Discussion

A conceptual framework was developed to implement FBDG, keeping the materials published by FAO as theoretical references, in addition to scientific articles. Although the field of public health nutrition has been discussing conceptual frameworks for the nutrition science implementation, as far as we know, none has proposed a conceptual framework for specific implementation of FBDG^{(Reference Tumilowicz, Ruel and Pelto66,Reference Sarma, D’este and Ahmed67)} . Adopted as a study case of the proposed model, the detailed process adopted in Brazil in each of the steps were analysed and described.

Given their instructive nature, several authors highlight the importance of FBDG as a broad national strategy for the promotion of healthy eating, with the commitment of several sectors^{(Reference Fischer and Garnett10,Reference Smitasiri and Uauy25,Reference Keller and Lang28,Reference Hop, Van and Thanh30,Reference Bechthold, Boeing and Tetens39,Reference Stockley40,Reference Machín, Aschemann-Witzel and Patiño42,Reference Olivares, Zacarías and González43,Reference Mozaffarian, Angell and Lang68)} . According to Tumilowicz^{(Reference Tumilowicz, Ruel and Pelto66)}, successful implementation requires a culture of inquiry, evaluation, learning and response among implementers; an action-oriented mission among the research partners; continuity of funding for implementation research and resolving inherent tensions between program implementation, research and society sectors. The literature review showed that some regional frameworks recommend countries to build their own integrated and broad national food and nutrition policy, from which FBDG must be part^{(Reference Bechthold, Boeing and Tetens39,Reference Stockley40)} .

Although the importance of FBDG implementation strategies being linked to plans, programs and public policies in an intersectoral way, this link is not explicit for most countries^{(Reference Olivares, Zacarías and González43)}. This gap decreases the potential for disseminating the recommendations, in addition to weakening the link with specific policy interventions and becoming vulnerable to the influence of specific interest groups⁽¹¹⁾. An exception on this regard is the USA, which clearly and systematically adopts the Dietary Guidelines for American as the basis for all food policies in the country (school, hospital, military, etc). In Brazil, although the link was not previously explicit, the existence of a previous set of policies to promote healthy eating was important in all stages of the implementation of the DGBP.

Some Brazilian’s legal frameworks operated as a driving force for the paradigm shift in the concept of healthy eating, which was consolidated in the recommendations. Namely, the Organic Law on Food and Nutrition Security of 2006 was the first to integrate health promotion, cultural diversity and environmental, cultural, economic and social sustainability in a single concept. National Food and Nutrition Security System, an intersectoral policy integrator system, was created through LOSAN to ensure multi-dimensional food and nutrition security⁽⁶⁹⁾. Furthermore, in 2010, the human right to adequate food was included in the federal constitution⁽⁵⁵⁾ and the State was imposed with a duty to guarantee this right.

Regarding FBDG’s preparation, the participation of different public sectors (such as health, education, agriculture, etc) and representatives of civil society, academia and private sector contribute to recommendations’ consistency, viability and popular comprehension^{(1,Reference Tee35,Reference Coats, Bernstein and Dodge37)} . However, some authors argue that the economic power and potential conflicts of interest linked to the private sector participation must be acknowledged^{(Reference Fischer and Garnett10,Reference Sirichakwal, Sranacharoenpong and Tontisirin31,Reference Olivares, Zacarías and González43)} . Accordingly, their participation must be conditioned by clear rules established by public authorities, determining their limits^{(Reference Fischer and Garnett10,Reference Mozaffarian, Angell and Lang68)} . The DGBP preparation was internationally recognised, as multiple stakeholders participated and its conduct was transparent^{(Reference Fischer and Garnett10,11)} .

In DGBP’s public consultation, representatives of the food industry adopted a strong opposition to the NOVA classification, denying the environmental impact of the food system, and defending individual freedom^{(Reference Davies, Moubarac and Medeiros70)}. This reaction is consistent with the fact that the DGBP identifies the hegemonic nature of the food system, which is dominated precisely by the private sector, as the root cause of a poor diet^{(Reference Davies, Moubarac and Medeiros70)}. The analysis of these contributions by the Ministry of Health was guided by principles that facilitated the entire creation of the recommendations, defined mainly within the expanded concept of healthy eating and the human right to adequate food.

Despite the resistance, adopting the NOVA classification has been shown increasingly benefit not only to the epidemiological point of view—considering the growing body of evidence regarding the association between ultra-processed food consumption and poor health outcomes—but also to the food culture perspective—since it isolates this food group, which tends to replace traditional foods^{(Reference da Oliveira and Silva-Amparo13,Reference Louzada, Canella and Jaime71)} . By recommending that fresh and minimally processed foods constitute a diet’s basis, the DGBP provides examples of traditional meals consumed in various regions of the country⁽²¹⁾. Therefore, NOVA is an appropriate tool to guide the recommendations based on dietary patterns that reflect the local characteristics^{(Reference Tapsell, Neale and Satija24)}.

Brazil did not create an icon to communicate the recommendations, which is justified both by NOVA’s adoption and renunciation of the indication of quantities or portions’ numbers. Although widely adopted by several countries^{(Reference Herforth, Arimond and Álvarez-Sánchez72)}, there seems to be no consensus in the literature regarding the contribution of icons to better communicate recommendations. According to Coats et al. ^{(Reference Barbosa, Granhen and Colares27)}, the elaboration of icons which include culturally recognised elements can facilitate the creation of a first sociocultural tie with the population. However, Oliveira et al. ^{(Reference da Oliveira, Arceño and de Sato41)} point out that icons tend to summarise the diversity of dietary practices in a single national identity, potentially resulting in negligence of certain forms of knowledge and culturally established practices in some specific groups of the population.

The conceptual framework highlights the importance of a widespread dissemination of educational materials and public policies⁽¹⁷⁾. In Brazil, a wide diversity of educational materials — such as videos, folders and a pocket version— aimed at different audiences and contexts, such as primary health care services, schools and the general population was elaborated through agreements between the Ministry of Health and public teaching and research institutions.

The predominance of educational measures over the promotion of public policies can be explained by the fact that the paradigm shift introduced by the DGBP required broad dissemination of recommendations. Furthermore, the role of FBDG as educational materials has been stimulated by FAO since they were proposed in 1998⁽¹⁾, unlike the promotion of public policies, which began to gain prominence only in more recent publications^{(Reference Fischer and Garnett10,11,16)} . According to a report published in 2016, most countries have not established public policies for FBDG yet⁽¹¹⁾.

Moreover, educational measures are easier to implement when compared to promotion or reformulation of public policies, since they tend to be less susceptible to private groups’ lobbying⁽¹¹⁾. However, public policies, although less numerous in the Brazilian case, have a higher potential impact. Aligning the national school feeding program with the DGBP recommendations, for instance, can potentially reach more than 40 million 74 people daily, corresponding to approximately 1/5 of the Brazilian population.

The literature reviews found that many countries spent significant efforts on the development of FBDG but did not draw up evaluation plans⁽¹¹⁾. Some countries conducted partial assessments through population-based food consumption surveys; however, these questionnaires could not ascertain what dietary changes could be attributed to the FBDG⁽¹¹⁾.

Only impact indicators were foreseen in the DGBP implementation plan, which is related to the strong Brazilian tradition with national surveys. The last report (2017–2018) of the Household Budget Survey shows that after the publication of the DGBP, there was a slowdown in the increasing trend of the share of ultra-processed foods in the total household food purchase⁽⁷³⁾. This indicator reveals DGBP’s potential impact in resisting the growing market expansion of ultra-processed products in developing countries^{(Reference Vandevijvere, Jaacks and Monteiro74)}. NOVA-based food consumption screeners have also been included in recent editions of other population-based surveys; however, these cannot be compared to periods preceding DGBP’s publication.

Although not foreseen in the implementation plan, in its last edition (2018), another traditional survey evaluating primary health care services in Brazil included questions regarding DGPB use by health professionals in their professional practices⁽⁶⁵⁾. About 85 % of the multidisciplinary teams of primary care reported their use of the DGBP.⁽⁶⁵⁾ Although this new indicator cannot be compared with other periods, it is a relevant process indicator, since several DGBP implementational efforts targeted the primary health care. Furthermore, it is also important since 60 % of Brazilian’s households are registered in the Family Health Strategy (national primary health care strategy), which is a wide coverage⁽⁷⁵⁾.

One limitation of the Brazilian implementation analysis in this study is the exclusion of measures carried out by local authorities (states and municipalities). Regarding public policies, for example, one Brazilian state regulated the supply of food in canteens of public and private schools based on the DGBP. Spontaneous initiatives from other public or private institutions, such as professional councils or universities, and media influencers which play an important role, were also not included. Although our method could not reveal the exact extent of implementation throughout Brazil, it highlighted the National government’s role, which is the main body responsible for implementing and inducing local measures.

Although educational actions have predominated, the DGBP’s recommendations were included in the National School Feeding Program, the largest national food program. Beyond that, both educational and policy measures worked in a complementary way, optimising the implementation of the recommendations in key contexts, such as education and health services. However, it was noted that the absence of sectors such as Ministries of Agriculture and the Environment, whose commitment in the implementation would be essential to consolidate the recommendations related to environmental sustainability. In addition to promoting greater intersectoral cooperation, it is also important to adopt process indicators already in the implementation plan.

The DGBP is recognised as one of the emblematic examples of a virtuous cycle of progressively ensuring the human right to adequate food, which has been underway in Brazil for more than two decades. However, the advances in the public health nutrition agenda observed during that period have been threatened for the last years due to a political crisis that results in President Dilma Rouseff impeachment and the election of a conservative and neoliberal president. As one of his first government measures, at the beginning of 2019, the President Jair Bolsonaro extinguished the National Council of Food and Nutritional Security, which meant a great loss for National Food and Nutrition Security System, since National Council of Food and Nutritional Security was responsible for bringing society’s priorities on food and nutritional security to the government agenda^{(Reference Castro76)}.

Besides, in 2020, the DGBP was directly attacked through a technical note from the Ministry of Agriculture addressed to the Ministry of Health calling for an urgent revision. The document claimed especially to a change in the recommendation to avoid ultra-processed foods, ignoring the strong evidence of its association with obesity and many chronic diseases. The energic reaction of the civil society and institutions from the nutrition field, as well as the visible poor technical quality of the technical note, forced a retreat from the Ministry of Agriculture^{(Reference Monteiro and Jaime77)}.

Both episodes experienced in Brazil point that even in country with a strong public health system and well established food and nutrition public health policies, the consolidation of a FBDG is not immune to the political context, which reinforces the importance of strong democracies to guaranteeing the human right to adequate food. Further research could analyse the impact of that on the effectiveness of the implementation measures.

In sum, the implementation of the Brazilian FBDG presented advances in all elements of the conceptual framework. The main enablers in the process were both the pre-existent background of public health and healthy-eating policies and the engagement of different stakeholders through all the process—namely, government, civil society and academy. On the other hand, the barriers were the lack of commitment of some sectors and political inertia and discontinuity of politics with the change of government.

This analysis showed that the conceptual framework suited well to the Brazilian case. The analysis of other countries’ employed measures using this framework could not only bring other possible enablers and barriers of FBDG implementation but also improve this proposed conceptual framework.

The novelty of this study is the proposal of a conceptual framework, which can guide the elaboration of plans and analyses of the process of FBDG implementation by other countries and enables comparative analyses. This model frames FBDG implementation as part of a larger set of intersectoral public policies to promote healthy eating, which is significant, given these documents’ importance as promoters of healthy and sustainable food systems^{(Reference Willett, Rockström and Loken6–Reference Ridgway, Baker and Woods9)}.

Further, it also equates the importance of educational measures and promotion of public policies, expanding the historically predominant sense that FBDG help to communicate recommendations on healthy eating. The role of FBDG as promoters of healthy and sustainable food systems must necessarily consider that implementation is carried out in an integrated manner, with multiple actions and with commitment to multiple sectors.

National experiences in FBDG implementation are little documented in the academic literature, and the existence of national implementation plans is fragile worldwide. The Brazilian’s case analysis can be helpful to decision makers in food policy across the globe be inspired by the Brazilian efforts, considering that the Brazilian guide was one of the firsts to has adopted a multidimensional paradigm of healthy eating, including diet sustainability.