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Cadernos de Saúde Pública

Print version ISSN 0102-311XOn-line version ISSN 1678-4464

Cad. Saúde Pública vol.35 no.12 Rio de Janeiro  2019  Epub Nov 28, 2019

http://dx.doi.org/10.1590/0102-311x00177418 

ARTICLE

Comparison of government recommendations for healthy eating habits in visual representations of food-based dietary guidelines in Latin America

Comparação das recomendações governamentais para hábitos alimentares saudáveis expressos em representações visuais de guias alimentares baseadas em alimentos na América Latina

Comparación de recomendaciones gubernamentales sobre alimentación saludable, expresadas en representaciones visuales de guías alimentarias de Latinoamérica

Mayara Sanay da Silva Oliveira1 
http://orcid.org/0000-0002-3243-2575

Mark Anthony Arceño2 
http://orcid.org/0000-0002-9046-1374

Priscila de Morais Sato1 
http://orcid.org/0000-0001-9850-6859

Fernanda Baeza Scagliusi1 
http://orcid.org/0000-0001-7590-4563

1 Universidade de São Paulo, São Paulo, Brasil.

2 Department of Anthropology, The Ohio State University, Columbus, U.S.A.


ABSTRACT

Visual representations of food-based dietary guidelines (FBDG) express diverse dietary and sociocultural norms, especially as they relate to healthy eating habits. This article investigates government recommendations for healthy eating habits expressed in the visual representation of Latin American FBDGs. Drawing on 15 images published between 1991 and 2017, we conducted an anthropological visual analysis guided by the methodology proposed by James Collier and Malcolm Collier: unstructured analyses, open viewing analyses, structured analyses and microanalyses. Here, we explore government recommendations based on visual representation shapes, food classification systems, lifestyle recommendations and embedded sociocultural elements. Our main findings relate to how dietary and sociocultural norms are used to promote eating practices considered healthy. Dietary norms focus on variety, proportionality, and moderation, as expressed in terms of food classification and food standards considered healthy. Sociocultural norms are referenced by the use of cultural symbols as strategies to promote traditional foods, cooking practices, commensality, water consumption and physical activity. Ultimately, we argue that FBDG visual representations contain embedded messages that counsel individuals to plan, buy, prepare and consume food with family; to consume foods considered healthy; to pay full attention to their meals, without distractions, such as television and cell phones; and to celebrate traditional, local and/or native foods and culinary preparations.

Keywords: Healthy Diet; Nutrition Policy; Qualitative Research

RESUMO

As representações visuais dos guias alimentares baseados em alimentos (GABAs) expressam normas dietéticas e socioculturais relacionadas aos hábitos alimentares saudáveis. Este artigo investiga as recomendações governamentais de hábitos alimentares saudáveis expressos nas representações visuais de GABAs latino-americanos. Estudamos 15 imagens publicadas entre 1991 e 2017. Realizamos uma análise visual antropológica guiada pela metodologia proposta por James Collier e Malcolm Collier: análise aberta e não estruturada; análise estruturada; e microanálise. Exploramos as recomendações governamentais a partir das formas das representações visuais, sistema de classificação de alimentos, recomendações de estilo de vida e elementos socioculturais. Nossos principais resultados estão relacionados as normas dietéticas e socioculturais usadas para promover hábitos alimentares considerados saudáveis. As normas dietéticas se concentram na variedade, proporcionalidade e moderação expressos nos conceitos de grupos e padrões alimentares saudáveis. As normas socioculturais estão relacionadas ao uso de símbolos culturais como estratégias para promover alimentos tradicionais, prática culinária doméstica, comensalidade, consumo de água e atividade física. Concluímos que as representações visuais dos GABAs contribuem com mensagens que aconselham os indivíduos a planejar, comprar, preparar e consumir alimentos com a família; aderir a padrões alimentares considerados saudáveis; realizar refeições com total atenção e sem distração de televisão e celulares; e celebrar comidas ou preparações culinárias tradicionais, locais e/ou nativas.

Palavras-chave: Dieta Saudável; Política Nutricional; Pesquisa Qualitativa

RESUMEN

Las representaciones visuales de las guías alimentarias basadas en alimentos (GABAs) expresan normas dietéticas y socioculturales, relacionadas con hábitos alimentarios saludables. Este artículo investiga las recomendaciones gubernamentales de hábitos alimentarios saludables, expresadas en representaciones visuales de GABAs latinoamericanas. Estudiamos 15 imágenes publicadas entre 1991 y 2017. Realizamos un análisis visual antropológico, guiado por la metodología propuesta por James Collier y Malcolm Collier: análisis abierto y no estructurado; análisis estructurado; y microanálisis. Investigamos las recomendaciones gubernamentales a partir de las formas de representaciones visuales, sistema de clasificación de alimentos, recomendaciones de estilo de vida y elementos socioculturales. Nuestros principales resultados están relacionados con las normas dietéticas y socioculturales usadas para promover hábitos alimentarios considerados saludables. Las normas dietéticas se concentran en: variedad, proporcionalidad y moderación, expresadas en conceptos de grupos y patrones alimentarios saludables. Las normas socioculturales están relacionadas con el uso de símbolos culturales como: estrategias para promover alimentos tradicionales, práctica culinaria doméstica, comensalidad, consumo de agua y actividad física. Concluimos que las representaciones visuales de las GABAs aportan mensajes que aconsejan a los individuos planear, comprar, preparar y consumir alimentos con la familia; adherirse a patrones alimentarios considerados saludables; realizar comidas con total atención y sin distracción de televisión y celulares; y celebrar comidas o platos culinarios tradicionales, locales y/o autóctonos.

Palabras-clave: Dieta Saludable; Política Nutricional; Investigación Cualitativa

Introduction

Food-based dietary guidelines (FBDGs) are tools for promoting healthy eating habits and lifestyles for a country’s population. FBDGs are government-written and/or -endorsed textbooks and present various formats, including textbooks, brochures, booklets, and posters 1. FBDGs may also be communicated to broader publics by translating population-specific nutritional goals into easily understandable images, referred to here as visual representations here 1,2,3. Importantly, FBDGs aim to contextualize scientific knowledge on food and nutrition within environmental, social, economic, and cultural aspects of human nourishment 1.

The use of dietary guidelines emerged in the 1970s, understanding food and nutrition as health determinants. These documents emphasized nutrients rather than foods and food choices 4. The incentive to develop FBDGs began at the first International Conference on Nutrition, which identified FBDGs as actions to improve food consumption and nutritional well-being 2,5. At the conference, several countries adopted the global Plan of Action for Nutrition, which included a section on promoting healthy diets and lifestyles, prompting governments to develop FBDGs to provide country-specific guidance 1,2,3. The Food and Agriculture Organization of the United Nations (FAO) has encouraged Latin American countries to develop their own FBDGs, and the main Latin American health agencies - the Institute of Nutrition of Central America and Panama (INCAP) and the Pan American Health Organization (PAHO) - have assumed responsibility for developing, implementing and evaluating dietary guidelines 6. In 2014, the FAO published a report entitled El Estado de las Guías Alimentarias Basadas en Alimentos en América Latina y el Caribe2, which presents the elaboration, implementation, evaluation and revision of FBDGs in our region of study. At the time of the publication, 10 Latin American countries presented visual representations of their FDBGs 2.

Researchers have focused on developing, implementing, evaluating and updating Latin American dietary guidelines 6,7,8; however, they did not evaluate the visual strategies used to promote healthy eating and lifestyles. Others have compared Latin American visual representations with images from different continents (Americas, Asia, Africa and Europe) 9,10,11. Among these studies, just one used qualitative methods 7, and only two analyzed Latin American FDBGs as a whole group (though without considering visual representations) 6,8. Our study addresses this literature gap by qualitatively engaging with FBDG visual representations of Latin America.

Specifically, our primary goal is to investigate government recommendations of healthy eating habits as expressed in Latin American FBDG visual representations. Here, we view visual representations as symbolic vehicles that have power and potential to communicate recommendations concerning eating habits 1,3. As such, we explore how FBDGs express cultural similarities and differences throughout Latin America regarding culturally-defined foods, ways of preparing and consuming them, and eating patterns considered healthy.

Material and methods

Selection of materials

To select images for our qualitative, documentary-based review of Latin American FBDG visual representations, we examined the publication El Estado de las Guías Alimentarias Basadas en Alimentos en América Latina y el Caribe2 and the FAO’s online repository of worldwide FBDGs 12. We accessed images electronically through the FAO’s website (http://www.fao.org/nutrition/nutrition-education/food-dietary-guidelines/en/) or that of the government agency responsible for their dissemination. From March to April 2017, we searched for visual representations that were the latest versions of visual representations launched, directed at people over two years old and publicly available. Representations aimed at health professionals or other service providers were not included. Regarding matters of ethical approval, the Brazilian resolution of ethics in health research 13 exempts from the need to obtain approval from an ethics committee for documentary-based investigation with public documents of unrestricted access.

Construction of the inventory

Fourteen Latin American countries have developed FBDG visual representations to accompany government-endorsed and -printed FBDG textbooks (Argentina, Bolivia, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Guatemala, Honduras, Mexico, Panama, Paraguay, Uruguay, and Venezuela); this does not include Brazil and El Salvador 2. We were unable to locate Nicaragua’s FBDG on its Ministry of Health’s website. We also reviewed Venezuela’s government-sponsored indigenous representation. We organized the selected visual representations (n = 15) in an inventory including country, official name, publication year, update year, development process and stakeholders, and description (Box 1). Most documents permitted the cited reproduction of images, though we avoided including them here. Instead, we inform readers about the methods used to access these materials and emphasize the provided bibliographic references.

Box 1 Inventory of the 15 Latin American food-based dietary guideline (FBDG) visual representations available online between March and April 2017. 

Data analysis

We performed an anthropological visual analysis, an interpretive approach concerned with relating an image to all objects and ideas of the social group that produced it and the researchers that interpret the meaning of those images, objects, and ideas 14. We engaged in a “direct visual analysis”, considering FBDG visual representations as “cultural images” 14 and examining the content and character of our selected images as data 15. The scope of anthropological visual analysis frames images as human experience that evidence how their producers have re-constructed “reality”, as well the relationship between producers and subject in which both play roles in shaping their character and content 15. Methods previously pioneered by visual anthropologists James Collier and Malcolm Collier are guided our analysis. This process entails: (a) unstructured, open viewing analyses; (b) structured analyses; and (c) microanalyses 15,16.

Unstructured, open viewing analysis

We surveyed the visual representations individually and collectively to elicit emerging comparative themes. We looked for elements shared among all images, as well as for those that stood out as unique. We extracted and coded these data from the FBDGs, organizing them in a matrix according to shape, food classification system, physical activity recommendations, water consumption recommendations, and perceived sociocultural elements (Box 2).

Box 2 Summary of elements that compose the 15 Latin American food-based dietary guideline (FBDG) visual representations available online between March and April 2017. 

Structured analysis

We compared how the images are similar to or different from one another within each of the abovementioned categories and in response to our overarching themes. We interpreted the duplication or frequency of specific images as indicative of common resources or practices (e.g., consuming particular quantities of an ingredient or a given food group) throughout the region. This aided our interpretations of what each element told us about government recommendations for healthy eating and lifestyles throughout Latin America. In addition, and as an ethical care strategy for preventing misrepresentation or altering meaning 17, the first author read the FBDG visual representations several times and referenced the accompanying textbooks as needed to support interpretations, highlighting characteristics related to the categories. Throughout this recursive process, the first author raised emergent themes (e.g., commensality, cooking practices, traditional foods) (Box 2), which were discussed with two researchers with experience in cultural food anthropology and nutrition until consensus on the categories was met 17.

Microanalysis

We conducted more detailed analyses of each FBDG visual representation to better understand not only the norms embedded in the respective composite images but also the entire collection of Latin American visual representations. We deconstructed each representation into subcomponents and further interpreted their symbolic meanings, repeating the above steps as necessary to elicit better understandings of our image inventory on national and regional scales (Box 2). This iterative process also helped us to understand the links between the FBDG textbooks and specific images that were chosen to represent recommendations. For example, we analyzed the foods comprising each food group. An individual image of a chicken is a representation of a chicken. However, grouping chickens alongside images of pigs and cows could mean collectively a suggestion to consume foods from a “meat” or “protein” category, while their inclusion alongside capybaras and insects may indicate traditional food sources of specific cultural groups 18.

Results and discussions

Development and stakeholders

Latin American countries published their first FBDGs between 1991 and 2011; many of these textbooks were updated between 2009 and 2015 (n = 10). All countries used the model proposed by INCAP to develop, review and update their respective FBDGs. The model promotes the involvement of national panels of scientists, policymakers and stakeholders to compile the best scientific, cultural and political evidence for health-promotion and disease-prevention behaviors available at the time of FBDG development 6,8. The Ministries of Health of each country had a central role in these processes, being responsible for leading or coordinating the national multisectoral work committees. These committees were composed of stakeholders from the academic sector, as well as of professional associations from the health area, civil society, agricultural sector, and food industry. Organizations such as FAO, INCAP, and PAHO have provided technical support to countries in developing their official dietary guidelines (Box 1). Most countries’ Ministries of Health endorse food guidelines, with co-authorship by universities, nutritionist or medical associations, and/or other ministries (education, agriculture, labor and development).

Shape of visual representations

In our study, we recognized four general shape patterns: circular, plate, “traditional cooking utensils” 11 and “unique” 9 (Box 3).

Box 3 General patterns of visual representation shapes of the Latin American Food-Based Dietary Guidelines available online, between March and April 2017. 

Circular FBDG graphics (represented by the images from Argentina 19, Chile 20, Costa Rica 21, and Uruguay 22) express proportions of food groups for a daily or weekly diet 23, using a geometric concept associated with a “continuous process” (without beginning or end) 24. The use of concentric circles in Argentina, Chile, and Uruguay highlights healthy lifestyles as more than just the consumption of balanced and healthy food; it also includes to varying degrees cooking, commensality, physical activity, and water consumption.

Plate visual representations (Colombia 25, Mexico 26, and Panama 27) differ from circular ones in that they express food group proportions relative to daily meals. The meal-based approach is further emphasized alongside cutlery, water glass and a placemat, all of which may suggest a normative way to present food based on hegemonically widespread cultural instruments in urban Western societies.

“Traditional cooking utensils” 11 - clay pot, pot, and mortar - as expressed in Dominican Republic 28, Guatemala 29, Honduras 30, and Paraguay 31 representations are illustrative frameworks that harken traditional foodways and cooking from scratch. This approach contrasts with representations of circles and plates, because it relies on a relatively hierarchical (bottom-up) reading of food groups, while the others feature a relatively horizontal (i.e., non-hierarchical) orientation 24,32. Furthermore, the traditional utensil approach emphasizes national culture not only in terms of food choices but also regarding physical activity (as we explore below).

“Unique” 9 visual representations that do not fit into one of the other groups vary in their overall structures, as well as their approaches to symbolically articulate proportionality (Cuba’s differently-sized plates 33), variety (Bolivia’s rainbow 34), and cultural relevance (Venezuela’s trompo 35,36). The recommended relative contributions of different food groups to the overall diet are a common denominator in these images 3.

Dietary norms of the visual representations

Dietary norms are a set of prescriptions based on scientific-nutritional knowledge, which change according to scientific progress over time 37. These norms emerged in our analysis, given FBDGs’ foci on variety, proportionality and moderation, as expressed in the concepts of food groups and food portions. Similar depictions of such recommendations are arguably unsurprising since Latin American countries have long shared similar sources when developing their FBDGs (e.g., adoption of the global Plan of Action for Nutrition and/or guidance from the INCAP model). These features are particularly salient when considering depictions of food classification systems and food standards considered healthy. While we would argue that these norms are inherently sociocultural, we make the distinction that they most immediately refer to dietary needs.

Food classification system

A food group is a system of food organization according to similarity in nutritional properties or biological classifications 38. Among the visual representations reviewed, we found symbolized nutrients of the food groups, which were not explicitly illustrated. The number of food groups varies from four to eight (Table 2), whereby basic organization appears to be rooted in macronutrients, biological classification (e.g., meats and fruits) or inclusion in regular meals. According to the simplest classifications, such as Costa Rica’s, food groups are organized by nutritional and biological characteristics: (1) fruits and vegetables; (2) cereals, leguminous, and starchy vegetables; (3) animal foods; and (4) sugars and fats.

Classification complexity increases due to greater subdivisions based on food processing level, industrial addition of micronutrients (food fortification), breastfeeding valorization, and inclusion of “empty calories” (e.g., sugars). Consider the Dominican Republic’s visual representation: (1) human milk; (2) normal or fortified cereals; (3) legumes; (4) starchy foods; (5) fruits and vegetables; (6) eggs, milk, and derivatives; (7) fish, poultries, meats and bowels; (8) fats, sugars, and iodized salt. We interpret this FBDG’s representation of breastfeeding as a normative mode of introducing food in early infancy, which coincides with recommendations by WHO and United Nations Children’s Fund (UNICEF) 39. The fact that this is included in an FBDG for people 2+ years old further suggests healthy eating starts in early childhood.

Food groups are closely associated with the FBDG concept of “variety”, which expresses proper proportions and food consumption quantities. Consequently, it is linked to the concept of food portions; this, in turn, corresponds to the average amount of food that should be consumed by a healthy individual, aiming at promoting adequate consumption of energy and nutrients 40. Here, we suggest using food groups and food portion sizes relates symbolically to daily recommendations for energy and nutrient intake 41. In circular, plate or arc diagrams, food groups are indicated by labels and/or images (stylized illustrations or photo-realistic images of specific foods), as well as the relative size of their portion of the diagram, with associated colors indicating relative serving amounts. By contrast, the verticality of traditional utensil representations indicates the frequency or suggested portions of consumption, whereas a “traffic light” color code system informs greater or moderate consumption of a food group, as in the cases of Mexico and Paraguay. All these fundamental informational elements determine the permission or restriction of a food group.

Food standards considered healthy

In addition to the food classification system, recent visual representations (such as that of Uruguay) emphasize levels of food processing, suggesting that healthy diets are based on in natura foods and that people should avoid consuming ultra-processed foods 42,43. While all visual representations illustrate several fresh foods, some also include the accompaniment of text that explicitly states the avoidance of specific foods (e.g., Chile; Cuba), or a minus (-) sign next to or near foods to avoid (e.g., Argentina; Uruguay). The Uruguayan visual representation also includes images and a list, written in Spanish, of foods that should be avoided altogether, many of them being ultra-processed (e.g., chicken nuggets and instant soups).

Food-processing level has become a public health concern given scientific evidence suggesting a positive association between consumption of ultra-processed foods and obesity and/or noncommunicable diseases (NCDs) in several countries 44,45. FBDGs began to emphasize food-processing levels from the Brazilian experience with the second edition of the Dietary Guidelines for the Brazilian Population, which uses the NOVA food classification 46,47. This classification is based on the nature, extent and purpose of food processing before food acquisition, preparation and consumption 42,43. Although no Latin American FBDG visual representation uses the NOVA classification, they do emphasize food-processing levels in other ways.

Among all the FBDGs reviewed, cereals comprise the most recommended food group to consume 27,29,30,31,33,34,35,36, followed by fruits and vegetables 19,20,21,22,26, dairy products 19,20,21,22,25,26,27,28,29,30,31,33,34,35,36 and, finally, meat and eggs 19,20,21,22,25,26,27,28,29,30,31,33,34,35,36. Some of these groups have caveats, as articulated in FBDG textbooks, though they are not necessarily conveyed on the FBDG images themselves. Cereals are encouraged in their whole form to increase consumption of complex carbohydrates and dietary fiber, as suggested by the inclusion of various grains on Bolivia’s food arc. As exemplified by Guatemala and Honduras, milks, cheeses and yogurts should be consumed in their skim form to reduce saturated fat intake. As for meats, there is an incentive to consume lean cuts and avoid fat ones, as well as to avoid consuming ultra-processed forms (e.g., ham, sausages and others, as illustrated on the Chile’s FBDG image).

Overall, it appears clear that consumers are advised not to consume sugary drinks, alcoholic beverages, sweets, artificial spices, and other ultra-processed foods. The concern with these foods derives from the intake of specific nutritional components such as simple sugars, saturated and trans fats, sodium and food additives (e.g., flavorings, colors, and preservatives) 19,20,27,28,29,30,31,33,34,35,36. Moreover, the consumption of ultra-processed foods and fast foods contributes to reducting the consumption of foods or culinary preparations based on in natura, native, and/or traditional foods 48.

Sociocultural norms of visual representations

Sociocultural norms are a set of conventions relating to the structural composition of food intake - during and outside meals - as well as to the conditions and contexts of food consumption 37. These norms emerged in our analysis through our identification of cultural symbols, i.e., the manifestation of a system of representations of a given culture, through which human beings communicate, perpetuate and develop their knowledge and attitudes towards life 49. Such symbols include typified traditional foods, national dishes, culinary tools, and images of people, which, in turn, act as markers of identity and social belonging and are key to implementation and subsequent response to issues of NCDs and overall health 50. In addition to evoking dietary recommendations, each country’s FBDG further contextualizes local food, cooking, customs, economy, and food production capacity 1,40.

Here, we suggest depictions of sociocultural norms are intended to counteract contemporary eating modes in Latin America, such as the devaluation of home-cooked meals, the mealtime flexibility and the individualization of eating rituals and timing 45,48,51. Consequently, this strategy would aim to restore and promote normative and social control systems, as evidenced by recommendations regarding traditional foods, cooking practices, commensality, water consumption, and physical activity.

Traditional foods

The repetition of certain foods became apparent when we compared the Latin American visual representations. Indeed, it seems quite logical that similar environments would produce similar ingredients for regional consumption 52. Concurrently, we were able to identify features that were arguably more unique or not repeated. We can more likely identify these images as “culturally important” (meaningful enough to the country that it is included on the visual representation); “native” (regionally or locally situated); and/or “traditional” (knowledge regarding specific foods and foodways shared between generations 53).

All the visual representations reviewed include some combination of this latter categorization. This is shown by including typical culinary preparations (e.g., fried corn tortillas, burritos, and tacos) as in the Chilean, Mexican, Paraguayan, and Uruguayan representations. We also observe depictions of regional and local foods and preparations that subscribe a “nationality” of eating practices, in the case of Bolivia (via the consumption of quinoa, amaranth, and chia), or mark ethnic-cultural differences, such as in the Venezuelan case, which values indigenous symbols and encourages the consumption of insects, wild animals and other local food sources.

We suggest including these culturally meaningful foods conveys the biological, nutritional and cultural importance of their consumption. Moreover, this is read as a strategy to connect and make visual representations relevant and acceptable to consumers 1,50. Through their adoption, one promotes not only local consumption, but also biodiversity and regional foodways 54. However, determining distinctive dietary guidelines for indigenous populations as separate from the national FBDG may lead to their ongoing marginalization by promoting norms of dominant groups that separate national (“us”) and indigenous (“them”) foods 18.

Cooking practices

In addition to consuming local traditional foods, Latin American visual representations appear to suggest cooking from scratch with fresh/raw ingredients is important. This is especially evident through the illustration of culinary utensils, such as the Dominican Republic’s mortar and pestle. This symbol of native cuisine is found in many Dominican kitchens and is an autochthonous item, meaning that the origin and learning of its use is transmitted from generation to generation.

Latin American visual representations generally acknowledge salt, sugar and fat as culinary ingredients, though in small quantities and in steering consumers toward non-frying cooking practices (e.g., boiling, simmering). However, only the visual representations of Panama and Uruguay address this theme of culinary practice per se. Panama’s illustrates natural seasonings and small quantities of oils and fats for cooking, whereas Uruguay’s promotes domestic cooking and traditional preparations, stating that using only small amounts of salt, sugar and fat is enough to produce flavors.

We infer cooking from scratch recommendations as strategies to increase the consumption of fruits and vegetables reduces the consumption of fast and/or ultra-processed foods and the risk of overweight and obesity 55. In addition, the appreciation of culinary practice recognizes national/regional preparations as processes related to the identities and senses of citizens’ social and cultural belonging, as well as the autonomy, pleasure and well-being of individuals and groups 56,57.

Commensality

In a strict sense, commensality means “eating with other people” 58. Only Uruguay’s visual representation conveys this notion. Its graphic also recognizes commensality as more than just consuming food with family members, but also buying and preparing food with them. It also normalizes places dedicated to meals and encourages meal consumption with little to no distraction.

Commensality is not a key feature across all the images we reviewed. However, we recognize related elements, which are expressed through recommendations to eat regularly (all visual representations), with attention (e.g., Uruguay) and with appropriate utensils in specific environments (e.g., plate images). Promoting commensality valorizes eating as a social activity, contrasting it with solo-dining models propelled by the ultra-processed food industry. Family environment is valued, which can greatly influence members’ eating habits, as it provides them with food for consumption, support for eating practices and development of food skills 58.

Having said this, we observe an emphasis on a single model of family organization across many of the visual representations - a typified heteronormative nuclear family - which could reflect a social pattern of representation, interpretation and communication that results in a non-recognition and disregard for other forms of familial grouping. Examples of this reading include potential families silhouetted in Colombia and Costa Rica’s visual representations.

Water consumption

Latin American visual representations generally emphasize the consumption of filtered, boiled or sanitary (i.e., safe) water; a minimum of six to eight glasses a day is suggested to maintain perfect balance so that the body can fulfill its functions, as depicted in some images (e.g., Chile). Consuming soft drinks, ultra-processed juices, flavored water, alcoholic beverages and other sugary beverages is considered harmful to a population’s overall health, as suggested by their depiction in visual representations (e.g., Uruguay).

Water consumption is represented as several glasses, drinking from a bottle, pouring from a pitcher or collecting from a faucet. This diversity demonstrates the multiplicity and variety of ways to consume water according to customs and the drinking water quality and sanitation infrastructures in each country. To this end, we proposed multiple interpretations: countries that encourage their population to drink from a faucet generally have better water quality or trust in the government and other sources to provide safe drinking water (e.g., Argentina 59); whereas those that picture bottled water (e.g., Bolivia and the Dominican Republic) may have relatively lower access to safe drinking water 45, or governments may be orienting FBDGs to social groups that can afford bottled water.

Here, we emphasize the importance of water, as it is essential not only for regular human consumption, but also for food production and preparation. Contaminated water is the vehicle for the transmission of any pathogens and pollutants from the environment and food chain at large, with ensuing implications for food safety 45. Thus, including water in FBDG images and emphasizing messages about its quality are strategies that place the “right to potable water” in the public health and social development agenda.

Physical activity

The visual representations reviewed communicate physical activity recommendations through images of individuals engaged in such activities or through written recommendations (Boxes 1 and 2). Recommendations are possibly related to: the energy balance of consuming energy through food and expending it through physical activity, the direct benefits of such practices to health 1,60, and more sedentary leisure activities (e.g., watching television).

Visual representations include specific textual messages, or images of children, adults and elderly people practicing physical activities. Across all shapes, physical activity is expressed in all traditional cooking utensil visual representations, as in the case of the Dominican Republic’s inclusion of dancing merengue or running. More cultural representations are used by Venezuela’s graphics, with a visual distinction for physical activity between nonindigenous (soccer, cycling, or running) and indigenous peoples (canoeing and fishing with a harpoon).

Limitations

Our study has some limitations. Visual anthropological approaches are often best paired with verbal cues (e.g., interviewing FBDG creators or citizens) 15,16, which were lacking here. In addition, our lack of knowledge regarding Nicaragua’s dietary guidelines may skew our interpretation of dietary behaviors throughout the region. However, our interpretations of all FBDG images available were further supported by FBDG textbooks and based on an understanding that visual representations influence public perceptions about healthy eating and lifestyles.

Conclusion

The visual representations reviewed express dietary and sociocultural norms influencing the construction of healthy eating and lifestyles, including local foods and foodways. Our review of Latin American FBDG visual representations reveals similarities in the ways that countries attempt to promote healthy eating and lifestyles using concurrent biological, social and cultural imagery. The presentation of certain foods conveys biological aspects with the logic that food provides the energy and nutrients necessary to maintain an active and healthy body. FBDG images reflect sociological arguments that promote a normative system and social control over quality, quantity and manners of eating foods.

At the same time, the choice of which symbolic elements to include in a visual representation reflects desires to connect with consumers and express the country's cultural uniqueness (compared with other FBDG images of the region) concerning the traditional foods and foodways of the people belonging to its population. This is particularly evident when considering the fruit and vegetable recommendations, which we further argue are related to production practices in each Latin American country 45, and the promotion of traditional culinary preparations and mealtime staples such as cereals, roots, and tubers.

Alongside reinforcing regional and local identity, food and eating can play roles related to the family ties, cultural identity and comfort of eaters 45,57. In the case of Latin American visual representations, such images convey normative behaviors that rely on typified family structures and urban eating habits. Some images also suggest a “proper” way to consume meals, using pictures of plates, cutlery, glasses, and people/families eating at the table. Moreover, directives to enjoy food and social relations that occur between diners at mealtime (e.g., do not watch television or use the cell phone during meals) are just as important as the food and dietary guidelines themselves.

Finally, visual representations tend to depict “national” food patterns or idealized meals that may obscure regional food patterns or diversity within the same country. As such, we suggest that FBDG visual representations could be neglecting certain forms of knowledge and practices about food, health, and nutrition, as well as sociocultural conceptions of the body and beauty of other ethnic and social groups. The inclusion of specific cultural symbols can thus help (or hurt) the successful implementation of FBDGs through cultural appeal and, by extension, a sense of relevant dietary guidance 50,61.

Acknowledgments

The authors are grateful for the financial support from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes, grant numbers 1718057); Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, grant number 2017/05651-0; grant number 2017/17424-9), and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq, grant number 311357/2015-6). We also would like to thank the members of the Research Group on Food and Culture of the University of São Paulo (GPAC/USP).

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Received: September 10, 2018; Revised: March 26, 2019; Accepted: May 24, 2019

Correspondence M. S. S. Oliveira Praça Claudino Alves 05, apto. 3C, Atibaia, SP 12940-800, Brasil. mayarasanay@gmail.com

Contributors

M. S. S. Oliveira, M. A. Arceño, P. M. Sato and F. B. Scagliusi designed the study; M. S. S. Oliveira and M. A. Arceño designed the study methodology, performed data colection, analysis, interpretation, and drafted the study with contributions from the other authors. All the authors read and contributed to the final approval of the manuscript.

Additional informations

ORCID: Mayara Sanay da Silva Oliveira (0000-0002-3243-2575); Mark Anthony Arceño (0000-0002-9046-1374); Priscila de Morais Sato (0000-0001-9850-6859); Fernanda Baeza Scagliusi (0000-0001-7590-4563).

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