INTRODUCTION

Obesity in adolescence has been interpreted as one of the major public health challenges in the XXI¹ century due to the phase being marked by different biological, cognitive, emotional and social transformations, being characterized by the transition from childhood to adulthood² . Having said that, strategies to prevent overweight and obesity, as well as treatment become even more complex, because the cycle is marked by the need for autonomy and independence in daily activities, responsibility for one’s own health, adherence to new habits and behavior^{3 , 4} . In order to guide actions aimed at reducing obesity rates, it is necessary to understand the etiology and pathogenesis of the disease, which in turn is a multifactorial disorder with prevalence attributed to various biopsychosocial processes, beyond the influence of the environment in which the individual live^{5 , 6} . Factors such as genetic predisposition, psychological disorders, physical inactivity and inadequate feeding⁷ are related to excessive weight gain in early life, which in turn are associated with social discrimination, behavior and learning problems, and negative self-image that persists in adult life⁸ .

Since March 2020, the world is facing the largest pandemic in history and the first in the globalized world9, the Coronavirus (COVID-19). In this context, research is unanimous in showing that children and adolescents are more likely to develop psychiatric disorders resulting from the pandemic and social isolation established as a measure to contain the contagion by the Sars-CoV-2^{10 , 11} virus. During social isolation, individuals in this age group are less exposed to the sun and practice less physical activity¹² , which is associated with negative states of emotion. At the same time, they consume more social media, which is also associated with negative states of mood¹³ .

The literature presents multiprofessional interventions - physical exercise, nutritional education and psychotherapy - as an effective standard procedure for directing changes in behavior that result in a healthier lifestyle^{14 , 15} . The indicated interventions involve multicomponent behavioral approaches, through the participation of professionals in medicine, nutrition, physical education, psychology, physiotherapy and biomedicina¹⁶ .

Regarding these multiprofessional programs, the study by Silva and co-workers¹⁷ states that, because they believe that interventions could lead to weight loss, participants develop many expectations regarding dietary changes and lifestyle habits, to understand and validate the importance of having a nutritionally adequate diet and a physically active life. In addition, the same study showed that participants changed the initial perception of health at the end of the program, considering the concept more broadly, reporting improvement in sleep quality, activities and increase in social coexistence.

Given the above, this study aims to describe the motivations of overweight adolescents to participate in a multidisciplinary health promotion project and assess the relationship of these expectations with the perception of their own health. In addition, it is intended to consider the possible effects of the pandemic on eating habits and physical activity in individuals of this age group.

METHODS

RESULTS AND DISCUSSION

The aim of this study was to compare, through qualitative methods of analysis, the perception of adolescents about their own health and before and after 12 weeks of multidisciplinary interventions carried out in a Multidisciplinary Health Promotion Program.

Regarding the characterization of the interviewed subjects, the average age was 13.8 years, 62.5% of the female adolescents and 37.5% of the male ones. The average Body Mass Index of the participants was 31.8 kg/m². Regarding family income, 29.16% had monthly income of one to three minimum wages, 41.66% had monthly income of 3 to 6 minimum wages and 29.18% had monthly income greater than 6 minimum wages. Regarding the educational level of parents, 70.83% of mothers had completed higher education, while 29.16% had completed high school.

The characteristic of the socioeconomic level found in the sample confirms a data already established in the literature on overweight in adolescents being more frequent in families with better socioeconomic conditions in developing countries²⁴ . However, the heterogeneity of the sample in relation to this aspect supports that, in Brazil, this growth occurs in all socioeconomic strata, including among families with lower purchasing power²⁵ . Regarding the parents’ schooling, we observed a significant majority of mothers with complete higher education, corroborating with the study of Guedes and collaborators²⁶ , in which it was observed that children are three times more likely to develop overweight/ obesity when parents have higher education.

Based on the similarities found in transcription and other contents during the analysis process, the following categories emerged: (1) motivation; (2) food; and (3) physical activity. The results were presented through word clouds, in which we can observe the frequency of certain terms in the discourse of the participants and their associations. The size of the word in the figure accuses its representativeness. In the case of category 1 (motivation), there was a higher frequency and representativeness of the word “slim” both before and after the intervention period. To a lesser extent, the word “health” also appears in both moments.

The above result shows that the subjects had as main motivation to participate in the multidisciplinary program, weight loss. The lower representativeness of the word “health” is justified by adolescents limiting health to thinness, which is a distorted definition possibly supported by a low degree of health literacy²⁷ . This, in turn, is a worrying factor because according to Berkman and collaborations²⁸ , the degree of health literacy is a strong indicator of the real state of health of the individual. Because they are overweight or obese adolescents, the fact of overvaluing weight loss as the main indicator of health suggests a certain psychological vulnerability of these individuals, since excess fat results in low self-esteem, high body dissatisfaction and behavioral disorders²⁹ .

In turn, at the time post intervention, the word “slim” is accompanied by words such as “learned”, “keep”, “change” and the verb “lost” now appears in the past ( figure 1 ), interventions were effective to broaden the concept of health and self-perception of participants. In addition, it was possible to conclude that, although this is not the initial motivation, adolescents realized the need to adopt the good habits they learned in the interventions, so as to be physically and mentally healthy, broadly and not only according to the simplistic definition of the absence of disease.

Figure 1 : Word clouds related to category 1 (motivation). 

Regarding category 2 (food), the word cloud referring to the pre-intervention moment, manifested with greater representativeness the word “eat”, associated with words such as “like”, “anxiety”, “nervous”, “exageration” and “crisis” ( figure 2 ). The result revealed at the time pre-intervention indicates that despite enjoying eating, for adolescents the act was associated with feelings such as anxiety and nervousness, and may be the cause of crises and exaggerations at the time of the meal. This sequence of events is connected by the fact that food is seen as gratification or as a form of compensation and numbness of emotions³⁰ .

Figure 2 : Word clouds related to category 2 (food). 

Still in the pre-intervention moment, it was possible to identify less representative words such as “time”, “moment” and “ran” that were used to portray how meals are made at home, a situation in which many reported factors such as lack of time and excessive dedication to work by parents. In previous studies, this reality was motivating the increase in the consumption of nutritionally inadequate foods and the omission of the main meals, because the parents presented a more negligent posture with food issues^{31 , 32} .

While in the post-intervention period (figure II), the words: “changed”, “healthy”, “learned” and “exception”, suggesting that adolescents acquired theoretical and practical knowledge about the theme during the project, which demonstrated the effectiveness of nutritional education and psychotherapy strategies in changing behavior in relation to alimentation³³ . The study by Silva, Frazão, Osório and Vasconcelos34 concluded that adolescents’ adherence to healthy eating is associated with liking some healthy foods, having access to and availability of these foods, being afraid of becoming fat, receive encouragement from the media and the family environment, as well as from school through educational feeding practices, thus confirming the importance of programs aimed at nutritional education in this age group ( Figure 3 ).

Figure 3 : Word clouds related to category 3 (physical exercise). 

Finally, the analysis of category 3 (physical exercise), show that at the time before the interventions, the words with greater representation were “make” and “like”, individuals with the practice of physical activity. However, there is a highlight for some modalities such as “walk”, “soccer”, “swimming”, “run”, “gyn”, “basketball” and “dance”, activities and/or practiced in community environments. Due to the social isolation imposed by the COVID-19¹¹ pandemic, such activities had to be paralyzed, which may explain the increase in body weight in adolescents during the period35 and the replacement of these words by other modalities such as “walk”, “bike”, and “treadmill” at the time after intervention.

These in turn are activities practiced individually, without the need for greater interactions and in environments with greater privacy such as inside the house, in the yard and on the street. The above mentioned picture, together with the expressive representation of the word “pandemic” in the post-intervention moment, highlights the reflection of the period of social isolation experienced by the COVID-19 pandemic, in which individual modalities and tele exercice³⁶ were encouraged.

The research conducted by Carneiro, Medeiros and Silva³⁷ reinforces the results found in this study, highlighting that actions developed in an interdisciplinary project aimed at obesity can lead to a significant experience in health promotion, behaviours in relation to unhealthy habits. In addition, intervention programs can support the public and private health system in the management of obesity, minimizing expenditure in the sector resulting from the treatment of obesity and associated comorbidities^{38 , 16 , 33} .

Despite the School Health Program (PSE)^{39 ,} to encourage the integral training of students through actions of health promotion, disease prevention and health care of children, adolescents and there are difficulties in the execution of interventions for this purpose in school environments, such as lack of material and human resources, and lack of training for the professions^{40 , 41} . The above-mentioned framework reinforces the importance of research and extension projects that overcome this demand, providing support and care to vulnerable communities - especially in times of overload of the public system, such as during the COVID-pandemic19⁴² , besides being indispensable to establish the link between university and society⁴³ .

The limitations of the study consist of: (1) difficulty in obtaining complete answers from adolescents during the interviews; (2) absence of a control group; (3) high dropout rate (43%) for various reasons such as difficulty in locomotion, lack of identification and incompatible schedules. As strengths of the study we can highlight: (1) qualitative methodology that allowed to analyze subjective aspects of the participants; (2) adequate intervention time according to Jensen et al. ⁴⁴. It is suggested that future research be performed with a larger sample and compare the results obtained with a control group.

CONCLUSION

Regarding the categories of analysis, it was identified that the motivations of the subjects to participate in the program, focused on the possibility of weight loss, which is a limited perception of health. However, the final interviews indicated that the interventions were effective to expand the concept of health of the participants. Regarding food, the interviews made it possible to understand that, at an early stage, adolescents associate the act of eating with feelings such as anxiety and nervousness. At the end of the program, it was possible to notice that adolescents acquired theoretical and practical knowledge about the subject, which confirms the effectiveness of nutritional education and psychotherapy strategies in changing behaviors related to food. The responses related to the category of physical exercises demonstrated a change in the modalities practiced by the participants, possibly due to the social isolation framework installed due to the COVID-19 pandemic. The results reinforce the importance of understanding adolescents’ perceptions about their own health and related habits, in order to develop effective strategies focused on the prevention and treatment of obesity, through health promotion.