Risk factors influencing food habits of overweight and obese incarcerated women

Introduction: Chronic diseases stand out on the world stage due to the impact they cause on population morbidity and mortality. In the case of persons deprived of their liberty, the situation is intensified by the restriction in the choice of food and access to physical exercise. Objective: To identify the risk factors that influence the eating habits of overweight and obese incarcerated women. Methods: Cross-sectional study, conducted with 31 participants. Data collection took place in the second half of 2018, comprising individual interviews of incarcerated women using a semi-structured questionnaire and measurement of anthropometric measures. The data were systematized in electronic spreadsheets and statistical analysis was performed in a descriptive way. The study complied with ethical standards from national guidelines. Results: A greater prevalence of overweight and obesity was identified in young, multiparous women, with low education and lower income. Most used tobacco and had less than a year in prison. Despite being overweight and obese, they felt good about their body, which may be reflecting on their lifestyle, through sedentary lifestyle, self-care deficit and consumption of products and foods with low nutritional value. Conclusion: Overweight and obesity are multifactorial and are not related only to behavioral aspects. It is necessary to carry out new research approaches that clarify the health weaknesses in prison, making it possible to provide a better quality of life for this population group.


INTRODUCTION
In recent years, excess body weight (overweight and obesity) has gained prominence in the international and national scope, becoming a public health problem. It is estimat- Such a condition predisposes to several risk factors that become an aggravating factor for the health condition, such as hypertension, diabetes, neoplasms, strokes, among Hattori TY, Silva EO, Nascimento VF, Atanaka M, Trettel ACPT ABCS Health Sci. 2020;45:e020020 others 3 . This increase in weight is related to factors such as physical inactivity, insufficient physical activity, unhealthy diet with a high content of fats and carbohydrates, smoking, drinking, in addition to genetic, metabolic, hormonal, environmental, behavioral, cultural and social factors 4,5 .
In addition, women have other causes for weight imbalance, such as hormonal, gestational and psycho-emotional aspects that can negatively affect their health condition 6 . And when these women are in the condition of incarceration, these risks are amplified, either by the new dynamics of life established or by the behaviors acquired collectively. It is important to highlight that when they are in prison, the break with the outside world and the new internal institutional/organizational rules distance them from the usual appearance and the perception of themselves as a woman, which consequently causes losses in self-image, self-esteem and self-care 7 .
These psychosocial issues 8,9 added to current environmental conditions and past life habits 10,11 , make this problem multifactorial and deserving more attention from health professionals, especially from prison system managers.
It is observed that data on nutritional status in incarcerated women are scarce in the literature, the few existing researches confirm the increase in these indexes, attributing only the behavioral factors to these disorders 11 . As food is one of the most affected aspects during incarceration, we sought to know the risk factors that influence the eating habits of overweight and obese reeducated women in the public chain of the Middle North of Mato Grosso, Brazil. This proposal in Mato Grosso is innovative and pioneering and is fundamental to support the approach and understanding of this theme.
Based on that, the objective was to identify the risk factors that influence the eating habits of overweight and obese incarcerated women.

RESULTS
The study included 31 women, with a mean age of 32.

DISCUSSION
Food is one of the basic needs of human beings and is among one of the most affected aspects during prison, an example of this were the studies carried out in Brazilian women's prisons that demonstrated the high percentage of overweight and obesity 10,14 .
In international surveys, a higher prevalence of obesity (48.0%) than overweight (39.0%) was observed among women deprived of their freedom 11 . In Seysse, France, women were obese when admitted and showed worsening obesity in incarceration 15 .
Likewise in Brazil, it appears that these women do not always develop this condition exclusively in prison, many are already overweight when entering prison, due to bad living habits (smoking, physical inactivity, use of illicit drugs) and conditions unfavorable socioeconomic conditions (unemployment, delinquency, poverty) that contribute to nutritional problems 8,10 .
In addition to the aforementioned factors, there was an association of age from 40 years onwards in the female population in general with weight gain 3,6 . One of the reasons is attributed to hormonal changes due to aging, which cause greater accumulation of fat and changes in its distribution 6,16 . Hormonal changes are also common in this age group, as a consequence of hypoestrogenism, The relationship between parity number and overweight in women is described in the literature, being more prevalent in Hattori TY, Silva EO, Nascimento VF, Atanaka M, Trettel ACPT ABCS Health Sci. 2020;45:e020020 multiparous women in the general female population 22 . The overweight of puerperal women in Porto Alegre was associated with the value of pre-gestational BMI (p<0.001), gestational weight gain (p<0.001) and age ≤20 years (p<0.001) 22 . In a study carried out in weight retention after 6 months postpartum 23  women's prisons regarding the high consumption of tobacco 24,25 in the state of Paraíba, Brazil, for example, 67.6% used it, while elsewhere in the country 8 26.1% had severe nicotine dependence.
Although national surveys in prisons have not assessed the relationship between weight gain and tobacco, a North American study found that women with pre-incarceration who used tobacco gained more weight (81.0%) than other women 9 .
It is noteworthy that in the institution studied, cigarette consumption is unrestricted, making the incarcerated woman a smoker have a greater desire to do so due to prison conditions.
The restriction or decreased access to tobacco contributes to the increase in body weight, since it leads to abstinence, causing feel- are precarious and unhealthy 27 . It was observed that the short period of detention (less than one year) was similar to that of other studies 22,28 . Incarceration affects the family bond, as the woman in that condition ends up losing her relationship with her children and the family. Therefore, this distance implies reports of feelings of sadness, abandonment, discouragement and revolt 7,8,29 .
The isolation resulting from incarceration leads to the distance between family, partners and friends. For women deprived of their liberty, this issue is greater, since maternal functions are transferred to other people, failing to exercise the necessary care for their children 8,30 . When analyzing the nutritional situation related to weight gain and the period of imprisonment, a higher percentage of obese women (46.7%) is observed, who coincidentally were detained for a longer time. One of the reasons may be due to the low perspective related to aspects of life and the return to post detention activities that are usually forgotten, as the long period of imprisonment makes the situation experienced increasingly inhospitable 31 .
In the face of an environment with no mirrors that makes it impossible for the incarcerated women to observe their own reflection, it makes them resort to the image of their companions in prison 31 . As all participants in the present study are overweight or obese, therefore, there is particularly a preference for maintaining a larger body than thinner silhouettes, which is why the results showed that the majority (54.8%) were are satisfied with the body. Issues related to excess weight are mainly associated with behavioral aspects 7,8,25 . This condition is related to the lifestyle of modern society with the adoption of a dietary pattern linked to a sedentary lifestyle and an unhealthy style 34 . In women deprived of their liberty, the behaviors associated with being overweight were confinement, smoking, unhealthy diets, abusive consumption of the foods offered, the use of laxatives, abstaining from sexual relations and recreational activities offered by the institution and the high consumption of processed foods brought by visitors or received by their cellmates 3,7,25 .
The conditions of the confinement are mainly related to the lack of adequate infrastructure in the prison system, where unhealthy places are common, accompanied by overcrowding, poor hygiene, lack of sufficient structure for health care, which are factors that affect the individual's physical integrity 35 . In the present study, the most reported recreational activities were soccer, burning, stretching, volleyball, walking during sunbathing hours, with the majority (96.8%) being considered insufficiently active/inactive, Hattori TY, Silva EO, Nascimento VF, Atanaka M, Trettel ACPT ABCS Health Sci. 2020;45:e020020 which can be justified by the lack of infrastructure suitable for carrying out these activities, since the court for these collective actions had been deactivated for weeks, with the sunbathing being carried out in a corridor with restricted dimensions.
Another point to be considered in the present study is joint pain in 54.8% of the participants, a factor that contributes to inactivity or poor adherence to these activities. A worrying factor is the overweight group in which their totality was classified as insufficiently active or inactive, which in the long run will have a greater chance of becoming obese. Physical inactivity can lead to short-term health problems in this population, such as a sedentary lifestyle, low self-esteem and difficulties in changing life habits, which, if not reversed, can later lead to health complications, such as the emergence of comorbidities and psychopathologies 36 .
In line with these results, a study carried out in other female prisons 8 points out that the majority of incarcerated women did not perform physical activity in prison, in France 90.9% of incarcerated women were considered to be inactive or minimally active, with this factor being associated with greater abdominal obesity (p<0.05) 11 . A study 10 describes that women reported discouragement and lack of motivation when participating in the only activity offered by the institution, sunbathing, which was not always available to them. Despite the legislation supporting assistance, education, work, recreation and sports practice in prison systems, it is a practice that is still very far from reality, which is characterized by the absence of regular physical activity that can lead to increased idleness and boredom.
Although the institution studied also works with re-socialization actions such as handicrafts, paintings, crochets that serve as a means of acquiring resources from the sale of products made for the purchase of what they need, it is observed that 45.2% participate in these activities. Most choose to spend most (87.1%) of their time watching television for a long period that often exceeds 5 hours a day (63.0%). The relationship between time in front of the television and excess weight is described 37 . Sitting time watching television is largely responsible for sedentary behavior and disordered food consumption in the general population 38 .
Among women, the frequency of watching television between three or more hours is higher when compared to the male population in general 39 . At the institution of the present study, three daily meals are offered, breakfast, lunch and dinner, the last two basically consisting of rice, beans, meat, pasta, sauteed vegetables and salad. This food is supplied by means of a bidding process, which arrives at the institution in thermal containers and, according to the scale, one to two incarcerated women are responsible for serving the others, being possible to customize the meal according to individual food preference. When analyzing the consumption of vegetables, a high percentage was observed, which can be justified by the fact that the meals offered make these types of food available and, in addition, few receive visits, thus being the only food options for consumption.
Even with the assistance of a nutritionist for the food offered, the unruly and disproportionate practice of consuming preferred foods can contribute to cases of overweight and obesity. It is reinforced that, in order to have a healthy diet, the consumption of macro and micronutrients must be balanced, respecting the recommended amounts 40 . As well, care must be taken as to the conditions for preparing meals in which the use of oil should be used sparingly.
The determining factors for overweight and obesity were identified as aspects of food and nutritional insecurity, namely the lack of access to healthy foods, wrong food choices, large amounts of food eaten, monotonous food without diversity and low nutritional quality 10,31 . When analyzing the situation of the prisons, including this research, it is observed the similarity with the aforementioned descriptions.
Being deprived of freedom, eating behaviors undergo drastic changes. One way to resume to habits before prison is usually accomplished through visitors. Food, cigarettes and hygiene products are the main received items. Among the food products, those industrialized emerged as the most common items brought in due to their unavailability in the prision. The absence of a storage place to perishable food also favors the increase in industrialized products in prisons. The precariousness and quality of the food provided by the institution as reported by some detainees also trigger requests for external food.
Among the limitations of the study, there was an absence of information that could contribute to deepening the results, such as weight before incarceration, pre-prison food history, prenatal history, complementary data related to psycho-emotional aspects.
No specific instruments were used to assess and quantify nutrient intake, such as the 24-hour recall or food diary.
It is concluded that despite being a local study, the results were similar to the surveys carried out at the national level, characterized by a vulnerable population with low education, brown race, young, without occupation, information that already induce a situation of food insecurity and nutritional status before imprisonment and that worsens with imprisonment.
In this sense, it is clear that being overweight does not refer only to behavioral factors, it is necessary to know the health situation and the basic conditions of life inside and outside prison.
Hattori TY, Silva EO, Nascimento VF, Atanaka M, Trettel ACPT ABCS Health Sci. 2020;45:e020020 The process of incarceration generates and triggers an experience permeated by suffering, being essential the understanding of internal cultural references and the way these women give meaning to everything that happens in that environment. Based on this more in-depth analysis, it will allow assistance subsidies consistent with reality. The need to encourage and carry out more research with this population is emphasized, because through this information it will be possible to make actions and policies that aim to reduce inequities viable, providing better living conditions and greater dignity to this group.