[interview: Carlos Monteiro and Patrícia Jaime] who devours the Brazilian dietary guidelines?
world-reference in research on epidemiological nutrition, Nupens – USP created the document, which remains untouched in the ruins of Brazil's public policies on food security
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Brazil has gone back decades in the debate on "real food" in Bolsonaro's government. If at the end of the 2010s the Dietary Guidelines for the Brazilian Population, published in 2014, was on subtext, after three and a half years we need to reaffirm the document as the starting point of the public debate to avoid fallacious arguments.
If the consumption rate of ultra-processed products in Brazil had not risen, we could even say that the Guide fulfills its function and, therefore, bringing it to the debate so often would be redundant. The next step would be to consolidate its role in the foundation of public policies to strengthen Brazilian food and nutrition security; but never loosen the understanding of what food is, equating ultra-processed products with complete meals.
Unable to tear up the Guide, Bolsonaro destroyed the game board, starting with the extinction of the National Food Security Council (CONSEA)1 on the first day of his mandate. Two months later, the Minister of Agriculture, Livestock and Supply, Tereza Cristina, announced the sale of public warehouses (of 180 units, 27 were in the first year of government and put up for sale) in February 2019, which implies, among other consequences, the decrease in storage capacity for rice, beans, corn, manioc flour and coffee, and the prices' regulation for the final consumer. These are the main ingredients in a Brazilian pantry, and the decrease in rice storage by the State caused 2021 the rise in rice prices and a controversy over the sale of broken rice.
The steps towards food insecurity began in the Temer government (vice-president of Dilma Rousseff, who took office in August 2016 after the coup so-called an impeachment), with the progressive reduction of the budget allocated to the Food Acquisition Program (PAA)2, reaching to reduce by 77.3% from 2014 to 2020, as well as the Cisterns Program, which had its worst performance in 2019, with an 80% drop in the number of cisterns built in five years. A weakened PAA and National School Feeding Program (PNAE)3 result in rural poverty as family farmers and smallholders lose sales channels. As there is no vacuum, the food industry, whose raw material comes from commodities, is who takes the place of vegetables, greens, bread, jams, and dairy products from small producers. The result: ultra-processed products from the industry replacing food that could come from the countryside.
The Dietary Guidelines for the Brazilian Population recommends a diet based on in natura or minimally processed foods (fresh, such as fruits, vegetables, and greens; or that undergo processing, such as rice, beans, nuts), culinary ingredients (everything that is added in food preparation, such as salt, sugar, oil, vinegar, etc.), and processed foods (which go through some process, such as cheeses, bread, pickles, etc.), avoiding the consumption of ultra-processed, which are industrial formulations that take only part of culinary ingredients, and are usually with higher salt, sugar and fat content than any other food.
Ultra-processed products can be ready-to-eat – snacks, cookies, biscuits, or loaves of bread –, or that need to be "finished" by the consumers, such as instant noodles, sausages, and frozen food (nuggets, hamburger, lasagna). In common, they are all hyper-palatable: they produce immediate pleasure, being recognized by the palate as "tasty". Nevertheless, they are non-food. Ultra-processed products are high in calories, but their nutrients and vitamins, even when added to "enrich" your formula, are not absorbed by our bodies in the same way as in fresh food. When in doubt whether a product is ultra-processed or not, pay attention to the packaging and the speech. Ultra-processed products have a great marketing campaign to promote their consumption – something that a head of broccoli or a bunch of cabbage never had.
Brazilians have almost 20% of their calories from ultra-processed foods. In Canada and the United States, this number approaches 50%. A population that eats poorly is a population that gets sick. In a country with a public health system4 like Brazil, this means burdening the sector with problems that can be avoided through investment in food and nutrition security and food education. The tool exists and we had a series of public policies that kick-started the promotion of food based on in natura foods. What we have now is an even worse scenario than the famine of the 1990s, when ultra-processed foods were still not as affordable as they are today. 33 million people going hungry in Brazil today, "thanks" to the disarticulation and exclusion of programs aimed at food security – Nexo Jornal provided an excellent summary of how we went from one scenario of hunger to another in 30 years.
The Bolsonaro government tried to amend the Guide, claiming that the classification by level of food processing was confusing. The argument is the same used by industry associations: that the guidelines are too rigid and make it impossible to feed the people, pretending that there are no tax exemptions for their large industries and the lack of regulations for their sector. Added to this, there is a lack of assistance and encouragement for those who produce real food. To give an overview, I recommend reading the interview with agronomist Nayla Almeida and article #11 | tossing cheeses into the litter: what hampers small farmers in Brazil to thrive.
The Guide remains in disrepair, still untouched, containing guidelines that cannot be followed by the public structure because there is nowhere to enforce them.
In this context of food shortages due to negligence by the State and academic papers that present increasingly robust evidence that the consumption of ultra-processed foods is linked to the increase in non-communicable chronic diseases, I requested an interview with researcher Carlos Monteiro, who coordinates the Center for Epidemiological Research in Nutrition and Health (Nupens), from the University of São Paulo (USP). Carlos suggested that the interview be done with Patrícia Jaime, professor at the Department of Nutrition at the Faculty of Public Health, scientific vice-coordinator of Nupens, and the Josué de Castro Chair of Healthy and Sustainable Food Systems. We did it by email, with Patrícia's participation especially in the last question, on public policies.
Created in 1990, Nupens is an interdisciplinary structure at USP, integrating researchers from different areas, such as economics, medicine, and nutrition, as well as other universities, such as the Federal de Minas Gerais (UFMG) and the State of Rio de Janeiro (UERJ), and other countries. Its focus is to produce knowledge about public health and nutrition, develop research methods to study how Brazilians eat and produce analyzes and diagnoses to guide public policies.
The Center is at the forefront of epidemiological scientific research in nutrition and health. In 2010, Nupens published the Nova classification system, which updated the paradigm in force at the time, the food pyramid. In 2014, the Dietary Guidelines for the Brazilian Population, developed by Nupens using the Nova classification, was published by the Ministry of Health. The Guide is a document endorsed as an example to be followed by the Food and Agriculture Organization of the United Nations, the World Health Organization, and Unicef, and served as a model for the dietary guides of Canada, France, Uruguay, Peru, and Ecuador.
Monteiro was listed four times as one of the most influential scientists in the world by the British consultancy Clarivate Analytics, and from Nupens come studies such as the one by Maria Laura Louzada, which links the increase in the prevalence of obesity in Brazil to the increase in the consumption of ultra-processed foods. "In recent years, nutritional epidemiology has entered a new stage of research, analyzing the relationship between ultra-processed foods and diseases that, initially, would not be so directly related to food. One of these new lines of research addresses mental health disorders. Some articles have already associated a higher consumption of ultra-processed foods with a higher risk of developing depression, for example. These are indications of new harmful effects of these foods, but which still need to be investigated in detail so that a clear association can be established", wrote Carlos Monteiro and Patrícia Jaime.
Below are the main excerpts from the email interview with the two researchers:
The Dietary Guidelines for the Brazilian Population was built on the Nova classification system, which replaced the food pyramid. While the pyramid categorizes by nutrient type, the Nova classification considers the level of food processing. When and how did you see the need to change the categorization type for the processing level?
During most of the last century, the biggest nutritional problem registered in Brazil was malnutrition. The most vulnerable populations in the country did not have adequate consumption of important nutrients such as proteins, vitamins, and minerals, which led to diseases such as beriberi (vitamin B1 deficiency) or pellagra (vitamin B3 deficiency), among others. In this context, the food pyramid made sense: it organized food by type of nutrient, informing the population about the sources of carbohydrates, fats, proteins, vitamins, and minerals.
Since the 1990s, however, nutritional epidemiology has noticed a reduction in cases of malnutrition and an increase in the prevalence of chronic diseases, such as diabetes and hypertension. This is what we call the epidemiological transition. At the same time, data on food purchases by the Brazilian population indicated a drop in the purchase of items used for cooking (oil, salt, sugar) and an increase in the purchase of semi-ready or ready-to-eat foods – in general, ultra-processed. This process is called nutritional transition. With this new context, the food pyramid lost its meaning, since it placed foods such as brown rice and, for example, potato chips in the same category ("carbohydrates").
Thinking about the nutritional transition, we realized that it was necessary to guide the population from a new logic, which is that of food processing, through the Nova classification. Nova was created just over ten years ago and had its impact amplified by the Dietary Guidelines for the Brazilian Population, launched in 2014.
We are experiencing a food crisis that resembles the one in the 1990s when 32 million Brazilians were starving. Currently, there are 33 million. How to talk about nutritionally adequate food at a time when access to food is difficult and restricted? How can we begin to "fix" this scenario?
In situations of increasing food insecurity, as we see today in Brazil, it is really difficult to talk about adequate and healthy food. Much of the population faces barriers in accessing fresh food – and lately, the biggest one has been the rising price of basic items such as rice, beans, oil, coffee, and vegetables.
It is necessary to remember, however, that less than ten years ago Brazil celebrated having left the UN Hunger Map, which was only possible with a broad set of public policies on food and nutrition. These are initiatives that range from income transfer programs to actions by food and nutrition security councils.
We learned that hunger is fought by public policies, and this is certainly the best way to fix this scenario.
Nutritional epidemiology plays a fundamental role in this context, which is to generate data and analysis to guide the construction of these policies and decision-making through government agents.
Nupens is a world reference in research and two years ago launched NutriNet, which aims to monitor the dietary pattern of 200,000 Brazilians. How many Brazilians have participated so far? Are there preliminary results or hypotheses that researchers are considering at this early stage?
Today, NutriNet Brazil has just over 100,000 participants. They are volunteers from all regions of the country and have different social strata and educational levels. To participate, you just need to be over 18 years old, be a resident of Brazil and answer questionnaires sent by email every three months. Entries can be made by the site.
Later this year, the first results of the survey began to be published. The idea of the study is to monitor the diet of the Brazilian population, understanding their different eating habits, their relationships with demographic profiles, and, above all, their associations with different health outcomes.
What are the research topics on ultra-processed products that are on the horizon for Nupens?
The next Nupens' research should involve precisely the data analysis from the NutriNet Brasil cohort. It will be possible to observe the associations between the consumption of ultra-processed foods and the occurrence of diseases of great frequency in Brazil prospectively – that is, we collect information at the time of exposure and follow the evolution of the participants for a long period. NutriNet also has relatively short periods between when food is consumed and the onset of illness. Obesity, diabetes, dyslipidemia, and arterial hypertension are some of the conditions that we will investigate.
Recent studies have provided robust evidence linking the consumption of ultra-processed foods to the increase in non-communicable chronic diseases, such as obesity, diabetes, and metabolic syndrome in different countries. The Dietary Guidelines for the Brazilian Population is internationally praised and served as a basis for guides from other countries, however, in Brazil the structures that would allow the Guide to be put into practice were dismantled, such as CONSEA and PAA. What role does the Dietary Guidelines for the Brazilian Population play when the structure that would put the Guide's recommendations into practice is extinguished and weakened?
It is a fact that it is through public programs and policies that the guidelines of the Guide are put into practice. A classic example is the National School Feeding Program (PNAE), which limits the supply of ultra-processed foods and expands the supply of fresh and minimally processed foods to public school students across the country.
Although we have witnessed the dismantling of several public policies on food and nutrition, the Guide, which is a document of the Ministry of Health, remains an official source of guidance for the adequate and healthy diet of the Brazilian population. In 2020, the attempt to amend the Guide generated a broad movement of defense on the part of the population, mainly by health professionals, and with good press coverage. This showed how the precepts of the document have been absorbed by the public.
Recently, researchers from Nupens published five fascicles dedicated to different populations (adults, elderly, pregnant women, children, and adolescents) that show health professionals how to apply the guidelines from the Dietary Guidelines for the Brazilian Population in individual consultations within the scope of primary health care in SUS. This is another role played by the Guide in Brazil.
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The council was a structure made up of two-thirds of participants from civil society and one-third from the government. Its main attribution was to integrate society in the formulation, monitoring, and evaluation of public policies on food and nutrition security.
PAA is a public policy started in 2003 to strengthen familiar agriculture and enhance food security on many fronts. It was renamed and reshaped to Programa Alimenta Brasil in 2021. Roughly speaking, the State is responsible for buying ingredients, products, and groceries from familiar farmers and destining them to public institutions such as hospitals, schools, nurseries, prisons, military quarters, etc; while also building regulatory food stocks. Since 2018, funds allocated to the program have fallen, reaching a drop of 95% from 2012 to 2019.
The program is responsible for transferring funds from the Union to states and municipalities for the purchase of school meals for children, elementary, high school, and youth and adult education. In its legislation, it provides that at least 30% of the budget be used to purchase products and food from family farming, with priority given to agrarian reform settlements, traditional indigenous communities, and quilombolas as suppliers.
The Unified Health Service (SUS) was created in Brazil in 1989, after the 1988 Constitution, inspired by the United Kingdom National Health Service. It is a network that encompasses both public health actions and services, such as vaccination campaigns, food inspection, medication registration, and free outpatient and hospital care for the population, from basic health care to simple and highly complex procedures, such as organ transplants.