Abstract

Introduction

Among other elements, emerging health and nutrition risks arise from the intensive use of technological processes ¹1. Beck U. La sociedade del riesgo: hacia una nueva modernidade. Barcelona: Paidós; 2002. associated with ultra-processed food products, due to their unbalanced nutritional composition ²2. 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.. Consisting almost entirely of low nutritional value ingredients, such products stand out among the risk factors for obesity and other chronic non-communicable diseases (NCDs) ³3. Monteiro CA, Moubarac JC, Cannon G, Ng SW, Popkin B. Ultra-processed products are becoming dominant in the global food system. Obes Rev 2013; 14 Suppl 2:21-8.^,44. Pan American Health Organization. Ultra-processed food and drink products in Latin America: trends, impact on obesity, policy implications. Washington DC: Pan American Health Organization; 2015.. These diseases make up the epidemiological scenario of most countries ⁵5. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. Geneva: World Health Organization; 2000. (WHO Technical Report Series, 894).^,66. World Health Organization. Fiscal policies for diet and prevention of noncommunicable diseases: technical meeting report, 5-6 May 2015. Geneva: World Health Organization ; 2016., including Brazil, whose rise has been persistent since 1989 ⁷7. Coitinho DC, Leão MM, Recine E, Sichieri R. Condições nutricionais da população brasileira: Adultos e idosos. Brasília: Instituto Nacional de Alimentação e Nutrição; 1991.^,88. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares - 2008-2009. Antropometria e estado nutricional de crianças, adolescentes e adultos no Brasil. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2010.. Recent data on the health of Brazilian adults indicate that 39.2% have high blood pressure; 15.9%, diabetes; 25.9%, obesity and 60.3%, overweight ⁹9. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Sau´de 2019: atenc¸a~o prima´ria a` sau´de e informac¸o~es antropome´tricas. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020.. Such situation shows the increase in caloric consumption and risk nutrients related to ultra-processed food products (industrialized breads, soft drinks, snacks, cookies, breakfast cereals, etc. ¹⁰10. Martins AP, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Increased contribution of ultra-processed food products in the Brazilian diet (1987-2009). Rev Saúde Publica 2013; 47:656-65., which already make up 20% of the caloric food intake ¹¹11. POF 2017-2018: alimentos frescos e preparações culinárias predominam no padrão alimentar nacional. Agência IBGE Notícias 2020; 3 abr. https://agenciadenoticias.ibge.gov.br/agencia-sala-de-imprensa/2013-agencia-de-noticias/releases/27298-pof-2017-2018-alimentos-frescos-e-preparacoes-culinarias-predominam-no-padrao-alimentar-nacional.
https://agenciadenoticias.ibge.gov.br/ag... ).

The increase in NCDs has led international organizations to recommend regulation of the nutritional components of ultra-processed food products to reduce the levels of sugars, fats and sodium ⁶6. World Health Organization. Fiscal policies for diet and prevention of noncommunicable diseases: technical meeting report, 5-6 May 2015. Geneva: World Health Organization ; 2016.^,1212. Food and Agriculture Organization of United Nations. The state of food and agriculture:food systems for better nutrition. Rome: Food and Agriculture Organization of United Nations; 2013.; advertising restriction of these products to children; warnings on their labels; regulation of their commercialization in schools and the increase in taxation to limit their consumption ⁴4. Pan American Health Organization. Ultra-processed food and drink products in Latin America: trends, impact on obesity, policy implications. Washington DC: Pan American Health Organization; 2015..

Controlling the consumption of ultra-processed food products is a challenge, both due to marketing strategies and the omission of information about their nutritional characteristics, which make people dependent on the market, often without ethical rules and limits, imposing them the purchase of products that are against the precepts of health. The corporate practices of transnational companies promote the homogenization of consumption patterns, weakening culture and eating practices ¹³13. Contreras JH, Gracia M. Alimentação, sociedade e cultura. Rio de Janeiro: Editora Fiocruz; 2011.. In addition to concentrating economic power, these companies still institute political action strategies that result in interference in national public health decisions ¹⁴14. Mialon M, Gomes FDS. 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..

Due to the worsening of the epidemiological panorama of food and nutrition, the Brazilian government set off initiatives to replace regulatory practices ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... . In 2007, the Brazilian Ministry of Health, following international recommendations ⁵5. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. Geneva: World Health Organization; 2000. (WHO Technical Report Series, 894)., signed a Cooperation Agreement with Brazilian Association of Food Industries (ABIA) to assess the sector’s potential to gradually reduce the levels of free sugar, both trans and saturated fats, and salt in the ultra-processed food products ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... .

In 2009, Brazilian Health Regulatory Agency (ANVISA) evaluated the nutritional composition of 24 ultra-processed food products, regarding the sodium content, sugars, both saturated and trans fats ¹⁶16. Agência Nacional de Vigilância Sanitária. Perfil nutricional dos alimentos processados. (Informe Técnico, 42/2010). https://nutritotal.com.br/pro/wp-content/uploads/sites/3/2010/11/195-AlimentosProcessadosANVISA.pdf (acessado em 22/Dez/2010).
https://nutritotal.com.br/pro/wp-content... , showing worrying results. Instant noodles, cookies, corn snacks, soft drinks, sausages and the like showed high values for these nutrients. Thus, successive agreements were signed with entities representing the industries to firstly reduce the sodium content in these categories ¹⁷17. Ministério da Saúde. Construção da agenda de reformulação de alimentos processados com as indústrias de alimentação. http://nutricao.saude.gov.br/sodio_reformulacao.php (acessado em 24/Jun/2014).
http://nutricao.saude.gov.br/sodio_refor... , although the epidemiological context also points to urgency for the reduction of the other risk components. These Agreements ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... are the essential parts of this article.

In view of this epidemiological context, Brazilian National Food and Nutrition Policy (PNAN) was updated. The guideline of the first edition - “guarantee of safety and quality of products and provision of services in the food area” - which is focused on the inspection and control of traditional health risks - harmlessness ¹⁸18. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. 2ª Ed. Brasília: Ministério da Saúde; 2008.(Série B. Textos Básicos de Saúde). - was replaced, in the 2012 edition ¹⁹19. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2012., by the guideline - “control and food regulation” - addressing the integrality of food risks, incorporating those related to the “nutritional profile” and emphasizing the regulatory strategy.

Considering the aformentioned statements, this study analyzed the comprehension of different strategic subjects about the health risks related to the ultra-processed food products and their resulting public intervention, focusing on the generic theme “Agreement and Regulation” and the matrix statement “Consent Regulation”. From the manifest speeches, it was possible to identify the convergent and divergent points on the recognized risks and injuries, the arguments for food regulation, the commitments to public health and the limits of action for public intervention on the nutritional profile of the ultra-processed food products.

Methodological trajectory

This is a qualitative empirical investigation aiming to understand the view on public regulation of health risks related to ultra-processed food products, made explicit by different subjects, based on the assumption that the meanings that constitute and build the discursive reality - risks of the ultra-processed food productsand regulation - can be explored through the use of language.

Theoretical reference

Depth Hermeneutics

To investigate the individuals’ opinions about the regulation of ultra-processed food products, the method of Depth Hermeneutics ²⁰20. Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação de massa. 8ª Ed. Petrópolis: Vozes; 2009. was chosen as a theoretical framework to deal with the senses mobilized by symbolic forms - opinions, ideas, beliefs, etc. For Thompson ²⁰20. Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação de massa. 8ª Ed. Petrópolis: Vozes; 2009., symbolic forms are significant and ideological manifestations expressed by the subjects, inserted in a specific socio-historical context, which take place both in the scope of daily life and in the sphere of institutions, structured in the discursive dynamics of interrelationship between meaning and power. To unravel such symbolic forms, we followed the interpretative process proposed by Depth Hermeneutics, which has three distinct and complementary analytical dimensions: Formal or Discourse Analysis, Socio-historical Analysis and Interpretation/Reinterpretation ²⁰20. Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação de massa. 8ª Ed. Petrópolis: Vozes; 2009..

The Discourse Analysis examines the constitution of the symbolic forms, their internal structural features, distinctive elements and their inter-relationships. The analysis of the interviews was adapted to the proposals of the Discourse Analysis structured by Orlandi ²¹21. Orlandi EP. Análise de discurso: princípios e procedimentos. 9ª Ed. Campinas: Pontes Editores; 2010. and Minayo ²²22. Minayo C. O desafio do conhecimento: pesquisa qualitativa em saúde. 9ª Ed. São Paulo: Editora Hucitec; 2006., respecting the flexibility admitted by Depth Hermeneutics ²⁰20. Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação de massa. 8ª Ed. Petrópolis: Vozes; 2009., which allows to problematize the determination of the meaning processes of the word or text and understand how the subjects interrelate and construct their speeches, constituted of ideologically determined meanings, which explain their position in a given socio-historical context ²¹21. Orlandi EP. Análise de discurso: princípios e procedimentos. 9ª Ed. Campinas: Pontes Editores; 2010.^,2222. Minayo C. O desafio do conhecimento: pesquisa qualitativa em saúde. 9ª Ed. São Paulo: Editora Hucitec; 2006..

With the empirical material, we followed the exploration of the discourse ²¹21. Orlandi EP. Análise de discurso: princípios e procedimentos. 9ª Ed. Campinas: Pontes Editores; 2010., corpus configuration (identification of the discourse regularities that were grouped into four generic themes); the structuring of the discourse-object - which allowed the formulation of five matrix statements based on the recurrence of ideas identified in the generic themes, observing the similarities or divergences and the conflicts and contradictions in the arguments used to construct the meanings; and the discourse analytical reconstruction - interpretation of the matrix statements based on the theoretical aspects to analytically reconstruct the discourses and make explicit the political-ideological interests of the subjects, regarding the risks of food and regulation. The discourses articulated to the social context (socio-historical analysis) allow to clarify the object under analysis in its complexity, reaching Interpretation/Reinterpretation, according to the theoretical model proposed by Thompson ²⁰20. Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação de massa. 8ª Ed. Petrópolis: Vozes; 2009..

This Article focuses on the generic theme “Agreement and Regulation” and the matrix statement “Consent Regulation”.

Subjects

Thirteen subjects were interviewed, defined by the criteria of approximation with the study object, by monitoring the discussions at national and international levels; accumulated experience; and compatible hierarchical position to express the interests of the linked institution (Box 1).

The subjects who were interviewed belong to one of these four categories: Public Sector (PS), Regulated Sector (RS), Civil Society (CS) and International Organization (IO).

From February to June 2013, individual face-to-face interviews were conducted in Brasília and São Paulo, lasting one hour (average). They were made from a semi-structured script previously tested (Box 2). The interviews were recorded and transcribed by the researcher. The institution category linked to the interviewee was identified by codes: PS, RS, CS and IO. The code was followed by a number for each interviewee.

The research was approved by the Ethics Committee of the Faculty of Health Sciences, University of Brasília (opinion n. 117/2012).

Results

The rationale adopted to address the risks attributed to the ultra-processed food products and the regulatory mechanisms is different when it is expressed by different subjects. In their fields of competence, each develops influencing strategies and acts to adapt political action to their interests. By means of differentiated contributions of symbolic and material capital ²³23. Bourdieu P. O poder simbólico. Rio de Janeiro: Bertrand Brasil; 2009. and social commitments that are not always attuned, the subjects follow specific trajectories that lead to different processes of understanding public policies.

When exploring the discourse achievements of the matrix statement “Consent Regulation”, regarding its enunciative function, it is observed that reaching a healthy product does not depend only on legal provisions, but involves a regulatory governance established between the interested parties, articulating the internalization market values and a healthy product. These discourse achievements are examined as for the differentiation of their meanings and the changes in their formulations between one set of interviews and another, aiming to delimit and interpret the game of concordances and conflicts that cross the expectations of a healthy food product.

Regulation: voluntary or compulsory?

In order to regulate market practices in the area of health, it is essential that there is a possibility or evidence of risks to the population’s integrity. The IO subject’s discourse is generic, but it addresses the elements that are necessary to trigger a regulation process for the ultra-processed food products: “The relationship between the consumption of industrialized foods and these diseases [NCDs] is clear. (...) they have some research showing (...) that their energy density is usually higher than in natura foods (...), which favors the overweight (...) and related diseases...”.

However, regulating is a technical and political initiative and, therefore, it is the convergences and divergences of the PS, RS, CS and IO subjects’ discourses that mark the regulatory environment explored below. Between the approach of recovering the State’s regulatory power and the approach of an institutional reform that aims to reduce bureaucratic processes and facilitate economic activities, the reflections of the CS and PS subjects are divergent. For the CS2 subject, the creation of regulatory agencies has boosted the State's regulatory activity: “...the Brazilian State has returned to an active role, (...) regained its regulatory role. (…) It is a capitalist system driven primarily by profit, if there are no clear rules, (...) the consequences for the population are dramatic”. For the PS5 subject, the regulatory agencies do not fulfill their formal role: “...I have doubts about the role of the agencies as an institutional model for the State’s arm (...). They end up being more hostages to the market than obeying the State”.

Seeing the urge to improve the nutritional profile of the ultra-processed food products, the government decided to institute formal pacts (Agreements) with entities representing the industries, jointly establishing flexible and long-term goals ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... . However, RS1 subject states: “We have made an Agreement with the Ministry of Health”. The personal pronoun “we” takes on the connotation of imposition, unilateralism as if the initiative of Agreement ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... and the decision to carry out the act fell predominantly on the subject who speaks. In fact, the formal initiative of this Agreement ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... came from the government in order to minimize the negative impacts on health and identify a probable acceptance by corporations when compared to mandatory regulation.

For other RS subjects, the Agreement is a demonstration of the government’s wisdom and understanding between the parties, recognizing the complexity involved in changing the formulas to bring them closer to products with a “healthy profile”. For them, regulating to remedy failures through mechanisms other than voluntary agreements would be an inconvenient attitude: “...it is radicalism, a regulation (...) it does not give the flexibility like the Agreement. The Agreement is a matter of understanding (...) saying that industrialized foods have to be regulated, I am against these controls” (RS1).

The understanding of the RS about the measures - Agreement and Regulation - is paradoxical. The first is seen as a symbol of dialog, common, rational and educational; in short, protector of the market. Regulation, on the other hand, represents radicalism, control, authoritarianism, inefficiency and inflexibility. Food regulation, a regulatory practice, instituted more than six decades ago by the Brazilian Ministry of Health ²⁴24. Brasil. Decreto-Lei nº 986, de 21 de outubro de 1969. Institui normas básicas sobre alimentos. Diário Oficial da União 1969; 11 nov. and, nowadays, by its autarchies, whose function is to act to protect collective health interests and to make competition between companies fair; now it becomes a controversial instrument as the RS1 subject previously expressed. For him, the food market introduces itself as a sovereign and self-regulating space, dismissing any type of imposition of rules and sanctions for non-compliance with them.

In the scope of the PS and CS groups, the speeches do not follow a uniformity regarding the Agreements. There are three positions: (a) favorable: it is up to the government to circumvent the divergences of interests with the industries, “...the government needs to be a partner of our industries” (PS4); “It is a governance measure combined with the industrial segment” (PS3); (b) conditioned to the preservation of the supremacy of the public interest and other prerogatives of the State: “I see no problem in signing Agreements, as long as there are no counterparts that will damage the State” (PS1) and “These Agreements are necessary, but insufficient and timid with regard to their goals” (CS1); and (c) contrary, considering that the content negotiated is relevant to public health, feasible and legal: “I am in favor of having regulations, even if a deadline is established (...) for the democratic construction of the rule” (PS5) and “...It [government] must have clear rules and even sanctions” (CS2).

Three scenarios emerge from the speeches above. The first points to an absence of internal harmony between the arguments of the CS subjects who, despite belonging to the same field of speech, express different socio-political views on the Agreement ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... ; similar effect was registered in the scope of the PS subjects. Another indicates the absence of a harmonious understanding of regulation. This involves a list of legal and compulsory, technical and administrative control measures to protect the population against health risks arising from production systems ²⁵25. Lucchese GA. Globalização e regulação sanitária: os rumos da vigilância sanitária no Brasil. Brasília: Agência Nacional de Vigilância Sanitária; 2008.. Regulating (with regulation) is the process undertaken by ANVISA, which implies extensive studies, involvement of interested parties, public consultation, before its approval/conclusion ²⁶26. Agência Nacional de Vigilância Sanitária. Agenda regulatória: ciclo quadrienal 2013-2016. http://www6.ensp.fiocruz.br/visa/files/Agenda_Regulatoria_Quadrienal_final_baixa%20(1).pdf (acessado em 02/Abr/2018).
http://www6.ensp.fiocruz.br/visa/files/A... . The third scenario shows the agreement as an expression of understanding and flexibility between the government and the industrial sector, comparing itself implicitly to regulation.

The consensus construction between the government and the food corporations formalized in these agreements demonstrates the receptivity and predisposition of these entities to cooperate. However, the result obtained from this consensus can result in balanced concessions or losses for one of the parties, including for public health. The Brazilian government’s option not to regulate, dismissing its prerogative in favor of the Agreement ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... can be understood as a setback in favor of the market, since a regulation could have been elaborated, through a participatory and dialogical process, with a legal negotiated deadline for effectiveness, following ANVISA’s practice. This is the impression of the CS2 subject: “I think there is this present vision - public-private partnership, (...) I realize there is a risk (...) of privatization, of granting power as if the market could regulate”.

It should be noted that the increase in the prevalence of NCDs and their association with the consumption of ultra-processed food products is already accumulating serious individual and collective consequences that impose a high cost on the society. Only the State is able to transform this demand into an object of public interest in the health agenda as expressed in PNAN 2012 ¹⁹19. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2012.. This was explained by the PS5 subject: “No one can expect the market to be spontaneously compatible with social rights, especially health, because it is geared towards profit. So it must always be regulated, socially controlled and with the State...”.

For the Agreement construction ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... , initially for the sodium content reduction, the government called only the corporations of the industries of greater economic relevance. The CS and PS subjects criticize this restriction: “...the society was not summoned and neither was the academy (...). Who took part in this Agreement was the Ministry of Health and the industries supported by ANVISA...” (CS1). The PS2 subject highlights: “Doing politics is to dialog, because democracy is made from this. This does not mean alignment. This means dialog, search for convergent agendas...”. These arguments express a clear confrontation between the “exercise of democracy” and the “extension of representation”. Extending democratic practice in public spaces requires the participation of all those that are interested in the deliberations whose impact is on the collective body ²⁷27. Bobbio N. Estado, governo e sociedade: para uma teoria geral da política. 12ª Ed. Rio de Janeiro: Paz e Terra; 2005.. The absence of the organized civil society in this institutional dialog compromises both the legitimacy of the deliberations, and demonstrates a setback in participatory management.

The Agreements ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... that were signed in 2007 break with the Brazilian institutional tradition of food regulation to deal with both harmlessness and nutrition problems. In the past, with the regulation by participatory construction with interested parties, it became possible to adopt mandatory rules to add iodine to the salt ²⁸28. Agência Nacional de Vigilância Sanitária. Resolução - RDC nº 28, de 28 de março de 2000. Dispõe sobre os procedimentos básicos de boas práticas de fabricação em estabelecimentos beneficiadores de sal destinado ao consumo humano e o roteiro de inspeção sanitária em indústrias beneficiadoras de sal. Diário Oficial da União 2000; 30 mar., and iron and folic acid to flours ²⁹29. Agência Nacional de Vigilância Sanitária. Resolução - RDC nº 344, de 13 de dezembro de 2002. Diário Oficial da União 2002; 18 dez..

This change in strategy was beneficial for industries in a double sense, as it allowed greater flexibility to establish the level of sodium reduction and the deadline for adapting their products. Also, it avoided punishments for eventual non-compliance with the Agreements, according to the CS and PS subjects: “...the government’s activity (...) is more related to the sense of relaxing than tightening the regulation” (CS1). “...as it was not possible to approve the rule, an Agreement was made, as there was an interest in not harming the national industry” (PS6).

Transnational corporations preserve their interests, maintaining an active channel of international articulation that allows the circulation of criticisms, pressures and mobilization within the scope of the World Health Organization (WHO), the United Nations for Food and Agriculture Organization (FAO), the countries and civil society organizations, with regard to the ultra-processed food products. Thus, they guide their entities to anticipate the defense of their interests. These entities call on their members to rethink of the formulas of the products, foreseeing an incisive action by the governments, according to what is stated in the speech “...the multinationals brought this idea (...) that extends to the rest of the world. So, they received the instruction that, at a certain moment, they would have to start thinking (...), we started long before the government addressed the problem” (RS1). Here, it is possible to observe another attempt by the RS to play a role in questioning the performance of the Brazilian government.

The influence of intergovernmental bodies in national processes is seen as a mixture of dependence and impotence, implying a partial loss of national sovereignty to define rules, even in the face of relevant justifications, according to the speech of PS4: “...agreeing on a regulatory measure involves an international agreement, because it is about Mercosur [Southern Common Market] (...) The regulatory agenda advancement [nutritional components] will depend on international tension, (...) and on arrangement, support from society...”. In the final section of this speech, it is observed that the government expects and foresees relevant demands from society, in the definition of processes and decisions. Theoretically, civil society could promote controversial issues such as the regulation of the nutritional components of the ultra-processed food products, leading to decisions beyond what was signed in international pacts or voluntary agreements.

On the market side, the RS subjects’ speeches show that the relationship established with supranational and intragovernmental bodies is the place (locus) where they express their intentions and exert influence on decisions, despite reporting an apparently limited performance: “...we participate in the discussion within Brazil and indirectly (...) as an observer in the Codex Alimentarius (...), for positioning, not voting, nor vetoing (...). And in Mercosur, we (...) participate in the different commissions through ANVISA” (RS3). When appropriate, such instances are reported as having a higher status than that of the State; for example, when the RS1 subject mentions the deadline elasticity for adjusting the sodium content in the formulas of the ultra-processed food products: “In our formulas, we will arrive by 2020 as recommended by the WHO...”.

To keep the food market competitive, companies invest in technologies and quality control mechanisms that rationalize the use of resources and increase profits. From this, there is a multiplication of products based on relatively cheap raw materials, nutritionally unbalanced and highly profitable formulations, which contradict the RS’s arguments: “who dictates the food qualities is the food itself or the land”. Aware of this marketing strategy, the RS3 subject subtly and thoughtfully reveals the intentions of the industry concerning the ultra-processed food products: “...there is a very large increase in the supply of products with (...) more sugar, excessive-fatty products...”.

Competitiveness in the food market exposes differences of interests and the existence of a stratification system among companies. There is a power hierarchy among corporations, which subject smaller industries and politically less expressive entities to almost obligatorily follow the procedures of the first-rate industries to remain in the market: “We are the majority (…) the 200 first companies in the country in production. If we lower the product [the nutritional levels], the others will have to follow, otherwise they will lose market share. Our companies take the lead to set an example... ”(RS1).

Thus, RS1 expresses the market vision that stands as the savior of the economy and of the State itself, expressed by the generation of jobs, contribution to the trade balance and taxes that guarantee the state machine functioning: “...we produce, we employ, we pay taxes, export, we have been there for 150 years”. Discourse that simultaneously indicates economic and political force, and implicitly ²³23. Bourdieu P. O poder simbólico. Rio de Janeiro: Bertrand Brasil; 2009. intimidates the government, compelling it to retreat from making political arrangements that negatively affect the business interests of the regulated sector to save it from possible retaliation.

In this sense, the PS4 subject’s discourse praises this adaptation in the action of the public power before the market: “...it is no longer possible to carry out that vigilance (...) of assessing, apprehending, (...) as in the old days (...). Today, modern health surveillance works with stakeholders, partnerships and is a (...) contemporary movement. (...) gives responsibility to the industry (...) gives it the voluntariness...”.

Recognized as legal and necessary in situations of risk to public health, administrative acts are depreciated and evaluated as outdated and inopportune in the contemporary context for those guided by the motto “market can everything”. It should be noted that the PS4 subject’s position, presented above, is not hegemonic, according to the following speech: “...ANVISA cannot escape this responsibility, (...) it must regulate and cannot be in the wake of the market” (PS5). The divergence between this manifestation and the previous one indicates that there is no harmony in the understanding of public-private interaction by the PS subjects and that the Agreements may fall short of the responsibilities of the public authorities towards the market and, therefore, be insufficient to deal with the health care needs of the community.

Discussion

The prevention and control of NCDs, particularly overweight, requires urgent and articulated actions by the public authorities, which are confronted with the logic of neoliberal policies of food corporations that are supported, on the one hand, by maximum profitability and wide market freedom and, on the other, by the weakening of state power and resistance to the compulsory regulation measures of the ultra-processed food products ³⁰30. Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Thamarangsi T, et al. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013; 381:670-9.. By mobilizing themselves to influence the design of public policies in favor of their interests ³¹31. Mialon M, Swinburn B, Wate J, Tukana I, Sacks G. Analysis of the corporate political activity of major food industry actors in Fiji. Global Health 2016; 12:18. and to propose non-regulatory measures with extensive deadlines ³⁰30. Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Thamarangsi T, et al. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013; 381:670-9., the conduct of these corporations ends up delaying the containment of these diseases. The results of this study show the complexity of the clashes, controversies and obstacles that cross the subjects’ speeches that are involved with the strategy to reformulate the ultra-processed food products.

It is noted that these corporations have massified the offer of ultra-processed food products due to their economic advantages: cheap raw materials, reduced production costs and highly palatable products ³²32. Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr 2009; 12:729-31., supported by an advertising apparatus that promotes sales ³²32. Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr 2009; 12:729-31.^,3333. Hawkes C. Marketing activities of global soft drink and fast food companies in emerging markets: a review. In: World Health Organization, editor. Globalization, diets and noncommunicable diseases. Geneva: World Health Organization; 2002. p. 23-78., even if it is ethically questionable ³⁴34. Stuckler D, Nestle M. Big food, food systems, and global health. PLoS Med 2012; 9:e1001242.. However, despite the negative impacts of ultra-processed food products on the health and nutrition of the current population and of future generations ³⁵35. Phillips L. Food and globalization. Annual Review of Anthropology 2006; 35:37-57. who are willing to consume them, these products are profitable for those who produce them, revealing the incompatibility between the purposes of the market and those related to health, according to PS5.

Unfortunately, it is the consumer who bears the burden of this global process of food corporations, since the introduction of ultra-processed food products in the food routine is not the result of strictly rational choices, but is influenced by social dynamics and stimulated by the advertising apparatus that exacerbates the consumption of these products ³³33. Hawkes C. Marketing activities of global soft drink and fast food companies in emerging markets: a review. In: World Health Organization, editor. Globalization, diets and noncommunicable diseases. Geneva: World Health Organization; 2002. p. 23-78.. For Bourdieu ³⁶36. Bourdieu P. Contrafogos: por um movimento social europeu. Rio de Janeiro: Jorge Zahar Editores; 2001., the driving force of the market threatens cultural goods (including eating habits and practices) in contemporary neoliberal society, and technological innovations and economic enterprises do not make these goods multi-diversified nor do they promote consumer satisfaction; they are profitable goods and indifferent to cultural ties, acceptable to the “maximum public” of all countries.

Hence, it is possible to understand the interface between the food market globalization, the food transition and the international dissemination of risk factors for NCDs ⁶6. World Health Organization. Fiscal policies for diet and prevention of noncommunicable diseases: technical meeting report, 5-6 May 2015. Geneva: World Health Organization ; 2016.^,3737. Tullao TS. The impact of economic globalization on noncommunicable diseases: opportunities and threats. In: World Health Organization, editor. Globalization, diets and noncommunicable diseases. Geneva: World Health Organization; 2002. p. 17-24.. With the intensification of NCDs and their association with the ultra-processed food products ⁵5. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. Geneva: World Health Organization; 2000. (WHO Technical Report Series, 894).^,66. World Health Organization. Fiscal policies for diet and prevention of noncommunicable diseases: technical meeting report, 5-6 May 2015. Geneva: World Health Organization ; 2016.^,3232. Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr 2009; 12:729-31.^,3434. Stuckler D, Nestle M. Big food, food systems, and global health. PLoS Med 2012; 9:e1001242., this neoliberal ideal of full market independence is undone, and the State is summoned and pressured to intervene in defense of public health, even if this implies conflicts between private interests and social demands ³⁸38. Magalhães R. Regulação de alimentos no Brasil. Rev Direito Sanit 2017; 17:113-33. in favor of a healthy product.

In view of this, social scientists point out that the sovereignty of national states has weakened with the economy globalization ¹1. Beck U. La sociedade del riesgo: hacia una nueva modernidade. Barcelona: Paidós; 2002.; assumes the role of local and global political dialog, since it is relativized and subjected to strong and constant influences of international food trade rules and agreements, especially those led by the Codex Alimentarius Commission to deal with matters of quality and health safety standards ³⁹39. Lucchese GA. A internacionalização da regulamentação sanitária. Ciênc Saúde Colet 2003; 8:537-5.. This loss of state autonomy was highlighted by PS4 and RS1. There is also constant pressure from public authorities to make more flexible rules and procedures in order to enhance the free market ³⁹39. Lucchese GA. A internacionalização da regulamentação sanitária. Ciênc Saúde Colet 2003; 8:537-5., such as the formalization of the Agreements ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... . Among the practices adopted by food corporations to mobilize the public agenda in favor of their interests are the lobbying practice, the threat of job cuts, the closure of industrial activities, lawsuits, etc. ³¹31. Mialon M, Swinburn B, Wate J, Tukana I, Sacks G. Analysis of the corporate political activity of major food industry actors in Fiji. Global Health 2016; 12:18.. The RS1 duly clarified this economic power of corporations in the face of the state apparatus.

Thus, presenting different justifications, the subjects linked to the RS and the PS point out, respectively, that they follow the guidelines of the multilateral organizations and that the national regulatory agenda advancement depends on international deliberations, characterized by prolonged debates and slowness in the results. At the time, the RS subject states the WHO has granted a longer deadline to adapt the formulas of the ultra-processed food products compared to those defined in the Agreements.

Brazilian health regulation foresees formal processes, with the active involvement of different representatives (RS, CS, universities and public health institutions - and open participation of stakeholders) ²⁶26. Agência Nacional de Vigilância Sanitária. Agenda regulatória: ciclo quadrienal 2013-2016. http://www6.ensp.fiocruz.br/visa/files/Agenda_Regulatoria_Quadrienal_final_baixa%20(1).pdf (acessado em 02/Abr/2018).
http://www6.ensp.fiocruz.br/visa/files/A... . It is in this environment that scientific evidence, political-ideological positions, expectations and strategic lines are confronted to protect the population from food risks. Under these different views interspersed with conflicting interests, it is necessary to modulate the possible consensus to enable the control of the risks of the ultra-processed food products and the establishment of effective public intervention measures to adjust market practices. Contrastingly, the Agreements ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... interrupt these processes, without allowing a plural and transparent debate, establishing restricted goals and with limited representation of corporations ⁴⁰40. Martins APB. Reduc¸a~o de so´dio em alimentos: uma ana´lise dos acordos volunta´rios no Brasil. Sa~o Paulo: Instituto Brasileiro de Defesa do Consumidor; 2014..

On the one hand, there is the need to regulate the ultra-processed food products and, on the other, there is the pressure from the international market - added to the absence of supranational rules and the economic expressiveness of the corporations involved. So, in view of that, the institution of Agreements to replace regulation was the strategy made possible by the Brazilian government to alleviate conflicts with the food market, guarantee its commitment and envision a possible advance. These Agreements were supported by the RS and part of the PS, sensitive to market demands.

However, in previous times, due to the increase in the regulatory function of the State mentioned by the CS2, there was a clash between the government and the food corporations of less economic power, and the regulation was approved, having the rules and sanctions instituted to ensure the addition of specific nutrients in salt ²⁸28. Agência Nacional de Vigilância Sanitária. Resolução - RDC nº 28, de 28 de março de 2000. Dispõe sobre os procedimentos básicos de boas práticas de fabricação em estabelecimentos beneficiadores de sal destinado ao consumo humano e o roteiro de inspeção sanitária em indústrias beneficiadoras de sal. Diário Oficial da União 2000; 30 mar. and flours ²⁹29. Agência Nacional de Vigilância Sanitária. Resolução - RDC nº 344, de 13 de dezembro de 2002. Diário Oficial da União 2002; 18 dez..

These Agreements are modalities similar to public-private partnerships in the field of health that are based on the sharing of objectives and/or decision-making between the public and private sectors to achieve results without significant political-institutional wear and tear ⁴¹41. Hawkes C. Working paper on public-private partnerships for health. ec.europa.eu/health/ph_determinants/life_style/nutrition/documents/ev20081028_wp_en.pdf (acessado em 23/Jul/2014).
ec.europa.eu/health/ph_determinants/life... . In Europe, numerous public-private partnerships in the field of health have been leveraged to face the phenomenon of overweight and obesity, aiming to revise consumption habits, as well as reduce components of ultra-processed food products ⁴²42. Borch A, Roos G. Public private partnerships fighting obesity in Europe. Anthropology of Food 2012; S7. http://aof.revues.org/7286.
http://aof.revues.org/7286... . The “flexible regulation” of the Agreements presumably softens the harmful impacts to public health and, simultaneously, benefits the market, ensuring an extended time for adjustments, without any consequences for non-compliance ⁴³43. Majone G. Do estado positivo ao estado regulador: causas e consequências da mudança no modo de governança. Regulação econômica e democracia: o debate europeu. São Paulo: Editora Singular; 2006.. However, this type of “flexibility” can result in excessive concession by the State to corporations as previously addressed by the CS1, PS5 and PS6, and in the commitment to the effective defense of public health interests - healthy products and reduction of NCDs.

The Brazilian Ministry of Health and ANVISA praise the Agreements for the sodium reduction as innovative, legitimate and transparent ⁴⁴44. Nilson EAF, Jaime PC, Resende DO. Iniciativas desenvolvidas no Brasil para a redução do teor de sódio em alimentos processados. Rev Panam Salud Pública 2012; 34:287-92.. Between extolling this practice and discarding its possible merits, considerations are necessary: firstly, the ideological nature of this measure, demonstrated by the waiver of the State'’s prerogatives in establishing rules for the market and by the option of flexible and long-lasting Agreements; secondly, weakening of the social control arenas for not involving the civil society representations in the discussions held in the public sphere.

In contrast to signifying advances in food control, being acts of understanding as pointed out by the RS subject or recognition of the industrial sector as a partner, as mentioned by the PS subject, the Agreements represent political-institutional limitations for the exercise of the health surveillance, in particular, in three aspects: (a) they create precedents to avoid regulation in order to reduce the levels of critical nutrients, which is a fundamental action to protect health; (b) they generate situations of institutional incoherence, since compliance with the Agreements cannot be monitored, and (c) they neglect the civil society role in the process of arranging public health measures.

In view of the driving force of the market, the defense of the common good is primarily in the hands of organized civil society, especially that which reaffirms the regulatory character of the State. One of the central qualities of the “good governance” of any initiative is the representation and participation in decision-making of those affected by the exercise of power ⁴⁵45. Hawkes C, Buse K. Public health sector and food industry interaction: it's time to clarify the term 'partnership' and be honest about underlying interests. Eur J Public Health 2011; 21:400-1.. The forced absence of civil society breaks with the practices provided in the 1988 Brazilian Federal Constitution of creating public spaces for intervention and for the expression of participatory democracy. Civil society can act as a distinguished member in the defense of the public interest and the primacy of health issues, and, in this case, it can contribute to the approval of impacting targets for the reduction of risk nutrients in the ultra-processed food products.

In a distorted way, although regulation is usually perceived as an authoritarian measure, it is opportune and necessary to prevent increasing health risks and it also provides opportunities for the potential PNAN 2012 guideline implementation ¹⁹19. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2012..

Conclusion

Regulating health risks associated with ultra-processed food products to avoid rising NCD rates is a challenging task for governments, as it implies dealing with the expressive power of food corporations and the limitations of national and international health agencies, in the face of an active civil society. Through the use of participatory strategies and practices, health regulation tries to manage the set of influences and divergent interests with the key subjects, in order to promote a fair, legitimate and extensive result, which is primarily oriented to guarantee healthy products without neglecting market interests.

In contrast to the regulation, the Agreements ¹⁵15. Ministério da Saúde. Trata sobre o Acordo do Ministério da Saúde com a Associação Brasileira de Indústrias de Alimentos para redução dos teores de sódio, gorduras e açúcares dos alimentos. http://189.28.128.100/nutricao/docs/geral/acordo_social_reducao_teores_sodio_acucar_gorduras.pdf (acessado em 15/Mar/2012).
http://189.28.128.100/nutricao/docs/gera... disregard the provisions of PNAN 2012 and represent a setback in view of their particular characteristics - malleability, restricted social participation, limited scope, with no provision for sanctions and penalties, and long-lasting - whose results will slowly interfere in the nutritional improvement of food products.

Acknowledgments

To Graduate Studies Coordinating Board (CAPES) for their support for the achievement of a sandwich doctorate at the Universidad Rovira i Vigili (Tarragona/Spain). To doctorate co-supervisor Professor Dr. Renata Monteiro from the Nutrition Department, Faculty of Health Sciences, University of Brasília. This article reports part of the thesis “Risks Emerging from Food: Regulation, Conflicts and Tensions”. To Patrick Dahlet, visiting professor at the Federal University of Minas Gerais, for his support in Discourse Analysis techniques.

References

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