Discussion

Findings were captured in a conceptual framework that confirms previous knowledge of two different ways of approaching healthy eating: a biomedical model and a social sciences-oriented approach⁽ Reference Walt ^{18 ,} Reference Nettleton ^{19 )}. On the one hand, disagreeing with the proposals made in the new guide, were the food industry and food organizations/unions, some bodies and associations related to nutrition, and some academics and individuals. The arguments used by this group to justify their interests showed a tendency to medicalize food consumption, supported by the authority of scientific evidence and a discourse around risk. They also stressed individuals’ responsibility for their own food choices. On the other side of the discussion were the organizations related to food and nutrition security, non-profit organizations, government, as well as the other academics and individuals. Their views reflected the idea of a more integrated nutrition, giving more value to the social and cultural dimensions of eating, to the multiplicity of knowledge, to the promotion of more sustainable food systems and viewing people more as citizens, with co-responsibility for their own eating habits.

The medicalization argument was used by the participants especially to question the classification of foods based on the extent and purpose of their processing, and the qualitative approach proposed by the new guide. The medicalization of nutritional sciences views food as something primarily to prevent disease and promote health, giving food the characteristics of medication, and devalues the symbolic, social and cultural act of eating⁽ Reference Walt ^{18 –} Reference Mayes ^{22 )}. This approach to food and health places little value on the relationship between food and the ways in which it is processed, nor on the cultural contexts in which it is eaten⁽ Reference Scrinis ^{4 )}. The practical experience of growing, preparing and eating food is reduced to the nutrients it contains and their impact on health⁽ Reference Scrinis ^{4 )}. Another implication of medicalization is that it produces professionals who are extremely specialized in a particular subject, concentrating the power of knowledge in the hands of a few and making it too technical for the average person⁽ Reference Beardsworth and Keil ^{23 )}. In ‘nutritionism’⁽ Reference Scrinis ^{4 )}, or ‘nutritional scientism’⁽ Reference Mayes ^{22 )}, authority for eating is transferred from individuals to ‘experts’, which devalues popular knowledge and people’s traditional food culture⁽ Reference Gracia-Arnaiz ^{24 )}. Contrary to the medicalization of food consumption, the new guide uses a qualitative approach to make communication with the population more accessible. This is in line with the opinions of Beardsworth and Keil⁽ Reference Beardsworth and Keil ^{23 )}, that ‘one has to consider limits on the application of rationalization to health and diet, as in the mundane routine of people, they are not equipped with devices to measure their food “consumption”’.

Participants in the consultation also made repeated use of the imperative of scientific evidence to justify their arguments. Although the use of science as a way of supporting positions is of course common in academia, it was observed that the food industry and their representatives also used science to defend their interests during the public consultation. Some key points should be taken into account when ‘speaking in the name of science’ in debates on policies and programmes in the area of food and nutrition. First, the existence of scientific evidence is not the only and obligatory principle in the implementation of policies⁽ Reference Beardsworth and Keil ^{23 )}; furthermore, in the words of Lang et al.⁽ Reference Lang, Barling and Caraher ^{16 )}, ‘sometimes the world cannot wait for evidence’ and it may take a significantly long time to obtain the ‘perfect’ scientific evidence to support a proposed policy. Some evidence may also be impossible to obtain, as conducting randomized studies to verify the risk of ultra-processed foods on human health would be considered unethical. Second, like the medicalization argument, the scientific argument facilitates the perpetuation of asymmetric power relations between experts and the general population⁽ Reference Beardsworth and Keil ^{23 ,} Reference Castoriadis and Cohn-Bendit ^{25 )}. As was observed in this consultation, disproportionate value is placed on clinical and epidemiological science over other forms of knowledge, thus reducing the cultural dimensions of food and encouraging the population to be dependent on health professionals⁽ Reference Beardsworth and Keil ^{23 )}. Another important implication of the scientific argument is the general belief that science is both objective and neutral, masking its role in the perpetuation of political and economic interests⁽ Reference Castoriadis and Cohn-Bendit ^{25 )}. An example of this is the evidence generated from scientific research funded by the food industry and the ethical questions raised by the results. Conducting scientific research usually requires considerable financial investment, which facilitates the establishment of partnerships between researchers and private institutions. This conflict of interest is a threat to the neutrality of scientific research; a study conducted by Lesser et al.⁽ Reference Lesser, Ebbeling and Goozner ^{26 )}, which investigated the influence of research funding by the food industry on scientific studies on the health effects of milk, juices and soft drinks, found that the chance of a study presenting results favourable its sponsors was eight times higher when funded by the food industry than when funded in other ways. Other factors that affect this partnership between scientists and the food industry range from the way in which the study is designed, to contracts which specify that authorization for results to be released will be given only when they are favourable to the food industry⁽ Reference Katan ^{27 )}. According to Barnoya and Nestle⁽ Reference Barnoya and Nestle ^{28 )}, Latin America is especially vulnerable to conflicts of interest related to nutritional science, and the authors point out the need to identify, limit and manage (or eliminate) the apparent and real conflicts until a more definitive solution to the question can be found. Both at national and international level, the food industry is always well represented in arenas dealing with laws, policies and programmes in the area of food and nutrition, and the asymmetrical power relationships that are noticeable in the discussions are evidence of the power of multinational food industries⁽ Reference Lang, Barling and Caraher ^{16 ,} Reference Lang and Heasman ^{29 )}.

The risk discourse was an argument widely used during the consultation and focused mainly on risks related to the body (e.g. risk of obesity, microbiological contamination or dehydration). This emphasis reflected a feeling that the act of eating or not eating certain nutrients/foods can pose a health risk and for this reason should be quantified, measured, monitored and self-managed (i.e. by establishing food portions, making explicit the quantities of sugar/salt/fat considered to be a disease risk and the amount of water that should be consumed). The superficiality of the risk discourse as a way of promoting healthy eating means that it can be a less effective way of communicating with the population. The notion of risk undermines the concept of healthy eating, creates anxiety, doubt and confusion, disconnects people from their food culture and makes it difficult to trust health information, as food risks can be constantly revised or even reversed (e.g. eggs and cholesterol)⁽ Reference Azevedo ^{30 )}. The risk discourse makes us ‘virtual victims’⁽ Reference Vaz ^{31 )} of probabilistic events related to health, often giving health professionals a normative, moralizing and hyper-preventive attitude to people’s individual behaviour⁽ Reference Castiel ^{32 )}. In addition, the risk discourse reinforces the unequal power relationship between professionals and the population by emphasizing scientific knowledge of the risks at the expense of the subjective ways in which risk is interpreted by individuals⁽ Reference Beardsworth and Keil ^{23 )}. Special attention should be paid to the risk discourse when it classifies as a risk traditional culinary preparations that may have cultural value for the population, which was the case in the public consultation analysed here, as this can have an iatrogenic and counterproductive effect on public health interventions⁽ Reference Walt ^{18 )}. Risk is something that is inherent in human life⁽ Reference La Mendola ^{33 )}, so it is important to be able to identify the risks that can and should be avoided, and to remember that the priority should be to examine the social and economic contexts in which these risks are most prevalent⁽ Reference Caponi ^{34 )}.

Participants who advocated for the inclusion of vegetarianism in the guide approached the question of risk in its broader sense, going beyond individual risk centred on the body by discussing the environmental risk from the production of processed foods and the importance of a healthy food system. The opinions of these participants questioning the current food system reflect the position taken by Beck⁽ Reference Giddens, Beck and Lash ^{35 )} with regard to ‘the risk society’ and ‘reflexive modernization’. According to this author, the social, political, economic and individual risks posed by industrialized society (such as environmental issues) have become a threat to civilization and need to be self-addressed and self-transformed by us all (what the author calls ‘reflexive modernization’); the knowledge of experts is questioned and new views gain credence (for example, the vegetarian views in this consultation). The question of the environmental impact of the food system requires more incisive, intersectoral action, encompassing all forms of knowledge and all members of society⁽ Reference Azevedo and Pelicioni ^{36 )}.

The food industry is a key player in addressing the environmental risks to which we are exposed and this issue has long been discussed within the industry itself, resulting in research into socially responsible technologies and actions that may mitigate negative environmental effects⁽ Reference Nestle ^{37 )}. However, in the public sphere, just as with the issue of chronic non-communicable diseases, environmental problems are treated more as threats than opportunities, and counteractive measures are limited by the need to remain financially competitive and to generate profit⁽ Reference Lang, Barling and Caraher ^{16 )}. This attitude can be observed in the consultation analysis, with those representing the food industry adopting a defensive position, denying the environmental problems related to food production or using the social responsibility argument (such as highlighting their policies to recycle packaging) to show that they are taking action on environmental issues. Another challenge to the development of environmentally sustainable systems is the intellectual division in the science of nutrition, which can be divided into three different areas: biomedical, social and environmental⁽ Reference Lang, Barling and Caraher ^{16 )}, divisions which were all evident in the consultation analysis. As these views represent different social and economic interests, the challenge is to reach a consensus in order to develop a fair food system and not simply to create new ideologies or new ecologically friendly food products⁽ Reference Lang, Barling and Caraher ^{16 )}. In addition to the food industry and nutrition professionals, non-governmental organizations and those linked to public interests also play a key role in environmental issues, by monitoring actions, educating and giving support to consumers, as well as reflecting their opinions⁽ Reference Lang and Heasman ^{29 )}.

With regard to Theme 2, Different Perceptions about the Role and Need of Individuals, some participants (associations and organizations linked to nutrition) considered that individuals are largely responsible and free to make food choices, an argument traditionally used by the food industry⁽ Reference Nestle ^{38 )}. Another argument along the same lines used by the food industry was that the market provides what consumers demand. First, this is a social myth, as it assumes a symmetrical power relationship between people and corporations⁽ Reference Lang, Barling and Caraher ^{16 )}; and second, this kind of argument reflects a neoliberal view of consumer society, in which actions and their consequences are the sole responsibility of the individual, thus diverting attention from more systemic questions such as social inequality, the constant influence of the environment on food choices, the interference of the food industry in science and nutrition information, etc.⁽ Reference Ferreira, Prado and Carvalho ^{20 ,} Reference Giesler and Veresiu ^{39 )}. This kind of message – that we are masters of our own destiny – leads to even more social individualization and increasingly prevents us from creating and implementing actions for the common good⁽ Reference Herman and Chomsky ^{40 )}. The statements made in the consultation regarding individuals as consumers are opposed to the concept of autonomy in health, which focuses on the co-responsibility of individuals for their health choices, and depends on external factors such as the economy, the political environment, the regulation of food advertising, food labelling with accurate information, etc.⁽ Reference Brownell, Kersh and Ludwig ^{41 ,} Reference Campos and Campos ^{42 )}. The definition of consumers for Lang et al.⁽ Reference Lang, Barling and Caraher ^{16 )} is also quite different from the neoliberal concept of the consumer adopted by some participants in this consultation. These authors use the term ‘food citizens’, viewing the population as able to actively pursue its rights and duties, and not simply as consumers of goods and services, for which non-governmental organizations play a fundamental role. In Brazil, the fight against hunger and the promotion of food and nutrition security have been part of the government agenda since 2003⁽ Reference Burlandy ^{43 )}, and the participation of members of the public in the formulation and implementation of federal policies has become increasingly important. Several government actions have been driven by partnerships with non-governmental organizations, helping to implement and strengthen programmes and policies in the area of food and nutrition, specifically with regard to malnutrition, obesity, the promotion of healthy eating, monitoring nutritional security, implementing intersectoral strategies and providing forums for the public to take part in policy-related discussions⁽ Reference Rocha, Jaime and Rea ^{44 )}. In the consultation analysis, the large number of participants who defended the interests of the population is a positive point that should be emphasized. Compared with the 2003 public consultation on mandatory food labelling⁽ Reference Davies and Jaime ^{45 )}, in which only 12 % of participants defended the interests of the population, in this consultation there was evidence of growing public participation in debates related to food and nutrition in Brazil. Although this group of participants tended to agree with the new food guide, they also criticized it for failing to include certain issues, or for not examining other issues in sufficient depth, such as pesticides, GMO and organic food, food advertising, and the lack of discussion related to existing nutrition and food policies in Brazil. These points are of particular importance to the food and nutrition agenda in Brazil, so it is understandable that the participants tried to use the new food guide as a platform to express their opinions and to call for new measures to be taken.

The qualitative analysis of public consultations in the development of food guides can be very useful for predicting how the implementation of the material will proceed and especially who may seek to undermine the implementation of the new guide. Counteractive measures of this kind have already been taken, for example the ‘Brazil Processed Food 2020’ project⁽ Reference Oliveira and Silva-Amparo ^{46 )}, which was created by organizations linked to the food industry to undermine the new food guide. Another example was an open letter posted online by an organization linked to nutrition academics, which questioned the scientific basis of applying the NOVA classification in the new guide. Countries such as the USA, which have also used this form of participation in the construction of their food guide⁽ Reference Millen, Abrams and Adams-Campbell ^{47 )}, may benefit from this type of research as well, as it provides insight into who the actors are and what kind of discourse takes place behind the scenes in the development of food and nutrition policies. This could be a useful example for organizations linked to public interests to plan mass-media campaigns that are more effective in raising awareness among the population and to pressure the government to ensure that the message of the new guide successfully reaches the population.

The process of open consultation conducted in Brazil to develop the new guide can also offer important lessons to other countries in Latin America which have developed and implemented their own food guides. Including a variety of actors in the discussion from the very start, such as organizations linked to public interests, is a form of virtuous cycle. It not only helps to attenuate the asymmetry of power that forms the background to discussions related to health and nutrition, but also helps those organizations to be more involved during the implementation of food guides, encouraging them to contribute to the success of the material. In Mexico⁽ Reference Pérez-Escamilla ^{48 )}, there has recently been a great deal of scientific debate and consultation of experts to develop a new Mexican food guide, and very important points related to public health nutrition were addressed. Unfortunately, this country did not conduct an open consultation like the one in Brazil and this lack of involvement by the population and/or public organizations could represent a threat to the successful implementation of the food guide.

A strong point of the current study was the originality of the theme, which on the one hand explores the conflicts of interest when designing and implementing food and nutrition policies related to the application of a food processing-based classification system, and on the other hand analyses the participation of civil society in the development of a food guide, which to the best of our knowledge has not been explored in any other scientific publication.

A limitation of the study is the type of data used (documents), which does not always allow for all the forms of communication used by the participants to be recorded, such as body language and facial expression. However, the authors believe that the large number of contributions made by stakeholders to the public consultation has provided abundant information for the debate proposed in this article. Another limiting factor is that two of the authors participated directly and indirectly in designing the food guide that was submitted for consultation. However, to mitigate possible analytical bias, these authors did not participate in the data coding or the identification of themes.