Social portrayal of nourishment and repercussions in nutritional habits of pregnant adolescents

The aim of this study was to analyze the impact of social repercussions in nutritional habits of pregnant adolescents conducted by a Primary Health Care Unit in the county of Sobral, Ceará. Using a qualitative approach, exploratory and descriptive, the data was collected through semi-structured interviews at the homes of 15 pregnant adolescents in 2014. Using the material obtained from the thematic perspective, the core issues were analyzed: the nutritional habits during pregnancy; myths/taboos, and intrinsic changes of pregnancy. Changes were observed in nutritional habits related to regularity in meal times and the consumption of fruits and vegetables. During the speeches there was the valorization about proper nourishment, however, the consumption of high-calorie foods coexists. Regarding the myths/taboos, they indicated the existence of ‘strong’ and ‘weak’ foods and the need to ‘eat for two’. It can be determined that the intrinsic change can interfere with nutrition. It was evident that their beliefs permeated during pregnancy, bringing repercussions in eating behavior, and that health professionals should understand the context experienced by pregnant adolescents, in order to provide adequate care.


Introduction
There is a high pregnancy incidence between the ages 15 and 19, with over 400,000 cases reported in Brazil.In the last two decades, the incidence has increased significantly, and at the same time the average age of pregnant adolescents has reduced (Instituto Brasileiro de Geografia e Estatística [IBGE], 2010).This aroused interest that addresses clinical, nutritional and psychological research.
A pregnancy in this age group, even though it may be desired consciously or unconsciously, usually unplanned, can be related to biological, socio-cultural and economic factors (Vitolo, 2014).Furthermore this poses risks for both the mother and the fetus.
It is considered that adolescence presents specific physiological and psychosocial needs that requires special attention to nourishment, identifying the importance and guidance of the nutritional needs which match the current state in order to ensure proper development of the mother and the fetus.
During pregnancy, consumer habits are usually modified, especially with regard to food, because pregnant women have new cravings along with constant changes in mood, that can directly influence the consumer, furthermore, the entrenched family culture environment that triggers strong influence on nutrition (Pereira, Oliveira, Santos, Prazeres, & Pires, 2011).
The main objective of the nutritional beliefs during pregnancy is to protect women's health and the fetus, however, not all taboos and dietary restrictions can be explained, because the vulnerability is not only related to the physiological condition, but also the social ambiguity.In other words, as an adolescent women transitions from a temporary status to a new social status, of being a mother, and for the adolescent this stage is even more complex, her condition is represented according to her culture, so that the rituals and taboos surrounding the pregnancy, also establishes the beginning of this transition and not only the prevention of health problems (Longdon & Wiik, 2010).
The ideas, images, and worldview are social representations of nourishment and nutrition that subjects have about reality, which are linked to social practices.At the same time, each social group prepares its representations according to their position in society, presenting correlation with their specific interests and the dynamics of everyday life (Canesqui, 2005).
The 'social food fact' describes the actions and social representations, revealing private and subjective debate of each individual or social group.It constitutes a new field of research, which merges nutritional sciences and social anthropology and has as its object the understanding of food choices, required for their development, and multidisciplinary collaborations (Camossa, Telarolli, & Machado, 2012).
During the discourse, the following questions arose: What is the social portrayal for pregnant adolescents in nourishment?Are there repercussions of these presentations in their eating behavior?What are these impacts?The study seeks reflections on the factors that impact eating behavior of pregnant adolescents from the perspective of social portrayal, revealing the need to understand the stages of this complex process of development in order to improve the provided pre-natal care to pregnant adolescents, offering nutritional support based on their needs and situations, and consequently promoting health on both the mother and child.
The purpose of this research was to analyze the impact of social portrayal of nourishment in eating behavior of pregnant adolescents accompanied by Primary Health Units in the county of Sobral, Ceará State, Brazil.

Material and methods
This was a qualitative study of exploratory and descriptive type, anchored in view of social portrayals (Reis & Bellini, 2011), developed in Sobral, Ceará State, Brazil.This scenario was selected intentionally by the high incidence of pregnant adolescents during the study period and the vehement approach in preventing reduction of maternal and infant mortality.During the period studied the Primary Health Care Information System from the county recorded a total of 1,764 registered pregnancies, among them 365 were adolescents, making it 20,7% of the total .
The data collected occurred between November and December 2014, through semi-structured interviews applied in the homes of participants, thus ensuring privacy and the proximity to the context experienced by pregnant women.Initially the identification of the pregnant women were identified by a triage, sorting through the prenatal chart records of the Primary Health Care Unit (UBS), and then organized a meeting with the Community Health Agents (ACS) to clarify the purpose of the research and to ensure their support.In home visits the ACS formulated a list of the women who agreed to participate.Thus, the interviews were previously scheduled by the availability of participants and conducted by the researcher.The participants were 15 pregnant adolescents, identified with the letter 'G' followed by Arabic numbers in ascending order.
During the study period, 24 pregnant teenagers were registered in the UBS system, and previously received information on the purpose of the study.After the first interview, only 15 pregnant women chose to participate.Therefore, the interviewee was predetermined as available to be a participant.
The booklet given to the pregnant women provided data from their last consultation.The anthropometric data (current weight, pre-pregnancy weight and height), were needed to characterize the nutritional status of these women, as well as results of laboratory tests already carried out were taken from their prenatal charts.To evaluate the nutritional status, it was used the Gestational Weight Gain Chart, proposed by the Department of Health (Brasil, 2012a).
The interview was based on 12 open questions, in which topics related to beliefs and nutritional habits before and after the diagnosis of pregnancy were addressed.
It was adopted for analysis the thematic technique (Minayo, 2010), being a method that aims to exceed the level of common sense and subjectivity in the interpretation of information, so we organized the empirical material, the interviews were transcribed, analyzed using theoretical reference and interpretive analysis of information, grouping them by units of process, which were: 1) eating practices during pregnancy; 2) myths and taboos on eating habits; 3) the nutritional behavior of pregnant adolescents.
The study followed the regulatory guidelines and standards for research involving human beings, according to the 466/12 Resolution of the National Health Council -CNS (Brasil, 2012b).It was approved by the Ethics Committee of the State University of Vale do Acaraú (UVA), CAAE: 35601614.1.0000.5053.

Results and discussion
Considering the need to understand the context in which adolescents live, it started with an orientation of the theoretical framework that specifically addressed to acknowledge their daily life, and the world they live in (Marques, Cotta, Botelho, Franceschini, & Araujo, 2011).Therefore, the Table 1 shows the characterization of the participants studied.Among the pregnant women interviewed, only three reported that they were already thinking of becoming pregnant, while twelve stated that the pregnancy had not been planned.Among these, nine showed that they felt prepared for their pregnancy, even without planning.
Regarding the family structure, only three pregnant women reported being married and living with their spouses, among the twelve unmarried pregnant women, six declared living with their partner and child in their parents' home, not ensuring privacy and comfort for this new period in their lives.Between the interviewed pregnant women, five have had at least one child, and two did not raise their children, who lived with their grandparents.
The pregnant adolescents showed little variety in eating habits and unfavorable health nourishment, which may have contributed to the nutritional problems found: seven of them had low weight for gestational age, five were overweight and only three were eutrophic.

Gestational process, food and health practices
In this study, there were changes in dietary practices after the discovery of pregnancy and habits that have been modified from the gestational process.Thus, with respect to meal times, it was presented that before the discovery of pregnancy, there was no set times for meals, which began during the pregnancy period, as shown by the following.
When I wake up, I drink coffee with crackers, later on I snack some fruit, banana, then lunch is rice, beans, meat or fish, sometimes fried egg, in the afternoon I snack fruit and at dinner equal to lunch (G1).Before I did not have time to eat, now I try to eat every three hours (G14).
The occurrence of being pregnant during adolescence usually demonstrates differences, by geographic areas and social groups.It is noteworthy that the economic situation of the adolescent family's, translated by the family income, is described as an important factor for pregnancy during this period, and this often unwanted pregnancy can maintain the low socioeconomic status (Dias & Teixeira, 2010;Penman-Aguilar, Carter, Snead, & Kourtis, 2013) Another aspect found was the variety of food as a proper diet, however, food consumption was still handicapped by poor socioeconomic condition, as shown below: [...] It is really hard for me to eat fruits, I like, but it is difficult because we do not have much money (G5).[...] I eat vegetable just at my mother-in-law's house, here I almost never buy it (G2).
Studies show that pregnant adolescents drop out of school because it becomes more difficult to effectively pursue it, other than taking care of their babies, they often need to start working.However, being pregnant is not necessarily a limiting factor for educational opportunities and the search for a better future.Corroborating this discussion, a study done with adolescents in the state of Pará, noted that being an adolescent mother strengthened the desire to stay in school (Xie, Harville, & Madkour, 2014;Kuldas, Hashim, & Ismail, 2015).
The research also revealed the idea of nutrition in relation to the health-wellness and maternal-fetal health.
Salty snacks, things that has a lot of salt, stuff that I can not eat, in my other pregnancy I had early eclampsia, so I can't eat any of it.Salty snacks and greasy food I can't eat (G2).I don't know why, but now every time I drink coffee I feel short of breath, I didn't feel that before.Only now, so I stopped drinking more coffee (G7).I stopped eating, because I wasn't feeling well, with bread, soda and chocolate, it wasn't good for me (G13).
The nutritional problems of pregnant adolescents may have serious repercussions for the mother and her fetus.Among these, the main issue is malnutrition, which entails greater obstetric risks, moreover the possibility of the fetus being born with low weight for the baby's gestational age.Furthermore excessive weight gain has been associated with high-risk complications during birth, maternal anemia, pre-term labor, fetal macrosomia and infant mortality.Because of that, it is recommended that the adolescent can attain and retain a good nutritional status of normal weight during pregnancy, maintaining good health for mother and fetus (Murphy, Stettler, Smith, & Reiss, 2010;Akbari, Mansourian, & Kelishadi, 2015).
Others said that the consumption of certain foods promoted, regulated or maintained health, and that turned the consumption encouraged and valued.
And there is this diet that doesn't cause anemia, eating lots of beans, liver ... those things, which is not to cause anemia and also not to pass it to the baby.Corn flour also helps with anemia (G4).The diet should consist of fruits, foods that contain vitamin C, vitamin D, vitamin E, vitamins that serves for both hair and skin health, for her to maintain ideal weight, and for the baby vitamins that have calcium, so the baby can grow up healthy (G5).I eat fruits, vegetables, because everyone says it is healthy.I like fruit, but vegetables not so much, just carrots, potatoes, tomatoes (G10).
Nutritional practices are incorporated as part of the way of life and become permeable to change, represented by the incorporation of new foods, form of preparation, purchase and consumption.Society modifies the conditions of life and work, ways of being, feeling, thinking and imagining.These changes in aspect of nutrition occur in view of customs and cultural beliefs that are transmitted by the family and also socially imposed (Contreras & Gracia, 2011).
However, there is still an elevated intake of inadequate and high calorie food by the pregnant women.In this category are included manufactured products.
In early pregnancy I just ate junk food (juice box, chips, salty stuff) I was only able to eat healthy after the third month (G2).Fruits and juice I consume well, but that's not all I eat, I eat junk food too.I eat more junk food that healthy meals (G3).

Myths and taboos on eating habits
This category aims to clarify some issues about the social portrayals still evident in the lives of pregnant adolescents gathered during observations and interviews.Foods considered strong and able to maintain a healthy pregnancy, the idea of heavy and light meals and the belief of the need to eat for two during this period.
They understood the motivation to eat and the concerns on food choices, revealing the acknowledgment of the importance to eat healthy during pregnancy, birth and raising of a child, taking in consideration the strong foods and its meaning for a new phase in life.
My mother says that's good I eat beans, do not know why, but I think it gives sustenance [...] I eat a lot of it (G2).I didn't eat fruit before, but now I try to eat it.Because fruits are good for pregnancy (G5).I think you should eat healthier food, fruits, vegetables, proteins, meat, to strengthen our organism, which is very weak when we get pregnant, and is very sensitive to certain foods and some diseases, so we need to eat well to be strong (G9).
The consumption of fruits, vegetables and legumes is related to health, and indirectly, the concept of nutritional risk, when it is deficient.Among pregnant women researched this concept was present in the actions of eating at the right times and initiate the consumption of fruits and vegetables, which in some cases may be restricted for economic reasons and cultural effects (Tanha, Mohseni, Ghajarzadeh, & Shariat, 2013).
Listening to these adolescents, it became clear the beginning of the consumption of certain foods after they found out they were pregnant, with the main motivation to strengthen their organism and consequently the necessary support for this new stage in life.
Acta Scientiarum.Health Sciences Maringá, v. 38, n. 2, p. 191-197, July-Dec., 2016 In the field of idealization of nourishment, emerged in the comments the categories of heavy and light meals, producing direct interference in the feeding behavior of these women.
I do not like to eat meals, I prefer eating snacks, meals are too heavy (G11).At night I only eat soup, the meal prepared is too heavy (G12).I want to eat, but then I think it will not be good for me, too heavy, heavy meals can make me feel bad, so then I don't eat (G13).
When the attention is drawn by pregnant women regarding nourishment and health-wellness, we are relating to the classification of food, which provides certain categories with the human organism, that of which its effects in the pregnant women draw attention to the relationship between health and disease, as in ensuring and maintaining health (Canesqui, 2005).
Other comments brought the idea of prohibition associated with a certain substance that could initiate a health problem their bodies.
Just yesterday my aunt made a duck and invited me to have lunch there, but our maid, who is from the countryside, said that I should not eat because duck is bad for us.I wanted to eat, but I didn't (G3).Pork is not good, as my grandmother says, she is very convinced with these things, and people say shrimp is also bad.Watermelon too, sugar-apple, they say ray-finned fish is also bad oh [...] and also duck (G11).Pork is not good for my health, but I don't think it's prohibited during pregnancy, only when I have a sore throat (G15).
Another myth/taboo found was the understanding that during pregnancy, women should eat for two, to ensure the growth and proper development of the baby.
[...] it's because when we are pregnant we need to eat more, I have to eat more because I'm eating for me and the baby, to give more sustenance for him and for me (G4).You have to eat a lot of food so the baby does not come out malnourished, it needs to be born healthy.And when I say eat food is to eat anything, my husband says that every time he looks at me I'm eating (G14).
It was clear to identify that there is a coexisting idea among the pregnant women that the act of a healthy nutrition, to guarantee the growth and adequate development of the baby, and also the amount of food intake, regardless of what it is, is what provides a proper quality of nourishment.
The value of good nutrition reveals both the existence of knowledge and the nutritional practices, as it was incorporated with the knowledge from the professional health workers, which are released by the media and health services (Baião & Deslandes, 2010).In the study it was well documented, that when pregnant women clarified the presence of nutrients in the food consumed, promoting health.

The feeding behavior of pregnant teenagers
In this category, it is assessed a cultural point of view, the behavior of the women interviewed regarding to changes in pregnancy such as nausea, typical and atypical food cravings and food aversions.
Baked chicken gave me nausea, the smell of it gave me nausea (G4).Oranges made me sick, it was something I used to eat a lot, but now I can't eat it anymore, papaya, apple, fruits made me nauseous.Also beef and chicken, everything made me nauseous (G7).
In a study conducted with obese pregnancies, it was easily identified, based on the statements, the preference for inadequate food intake.This behavior was related to the level of anxiety demonstrated by the women (Baião & Deslandes, 2010) and was also manifested by the adolescents interviewed.
Many prescriptions and food restrictions are based on a binary classification system, taking the contrast between strong or weak foods, where nourishment/strong food means good quality, as opposed to the weak, devoid of vitamins.There is also the prospect that strong food can be interpreted as something harmful, able to damage the body, as opposed to mild or weak, that does not bring harm to health and may even be consumed by sick, convalescent, pregnant and postpartum women.Those beliefs are not substantiated by science or health, even though it may be associated with characteristics which can make the food harmful in that situation to the human organism (Canesqui, 2005;Quintanilha & Menezes, 2010;Arnaiz, 2010).
The women complained of nausea and vomiting in early pregnancy, and for most of them, these discomforts interfered in their eating habits.They also expressed food cravings.that often lasted throughout the pregnancy.
After pregnancy I have this huge craving of eating junk food, chocolate, Sandwich, sodas, those things, I really crave it, so I eat it (G3).I crave watermelon and green mango (G4).I crave ice cream, also certain types of fruits like mango and watermelon (G5).Despite being characterized as strange, the desire to intake substances that are not considered food was mentioned by the women interviewed.I also craved, but it was only a little thing [.The peculiarity of food cravings reveals that strange eating habits are common during pregnancy.For most, these were merely an exaggerated desire for foods that were already part of the usual diet, still occurring, for some, food by desires never before appreciated and/or experienced, but that did not bring significant changes in eating behavior.
During pregnancy eating habits are usually modified, especially with regard to food, because pregnant women start to show new cravings, and constant mood swings as well as possible nausea and vomiting, which directly influences the consumer (Contreras & Gracia, 2011).
There were comments indicating food aversions, and therefore, changes in the eating behaviors of pregnant women.
I do not eat peppers or onions, I don't like it at all (G4).I don't eat anything green, only potato and carrots (G6).Just the vegetables, I don't like (G7).I do not eat papaya, guava, pear, watermelon, tomato and pepper (G8).
From a cultural perspective, there is the popular belief that pregnant women need to eat for two.Eat more and eat foods considered healthy by the social group they belong to, reflects the ideal mother image that they are concerned with the health of their child (Canesqui, 2005;Ayeta, Cunha, Heidelmann, & Saunders, 2015).
For about two thirds of women, pregnancy is accompanied by changes in taste and smell of certain foods, not knowing why this happens.Thus, identifying the possible factors that underlie the development of craving and dislikes for food may be related to changes in taste and olfactory sensitivity, or metabolic changes that can be associated with pregnancy.Thus, it can be triggered an eating disorder called pica, which is characterized by eating atypical combinations of foods and substances (Quintanilha & Menezes, 2010;Ayeta et al., 2015).

Conclusion
From the foregoing, it is clear that permeated beliefs during pregnancy are intended to maintain the health of mother and fetus.However, what still remains, are the erroneous beliefs in light and heavy food, and the need to eat for two during this period.
The study does not exhaust the subject, but suggest the need for more research to discuss the nutritional behavior and its effects, especially in pregnant adolescents.It is important to health professionals the understanding about the eating habits of the public, in order to prevent complications from non-beneficial practices.
..] (laughs) It was fish, raw meat.Just the other day I a piece of raw meat, and another time I ate a piece of pork's ear, but right after I vomited (G7).