17)., present in policies for the prevention and control of NCDs sparks reactions by the private sector that point to disputes over the issue. “Unhealthy eating” is characterized by nutritional parameters (excessive consumption of calories, salt, free sugars, and saturated and trans fats) and dietary parameters (low consumption of fruits and vegetables) for which there is robust evidence of associations with negative health outcomes ¹¹11. World Health Organization. Global strategy on diet, physical activity and health. Fifty-seventh World Health Assembly 2004. Geneva: World Health Organization; 2004. (WHA57.17).^,1212. World Health Organization. Global status report on noncommunicable diseases 2010.Geneva: World Health Organization; 2011.^,4848. Departamento de Análise de Situação de Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: Ministério da Saúde; 2011.^,4949. World Health Organization. The 2008-2013 action plan for the global strategy for prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2008..

There is a clear distinction between “healthy foods” and “unhealthy foods” in the Pan American Health Organization Nutrient Profile Model¹⁴14. Organização Pan-Americana da Saúde. Modelo de perfil nutricional da Organização Pan-Americana da Saúde. Brasília: Organização Pan-Americana da Saúde; 2016., which is based on the NOVA classification, in dialogue with the Guidelines 2014, establishing what it considers “critical nutrients” to orient regulatory measures. The private commercial sector does not acknowledge the model as an instrument to orient nutritional labeling, considering it too restrictive, since most products on the market would be classified as “unhealthy”, even when “registered and analyzed by the competent authority” ⁵⁰50. Coca-Cola Company. RE: WTO Notification Number: G/TBT/N/URY/14. https://brecha.com.uy/wp-content/uploads/2018/01/Carta-de-Coca-Cola.pdf (acessado em 20/Jun/2020).
https://brecha.com.uy/wp-content/uploads... (p. 2). Consumer defense organizations, research groups, and governments such as that of Mexico ⁵¹51. Agência Nacional de Vigilância Sanitária. Relatório de análise de impacto regulatório sobre rotulagem nutricional. Brasília: Agência Nacional de Vigilância Sanitária; 2019.^,5252. Secretaria de Economía. Modificicación a la Norma Oficial Mexicana NOM-051-SCFI/SSAI-2010. Ciudad de México: Secretaria de Economía; 2020. adopt and support the model, precisely because it specifies safe limits for ultra-processed foods. Another tension point is the proposal of taxation to limit consumption of unhealthy foods, present in the document. The private commercial sector reacts by claiming that “taxes don’t make health” and that it is necessary to tackle obesity with educational measures and incentives for healthy practices ²²22. Associação Brasileira das Indústrias de Refrigerantes e de Bebidas não Alcoólicas. Revista ABIR 2019; 2018/2019. https://abir.org.br/abir/wp-content/uploads/2019/01/REVISTA-ABIR-2019.pdf.
https://abir.org.br/abir/wp-content/uplo... .

This approach to foods is consistent with an expanded perspective of healthy eating identified for example in the global strategy on diet, physical activity, and health ¹¹11. World Health Organization. Global strategy on diet, physical activity and health. Fifty-seventh World Health Assembly 2004. Geneva: World Health Organization; 2004. (WHA57.17)., which considers both the individual and contextual dimensions of diet, its multidimensional nature, besides the generational and gender perspectives. Consistently, the proposed actions highlight multisector and multilevel responses that promote development, local production, and sustainability. The document assumes the State’s central role in the promotion of equity and the need to prevent conflicts of interest with the private commercial sector, although signaling the importance of the latter´s actions in controlling obesity (Supplementary Material: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf).

Following this approach, the Pan American Health Organization (PAHO) document on obesity prevention in children and adolescents ¹³13. Organização Pan-Americana da Saúde. Plano de ação para prevenção da obesidade em crianças e adolescentes. Brasília: Organização Pan-Americana da Saúde; 2015. adopts a perspective on healthy eating that includes daily consumption of some certain food groups (fruits and vegetables, among others) and low consumption of red and processed meats. The document states that traditional cooking can contribute to the promotion of healthy eating and that the availability, accessibility, and affordability of foods consistent with such eating require “solid and enabling” agricultural and food systems. The document also proposes regulatory measures such as fiscal policies and food labeling, among others ¹³13. Organização Pan-Americana da Saúde. Plano de ação para prevenção da obesidade em crianças e adolescentes. Brasília: Organização Pan-Americana da Saúde; 2015. (Supplementary Material: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf).

Recognition of the relevance of inter-sector and multisector actions (including regulatory measures) and the realization that NCDs are conditioned by poverty and global socioeconomic development are present in other international policy documents. Thuse, the focus on poor eating as a risk factor for diseases coexists with a broader approach to eating ¹²12. World Health Organization. Global status report on noncommunicable diseases 2010.Geneva: World Health Organization; 2011.^,4949. World Health Organization. The 2008-2013 action plan for the global strategy for prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2008.^,5353. United Nations. Political declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases: draft resolution. New York: United Nations; 2011.. The Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Noncommunicable Diseases ⁵³53. United Nations. Political declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases: draft resolution. New York: United Nations; 2011. acknowledges two watersheds of action: the reduction of risk factors and the creation of health-promoting environments. These documents also highlight the role of government leadership and participation by society and the private sector in the control of NCDs. However, conflicts of interest are only mentioned in relation to the tobacco industry.

In short, the concepts of healthy eating in these policies mix ideas centered on greater or lesser degree of specific core meanings, namely: nutritional and biological, eating as a risk factor associated with the prevention of NCDs, and health promotion.

As refers actions in promotion of healthy eating, we identified different watersheds combined in a single policy, also evidenced in the study by Henriques et al. ⁵⁴54. Henriques P, O'Dwyer G, Dias PC, Barbosa RMS, Burlandy L. Políticas de saúde e de segurança alimentar e nutricional: desafios para o controle da obesidade infantil. Ciênc Saúde Colet 2018; 23:4143-52., including the following types of measures: regulatory (taxation, labeling, advertising); reconfiguration of socioenvironmental and institutional contexts (e.g.: schools, workplaces); and education, communication, and behavior changes through individual responsibility (Box 1).

The concept of adequate and healthy eating and the food and nutritional security agenda

The concept of food and nutritional security is systemic and assumes an integrated approach to the production, marketing, and consumption of foods. Developed by various collective subjects, the concept is strengthened in the experience of social and governmental dialogue promoted by CONSEA. The concept of adequate and healthy eating, which encompasses food’s cultural, social, economic, and environmental adequacy, is the result of this process ³3. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318.^,3030. Conselho Nacional de Segurança Alimentar e Nutricional. Grupo de Trabalho Alimentação Adequada e Saudável: relatório final. Brasília: Conselho Nacional de Segurança Alimentar e Nutricional; 2007. and is oriented by proposals by CONSEA submitted to various government sectors ⁵⁵55. Câmara Interministerial de Segurança Alimentar e Nutricional. II Plano Nacional de Segurança Alimentar e Nutricional - PLANSAN 2016-2019 revisado. Brasília: Câmara Interministerial de Segurança Alimentar e Nutricional; 2018.. The concept has backed such demands as the ban on pesticides and genetically modified seeds and the elaboration of national policies on agroecology and food supply, as well as the Manifesto for Real Food ⁵⁶56. Conselho Nacional de Segurança Alimentar e Nutricional. Manifesto da 5ª Conferência Nacional de Segurança Alimentar e Nutricional à Sociedade Brasileira sobre Comida de Verdade no Campo e na Cidade, por Direitos e Soberania Alimentar. Brasília: Conselho Nacional de Segurança Alimentar e Nutricional; 2015., resulting from the 55th Brazilian Conference on Food and Nutrition Security.

The concept of real food (Supplementary Material: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf) became the object of clashes with the private commercial sector, which refuted the concept by stating that there is no real food or fake food, and all processed food is actually food ⁴²42. Instituto de Tecnologia de Alimentos. Mitos e fatos. MITO: alimento processado com aditivos químicos é comida de mentira. https://alimentosprocessados.com.br/ingredientes-alimentares-mitos-fatos-comida-mentira.php (acessado em 20/Jun/2020).
https://alimentosprocessados.com.br/ingr... .

The interactions between PNAN and PNSAN contributed to the impact of the concept of adequate and healthy eating on Brazil’s health sector policies (Supplementary Material: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf). This was the context for publication of the Reference Framework for Food and Nutrition Education for Public Policies⁵⁷57. Secretaria Nacional de Segurança Alimentar e Nutricional, Ministério do Desenvolvimento Social e Combate à Fome. Marco de referência de educação alimentar e nutricional para as políticas públicas. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2012. (Framework), which defined food and nutrition education as a continuous, multidimensional, problematizing, dialogical, and active process and announced principles and approaches that were expressed two years later in the Guidelines 2014. It reconfigures and problematizes the traditional concept of nutrition education, based on nutritional rationality and the medicalizing perspective that orients part of the discursive repertoires on healthy eating (Box 1).

Another example of this period from 1999 to 2015, particularly rich in more complex and comprehensive public initiatives for the promotion of healthy eating, was the publication of the National Pact for the Promotion of Healthy Eating (PNPAS) ⁵⁸58. Brasil. Pacto nacional para a promoção da alimentação saudável. Brasília: Subchefia para Assuntos Jurídicos, Secretaria-Geral, Presidência da República; 2015.. Conceived in the Inter-Ministerial Chamber for Food and Nutritional Security, it intersects with the perspectives of human right to adequate food, eating as a sociocultural practice, poor diet as a risk factor for diseases, sustainability, and healthiness of foods according to the degree of processing.

The concept of adequate and healthy eating thus links to policies that address support for family and organic agriculture, agroecology, food sovereignty, and locally produced food ¹1. Azevedo E. Alimentação saudável: uma construção histórica. Revista Simbiótica 2014; 7:83-111.. It refers to another approach to “risk factors”, associated with threats to food systems’ environmental, social, economic, and cultural sustainability. The concept connects to a notion of socially fair food systems that contribute to human health and various dimensions of sustainability ²2. Martinelli SS, Cavalli SB. Alimentação saudável e sustentável: uma revisão narrativa sobre desafios e perspectivas. Ciênc Saúde Colet 2019; 24:4251-61.. This context includes the emergence of proposals to reduce the consumption of meat and animal fats as a way of synergically guaranteeing health and sustainability ⁵⁹59. International Panel of Experts on Sustenable Food Systems. From uniformity to diversity: a paradigm shift from industrial agriculture to diversified agroecological systems. Brussels: International Panel of Experts on Sustenable Food Systems; 2016..

Food systems are shaped by the linkage between all the elements and activities related to the production, processing, distribution, preparation, and consumption of foods and their results and effects. The predominant agro-industrial systems generate environmental, social, cultural, and health problems and concentrate power ¹⁶16. High Level Panel of Experts on Food Security and Nutrition. Nutrition and food systems: a report by the HLPE of the Committee on World Food Security. Rome: High Level Panel of Experts on Food Security and Nutrition; 2017.^,5959. International Panel of Experts on Sustenable Food Systems. From uniformity to diversity: a paradigm shift from industrial agriculture to diversified agroecological systems. Brussels: International Panel of Experts on Sustenable Food Systems; 2016.. The narratives that acquire greater or lesser visibility in the public policy proposals that affect these systems are also the expression of inequities, considering the prevailing power asymmetries and conflicting interests ¹⁵15. International Panel of Experts on Sustainable Food Systems. Unravelling the Food-Health Nexus: addressing practices, political economy, and power relations to build healthier food systems. Brussels: International Panel of Experts on Sustainable Food Systems; 2017.^,6060. Recine E, Beghin N. Equity. In: Laurance M, Friel S, editors. Healthy and sustainable food systems. London: Routldge; 2019 p. 23-4..

These asymmetries are exacerbated over the course of a process called “dematerialization of food”, which shifts the decision-making power away from the actual farming systems to financial agents, increases the distance between growers and consumers, causes expropriation of land and other resources, and weakens the local, national, and global spaces as decision-makers ⁶¹61. Quando os alimentos se tornam imateriais: confrontar a era digital. Observatório do Direito à Alimentação e Nutrição 2018; (10). https://www.righttofoodandnutrition.org/pt/suplemento-observatorio-do-direito-alimentacao-e-nutricao.
https://www.righttofoodandnutrition.org/... .

The issue of sustainability is the object of disputes with the private commercial sector, which coopts and distorts ideas, as expressed in the publicity campaign “Agro: A Indústria-Riqueza do Brasil” (in free translation, “Agribusiness: Brazil’s Wealth-Producing Industry), a prime example of the dispute of narratives over healthy eating that publish content sponsored by corporations but without making this explicit to viewers ⁶²62. Dias J. Cozinhar e comunicar: uma abordagem ecobiocultural sobre sistemas de alimentação e comunicação [Tese de Doutorado]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2018.. The campaign aims to consolidate the “Agro” (agribusiness) trademark, neutralizing conflicts of interests by pointing to a purported convergence between conceptions and practices from different agricultural systems (global, organic, and agroecological). It intends to demonstrate the omnipresence of agribusiness in opposition to the production chain´s problems involving slave labor, deforestation, pesticides, and NCDs.

This simulacrum of agribusiness as a totalizing notion of agriculture is the result of three decades in which the hard core of political spokespersons for Brazilian corporate agriculture (the part) appropriates for itself the broad range of functions contained in the notion of agribusiness (the whole). The political spinoffs are reflected in the extinction of structures linking policies for family farming and in the discourse emphasizing a purported lack of separation between small and large farmers ⁶³63. Pompeia C. "Agro é tudo": simulações no aparato de legitimação do agronegócio. Horizontes Antropológicos 2020; 26:195-224..

Finally, although the concept of healthy eating adopted in the dietary guidelines provides for the sustainability dimension, the Brazilian government is currently opposing the adoption of the concept of healthy and sustainable eating, presented in a technical document by Food and Agriculture Organization of the United Nations (FAO)/World Health OrganizationWHO ⁶⁴64. Food and Agricukture Organization of the United Nations; World Health Organization. Sustainable healthy diets: guiding principles. Rome: Food and Agricukture Organization of the United Nations; 2019., and which was adopted in the negotiation of the Voluntary Guidelines of Food and Nutrition Systems⁶⁵65. Committee on World Food Security. Voluntary guidelines on food systems for nutrition (VGFSyN): matrix with inputs provided by CFS stakeholders on the draft for negotiations. http://www.fao.org/fileadmin/templates/cfs/Docs1920/Nutrition_Food_System/28-29_maggio/CFS_OEWG_Nutrition_2020_05_28_01_Matrix__1_.pdf (acessado em 20/Jun/2020).
http://www.fao.org/fileadmin/templates/c... (Supplementary Material: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00195520-ingles_4593.pdf).

Discussion

The conceptual debate on healthy eating, sometimes considered “abstract”, is essential for understanding the political conflicts in the sphere of health and nutrition ⁴4. Kramer FB, Prado SD, Ferreira FR, Carvalho MCVS. O discurso sobre alimentação saudável como estratégia de biopoder. Physis (Rio J.) 2014; 24:1337-59.. The analysis signaled tensions and conflicts between the ideas that contribute to certain proposals vying for space on the government agenda. Distinct perspectives of healthy eating emerge through movements of reconfiguration of ideas, approaches that mix and coexist, comprising a multidimensional spectrum of eating. Some are established in opposition to others, generating tensions, disputes, and conflicts between ideas that may not be reconcilable because they drive antagonistic actions.

As regards perspectives on healthy eating, the set of policies in the health sector indicates a reconfiguration of ideas developed in the context of emergence of nutrition science, when healthy eating was defined as a food consumption profile capable of guaranteeing all the necessary nutrients for growth and for maintenance of the body’s biological functions and/or of preventing nutritional disorders ³3. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318.^,44. Kramer FB, Prado SD, Ferreira FR, Carvalho MCVS. O discurso sobre alimentação saudável como estratégia de biopoder. Physis (Rio J.) 2014; 24:1337-59.. This perspective, referred to here as nutritional (centered on nutrient) and biological (centered on the biological body), is grounded in the logic of meeting standard nutritional recommendations and requirements. This approach backs actions in the prevention of diseases caused by specific nutrient deficiencies ³3. Paiva JB, Magalhães LM, Santos SMC, Santos LAS, Trad LAB. A confluência entre o "adequado" e o "saudável": análise da instituição da noção de alimentação adequada e saudável nas políticas públicas do Brasil. Cad Saúde Pública 2019; 35:e00250318. and may be medicalizing, since it treats eating, previously not considered a medical problem, through the lens of medicine ⁶⁶66. Camargo Jr. KR. Medicalização, farmacologização e imperialismo sanitário. Cad Saúde Pública 2013; 29:844-6.^,6767. Carvalho S, Rodrigues CO, Costa FD, Andrade HS. Medicalização: uma crítica (im)pertinente? Physis (Rio J.) 2015; 25:1251-69..

However, the progressive process of medicalization of eating and the advent of NCDs contributed to a perspective of healthy eating referred to here as biomedical and medicalizing which, besides nutritional and biology-centered, is focused on the prevention of diseases based on a risk factor logic. Such medicalization now viewed eating and certain foods and nutrients as risk factors (or protective factors) in relation to NCDs, an idea that had not previously provided the basis for the public agenda. The notion of food risk already existed in premodernity, but it was associated with physical contamination and food shortages. The context was marked by a culturalist perspective of healthy eating, defined according to culture and territoriality, when dietary interventions to treat diseases were based on knowledge of foods´ therapeutic power, referenced not on their active ingredients or functional qualities but according to other rationalities ¹1. Azevedo E. Alimentação saudável: uma construção histórica. Revista Simbiótica 2014; 7:83-111..

Medicalization is also a field of disputes over meanings. On the one hand, this can strengthen medical power by interconnecting the ways of controlling multidimensional issues such as eating, reducing it to the lens of a science with a specific rationality, namely that of traditional Western medicine ¹1. Azevedo E. Alimentação saudável: uma construção histórica. Revista Simbiótica 2014; 7:83-111.. Meanwhile, medicalization can produce new “truths” and techniques aimed at meeting distinct human needs and possibilities for action in society ⁶⁷67. Carvalho S, Rodrigues CO, Costa FD, Andrade HS. Medicalização: uma crítica (im)pertinente? Physis (Rio J.) 2015; 25:1251-69..

The consolidation of Nutrition as both a science and a paramedical profession was linked to the discovery of nutrients and calories and to the definition of standardized human nutritional needs. This logic of rationalization based on foods’ nutritional value and/or on the medicalization of eating ⁶⁸68. Viana MR, Neves A, Camargo Jr. KR, Prado SD, Mendonça ALO. A racionalidade nutricional e sua influência na medicalização da comida no Brasil. Ciênc Saúde Colet 2017; 22:447-56. can be identified in distinct ideas comprising the discursive repertoires on healthy eating, such as: (1) the association of certain foods and nutrients with the risk or prevention of diseases; (2) the association between healthiness and foods with low levels of calories, fats, and other specific nutrients; and (3) healthiness related initially to food supplements/complements based on micronutrients and/or fiber and progressively to the consumption of “functional” foods, the so-called “superfoods”, and to food fortification.

The above-mentioned configuration expresses not only medicalization but a pharmaceuticalization of eating, namely the use of products without a specific therapeutic function to achieve a certain “supernormality” ⁶⁶66. Camargo Jr. KR. Medicalização, farmacologização e imperialismo sanitário. Cad Saúde Pública 2013; 29:844-6.. This favors the consumption of pharmaceutical products or “fortified” seeds and “enriched” foods in keeping with the private commercial sector’s interests ¹1. Azevedo E. Alimentação saudável: uma construção histórica. Revista Simbiótica 2014; 7:83-111.. Thus, food systems have progressively incorporated industrial technologies and mechanisms to process seeds and foods, aimed at altering their nutritional composition and increasing their yield and durability ⁵⁹59. International Panel of Experts on Sustenable Food Systems. From uniformity to diversity: a paradigm shift from industrial agriculture to diversified agroecological systems. Brussels: International Panel of Experts on Sustenable Food Systems; 2016.^,6969. International Panel of Experts on Sustenable Food Systems. Too big to feed. Exploring the impacts of mega-mergers, consolidation and concentration of power in the agri-food sector. Brussels: International Panel of Experts on Sustenable Food Systems; 2017.. In this sense, PNAN 1999 took a step forward by valuing the monitoring of the industrialization and marketing of pharmaceutical and dietary products, an action that was not emphasized in PNAN 2013, despite the intensive pharmaceuticalization of eating.

Ideas on healthy eating related to foods’ functionality and discourses on selfcare, with the exacerbation of health concerns and the cult of the body and aesthetics, have driven both the franchises related to “healthy eating” and the consumption of basic, organic foods. The perspective of preventing or treating diseases gives way to practices aimed at wellness, fitness, and “happiness”, but also based on scientific standardization and an ideal of healthy eating ⁴4. Kramer FB, Prado SD, Ferreira FR, Carvalho MCVS. O discurso sobre alimentação saudável como estratégia de biopoder. Physis (Rio J.) 2014; 24:1337-59..

The allusion to the principles of “health” lend legitimacy to the consumption of certain foods and products and drive market niches and specific policies. In parallel, other principles, values, and ideas not circumscribed within the cognitive matrices of health gained growing force in the repertoires on healthy eating: environmental sustainability, equity, and social justice, family traditions, traditional peoples’ cultures, and local produce.

Some inflections and tensions contributed to the reconfiguration of the biology-centered, nutritional, and/or medicalizing perspective of healthy eating, which persists and is strengthened with new trappings. A turning point is established with ideas associated with the concept of “eating practices”, encompassing nutrients, foods, meals, purchases, consumption, and preparation in their biopsychosocial dimensions, seen here as a multidimensional perspective of healthy eating, identified in some health sector policies. The main turning point came with the concept of adequate and healthy eating, originating from the debate on food systems, sustainability, food and nutritional security, human right to adequate food, and the notion of real food, seen here as a systemic perspective of healthy eating, encompassing elements of multidimensionality, but grasping them with an interdisciplinary approach. This conception is conditioned by inter-sector and socially participatory institutionality, and the documents’ authorship mixes civil society and government segments. The concept of adequate and healthy eating problematizes the discussion of risk factors, encompassing both biological/health, nutritional, and socioenvironmental risks and redefining the term “adequate” itself, beyond a minimum package of specific nutrients.

The ideas comprising these different repertoires can reinforce specific action proposals: (1) the biology-centered nutritional perspective features changes in individual consumption with a focus on nutrients and food composition; (2) the biology-centered and medicalizing nutritional perspective features the control of risk factors from an individual and/or collective approach; (3) the multidimensional perspective features actions on the multiple conditioning factors of eating practices and on ways of life, living conditions, and institutional environments; and (4) the systemic perspective features inter-sector links and impacts on environmental, social, economic, and cultural sustainability and fair and agroecological transitions.

A distinction between the multidimensional and systemic approaches to healthy eating is that the latter is based on an integrated analysis of the multiple dimensions of healthy eating, thereby strengthening inter-sector policies. Even so, the multidimensional perspective of healthy eating is reconfigured in health policies, progressively incorporating reflections on food systems, human right to adequate food, food and nutritional security, and inter-sector action. In a two-way process, the inter-sector and participatory institutionality of food and nutritional security favored this movement. The systemic approach to healthy eating expresses the multiple views and interests of actors, especially those from civil society, who invest their political action in the cognitive matrices and interpretative systems of food and nutritional security, pointing to a unity between “food systems and nutrition”. This process illustrates how the ideas are conditioned by institutionality and simultaneously institute their contours, linking to the interests and institutional context, mutually affecting each other.

The private commercial sector displays a fragmented appropriation of the ideas present in different perspectives of healthy eating by limiting its discursive repertoires to specific conditioning factors of healthy eating, such as individual responsibility, driven by “educational actions” and neutralizing conflicts, suggesting that there are no distinctions between their practices and products when compared to other segments of producers who in fact operate under totally distinct and even opposing principles and logics (such as the agroecology component) ²⁰20. Associação Brasileira da Indústria de Alimentos. Documento submetido à Agência Nacional de Vigilância Sanitária (Maio 15 2018). https://pt.scribd.com/document/382022379/Abia-apresenta-documento-a-Anvisa#from_embed (acessado em 20/Jun/2020).
https://pt.scribd.com/document/382022379... ^,2323. Associação Brasileira das Indústrias de Refrigerantes e de Bebidas não Alcoólicas. Revista ABIR 2020; 2019/2020. https://abir.org.br/abir/wp-content/uploads/2020/03/revista-abir-2020.pdf.
https://abir.org.br/abir/wp-content/uplo... ^,6262. Dias J. Cozinhar e comunicar: uma abordagem ecobiocultural sobre sistemas de alimentação e comunicação [Tese de Doutorado]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2018.. The private sector thus aims to depoliticize the debate by coopting some principles of healthy eating without addressing them comprehensively. The partial appropriation of issues related to the food system’s sustainability while overlooking the other principles of food and nutritional security and human right to adequate food, can lead to pseudo-solutions such as “organic” ultra-processed foods, produced by intensive practices and monoculture.

In other cases, the disputes are even more visible, such as in the private sector’s strategy of denying the idea that “healthy foods” and “unhealthy foods” exist, or of denying and disqualifying the NOVA classification (especially its concept of ultra-processed foods), besides denying the term “real food”, arguing that all foods are real and that there is no such thing as fake food. Other tensions with the private commercial sector emerge in the biology-centered and medicalizing nutritional perspective due to the association between foods’ nutrients/nutritional composition, including those of ultra-processed foods, and NCDs. Paradoxically, this same perspective favors pharmaceuticalization and drives strategic markets for this sector, as mentioned. In addition, the private commercial sector coopts elements that associate healthiness with nutritional attributes aiming to add nutrients to ultra-processed foods or make voluntary agreements to reduce them (e.g., sodium), which contradictorily assumes that their original formulation characterizes them as “unhealthy foods”.

The disputes over these various narratives and political actions affect government decisions through formal institutional spaces that allow participation by civil society and the private sector (in many cases disregarding conflicts of interest) and by processes taking place in the political backstage. State organization (both formal and informal) may occasionally favor the linkage between converging interests of the public, private, and/or civil society segments. In a two-way process, the actors may establish policy networks that traverse the different institutions and lead to alliances that affect decision-making processes in different directions, depending on their power resources.

Conclusions

The principal disputes identified here concern ideas on the following: the existence of “unhealthy foods”; attributions, limits, and forms of State action (which ones should be regulated, and how); eating as an individual or public matter; and the meanings of sustainability, commensality, culture, and food. Policy positions in relation to pesticides, food fortification, and supplementation - including the regulation of these practices - also signal key elements in these disputes.

In the political action sphere, fragmentation, downplaying, and distortion of meanings are strategies used by the private commercial sector that particularly reinforce the polarization between individual actions and environmental interventions and convey a limited conception of nutrition education. The discursive repertoire and private corporate action are aligned with commercial interests and are adjusted to various market niches (including segments concerned with healthy eating), aimed at consolidating ideas on healthy eating that can be served by their products. Civil society exerts political impact by pressuring governments to include concepts and principles in their policies that directly impact the parameters in dispute, such as adequate and healthy eating, human right to adequate food, and food and nutritional security. Civil society, government sectors, and the private commercial sector (which are heterogeneous) compete for public resources, and the governments’ degree of permeability to pressures from the actors (both internal and external) depends on their profile and types of interests they are intended to promote. The State’s institutionality can contribute to policy profiles that are variably hybrid or plural (attempting to serve different interests) by favoring social participation or inter-sector action to greater or lesser degrees. The types of discourses and institutionalities are heterogeneous.

The different segments of actors complexify their strategies by aiming to incorporate (in different ways) the ideas comprising the systemic perspective of healthy eating, consistent with their interests. The terms of the discourses can be used to foment ideas devoid of the meaning contained in the political action that propelled them.

The obsession with “risks”, health, or “healthy”, limited to the biological perspective, favors medicalizing solutions. The ideas that downplay the different types of risks, as part of private corporate action, can encourage the consumption of ultra-processed foods and undermine regulatory strategies.

This fragmented way of dealing with eating generates pseudo-solutions. It is thus important to consolidate perspectives of healthy eating that avoid treating the different dimensions of eating dichotomously and partially. The systemic perspective points to paths in this direction, based on interdisciplinary knowledge, linking different types of knowledge in inter-sector policies and institutionality. This vision complexifies the public decisions and requires redesigning policies in keeping with a logic of integrated planning.

The area of the promotion of healthy eating features the challenges of implementing regulatory measures and policies that affect living conditions and build educational practices and healthcare from the perspective of food and nutrition education. These State attributions are nontransferable and affect the unequal conditions of food “choices” and care. The disputes over ideas reveal tensions between public and private responsibilities and require the development of personal and collective skills, critical capacity, and autonomy, as reiterated by the Framework. These topics also create disputes, since autonomy in care can be conceived as either a positive principle or as delegation of responsibilities to the individual, and in the latter case it can result in undermining policies and compromising the State’s public responsibilities.

It is essential to understand how the process of dispute over ideas has driven action by different actors to promote effective impact on policymaking. To problematize and increase the visibility of this topic helps identify and justify priorities for the government food and nutrition agenda.

Acknowledgments

To Brazilian National Research Council (CNPq; Grant #313714/2020-7) for the financial support.

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