Nursing interventions with people with obesity in Primary Health Care: an integrative review

Braga, Vanessa Augusta Souza; Jesus, Maria Cristina Pinto de; Conz, Claudete Aparecida; Tavares, Renata Evangelista; Silva, Marcelo Henrique da; Merighi, Miriam Aparecida Barbosa

doi:10.1590/S1980-220X2017019203293

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Revista da Escola de Enfermagem da USP

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Sumário

REVIEW • Rev. esc. enferm. USP 51 • 2017 • https://doi.org/10.1590/S1980-220X2017019203293 copy

Nursing interventions with people with obesity in Primary Health Care: an integrative review

Intervenciones del enfermero en las personas con obesidad en la Atención Primaria de Salud: revisión integrativa

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

Identify the knowledge produced on nursing interventions with people suffering from obesity in Primary Health Care.

Method

Integrative literature review of publications indexed in the databases: CINAHL, LILACS, MEDLINE, SciELO, SCOPUS and WEB OF SCIENCE, between 2011 and 2016.

Results

Thirty-three articles were selected. The knowledge produced covered two themes: “Counseling aimed at weight control and promotion of healthy lifestyle habits” and “Perception of Primary Health Care nurses regarding interventions with people with obesity.”

Conclusion

The results may help prompt reflections on professional training, management, and health services in terms of the relevance of nurses working with people suffering from obesity, with the support of digital technologies, motivational techniques, and nursing consultations. This could enhance their activities in the multiprofessional teams in which they participate at this healthcare level.

Obesity; Nursing Care; Primary Care Nursing; Review

Database	Search strategy
SCOPUS	Keywords – “nurses” OR “health personnel” OR “nurse practitioners” AND “primary health care” AND “obesity”
CINAHL	CINAHL terms – “nurses” OR “health personnel” OR “nurse practitioners” AND “primary health care” AND “obesity”
MEDLINE	Descriptors (MeSH) – “nurses” OR “health personnel” OR “nurse practitioners” OR “nursing” AND “obesity” AND “primary health care” OR “primary care”
LILACS	Descriptors (DeCS) – “nurses” OR “health personnel” OR “nurse practitioners” AND “primary health care” AND “obesity”
WEB OF SCIENCE	Keywords – “nurses” OR “health personnel” OR “nurse practitioners” OR “nursing” AND “primary health care” OR “primary care” AND “obesity”
SciELO	Keywords – “nurses” OR “health personnel” OR “nurse practitioners” AND “primary health care” AND “obesity”

Authorship/Country	Design / Participants	Interventions	Outcome
Dillen et al., 2014⁽¹⁰10. van Dillen SM, Noordman J, van Dulmen S, Hiddink GJ. Examining the content of weight, nutrition and physical activity advices provided by Dutch practice nurses in primary care: analysis of videotaped consultations. Eur J Clin Nutr. 2014;68(1):50-6. DOI: 10.1038/ejcn.2013.219⁾ Holland	Observational, descriptive n=100	Analysis of the content of advice given to people with obesity during nursing consultations.	The main categories for each type of advice were: lose weight, eat less fat and be physically active.
Laws et al., 2015⁽¹¹11. Laws R, Campbell KJ, van der Pligt P, Ball K, Lynch J, Russell G, et al. Obesity prevention in early life: an opportunity to better support the role of maternal and child health nurses in Australia. BMC Nurs [Internet]. 2015 [cited 2017 Mar 15];14:26. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4429503/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ Australia	Observational, mixed methods n=56	Survey and semi-structured interviews with nurses on advice for obesity given during routine nursing consultations with children from 0 to 5 years old.	The nurses never/rarely used growth graphs to identify children at risk of overweight/obesity. Most gave advised on nutrition, and less than half promoted physical activity and routinely discussed sedentary behavior.
Bogt et al., 2011⁽¹²12. Bogt NCW, Bemelmans WJ, Beltman FW, Broer J, Smit AJ, Meer K. Preventing weight gain by lifestyle intervention in a general practice setting. Arch Intern Med. 2011;171(4):306-13. DOI: 10.1001/archinternmed.2011.22⁾ Holland	Clinical trial, randomized, controlled n=457	Interventions carried out by nurses to prevent weight regain in adults, through guidelines via software, compared with conventional guidelines given by physicians, over a period of three years.	There was no significant weight change difference in the two groups. In both, 60% of the participants were able to maintain the weight after three years. There was a significant difference in blood glucose reduction in the group guided by nurses, but not for blood pressure and lipid levels.
Barte et al., 2012⁽¹³13. Barte JCM, Bogt NCW, Beltman FW, Meer K, Bemelmans WJE. Process evaluation of a lifestyle intervention in primary care: implementation issues and the participants’ satisfaction of the GOAL study. Health Educ Behav. 2012;39(5):564-73. DOI:10.1177/1090198111422936⁾ Holland	Quasi- experimental, intervention in the community n=214	The participants in the intervention group (adults) received a structured questionnaire seven months after the end of the intervention for lifestyle changes. Four nursing consultations and one phone call took place.	The overall satisfaction of the participants was high, especially among those with low levels of education. Nurses were viewed as motivators for learning about and maintaining a healthy lifestyle.
Dillen et al., 2015⁽⁴4. van Dillen SM, Noordman J, van Dulmen S, Hiddink GJ. Quality of weight-loss counseling by Dutch practice nurses in primary care: an observational study. Eur J Clin Nutr. 2015;69(1):73-8. DOI: 10.1038/ejcn.2014.129⁾ Holland	Observational, descriptive n=100	The quality of counsel given in nursing consultations about weight loss was assessed.	Nurses focused on the behavior of people with obesity, using motivational communication. They rarely tackled obstacles and ensured weight control support.
Riiser et al., 2014⁽¹⁴14. Riiser K, Londal K, Ommundsen Y, Smastuen MC, Misvaer N, Helseth S. The outcomes of a 12-week internet intervention aimed at improving fitness and health-related quality of life in overweight adolescents: the young & active controlled trial. PLoS One [Internet]. 2014 [cited 2017 Mar 15];9:12:e114732. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4257715/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ Norway	Clinical trial, randomized, controlled n=120	Participants were aged 13 to 15 years. The intervention group received a 12-week access to an online program that provided advice on exercise based on the theory of self-determination and motivational interviews. The control group received standard follow-up from the nurses.	The intervention had a slight impact on cardiorespiratory fitness and a moderate impact on quality of life. The intervention group had a significantly lower increase in body mass index (BMI) in relation to the control group.
Isma et al., 2013⁽¹⁵15. Isma GE, Bramhagen AC, Alhtrom G, Ostman M, Dykes AK. Obstacles to the prevention of overweight and obesity in the context of child health care in Sweden. BMC Fam Pract [Internet]. 2013 [cited 2017 Mar 15];14:143. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3852529/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ Sweden	Observational, phenomenological n=18	Open interviews with nurses to understand their views on preventive approaches to overweight and obesity in childhood.	The nurses viewed their work as difficult due to lack of standardization in guidelines for obesity and overweight prevention and management. The organization and management of the services were also deficient.
Teixeira et al., 2015⁽¹⁶16. Teixeira F, Pais-Ribeiro JL, Maia A. Uns desistem, outros insistem: semelhanças e diferenças no discurso de profissionais de saúde face à obesidade. Rev Port Sau Pub [Internet]. 2015 [citado 2017 mar. 15];33(2):137-47. Disponível em: http://www.scielo.mec.pt/pdf/rpsp/v33n2/v33n2a03.pdf http://www.scielo.mec.pt/pdf/rpsp/v33n2/... ⁾ Portugal	Observational, descriptive n=44	Semi-structured interviews with nurses, physicians, and nutritionists regarding the discourse of health professionals when faced with obesity.	The professionals had negative beliefs and attitudes in relation to people with obesity. Nutritionists and nurses felt they were able to influence the motivation of these people.
Robinson et al., 2013⁽¹⁷17. Robinson A, Denney-Wilson E, Laws R, Harris M. Child obesity prevention in primary health care: investigating practice nurse roles, attitudes and current practices. J Paediatr Child Health. 2013;49(4):E294-9. DOI: 10.1111/jpc.12164⁾ Australia	Observational, descriptive n=59	Questionnaire and semi-structured interviews to understand the practices and attitudes of nurses in relation to child obesity prevention.	The nurses described prevention work as pleasant. Seventy percent were interested in getting more involved in children’s health tests, and 85% expressed interest in receiving training in child obesity prevention.
Tucker et al., 2013⁽¹⁸18. Tucker SJ, Ytterber KL, Lenoch LM, Schmit TL, Mucha DI, Wooten JA, et al. Reducing pediatric overweight: nurse-delivered motivational interviewing in primary care. J Pediatr Nurs. 2013;28(6):536-47. DOI: 10.1016/j.pedn.2013.02.031⁾ USA	Quasi-experimental, intervention in the community n=130	Intervention through motivational interviews carried out by nurses to reduce excess pediatric weight compared to standard clinical care.	The effects of the intervention included increased daily consumption of fruits/vegetables, more physical activity and fewer hours watching television.
Jarl et al., 2014⁽¹⁹19. Jarl J, Tolentino JC, James K, Clark MJ, Ryan M. Supporting cardiovascular risk reduction in overweight and obese hypertensive patients through DASH diet and lifestyle education by primary care nurse practitioners. J Am Assoc Nurse Pract. 2014;26(9):498-503. DOI: 10.1002/2327-6924.12124⁾ USA	Quasi-experimental, pre- and post-intervention time series n=45	Actions implemented during two months with people suffering from obesity associated with hypertension. These actions included addressing dietary issues and lifestyle changes. The nursing intervention consisted of three in-person group meetings and two phone calls for personal counseling.	The participants made statistically significant improvements in their diets and lifestyle scores, in addition to losing a significant amount of weight (mean of 1.6 kg lost) during the two-month intervention.
Karnon et al., 2013⁽²⁰20. Karnon J, Afzali HHA, Gray J, Holton C, Banham D, Beilby J. A risk adjusted cost-effectiveness: analysis of alternative models of nurse involvement in obesity management in primary care. Obesity. 2013;21(3):472-9. DOI: 10.1002/oby.20100⁾ Australia	Observational, descriptive n=175	Analysis of clinical data and outcomes (weight, BMI, obesity-related complications) and use of resources (primary, pharmaceutical and hospital care) to assess the cost-effectiveness of actions by nurses with people suffering from obesity.	Low involvement of nursing professionals in clinical activities with patients with obesity was identified. When nurses were involved, care costs were lower and more people lost weight.
Nolan et al., 2012⁽²¹21. Nolan C, Deehan A, Wylie A, Jones R. Practice nurses and obesity: professional and practice-based factors affecting role adequacy and role legitimacy. Prim Health Care Res Dev. 2012;13(4):353-63. DOI: 10.1017/S1463423612000059⁾ England	Observational, descriptive n=22	Semi-structured interviews with nurses regarding the response to problems of people with obesity and the legitimacy of the work of these professionals.	In terms of positive factors, the nurses listed links with patients, participation in training, and support for investing in obesity management. The negative factors included lack of priority in obesity management, time and clarity in relation to protocols and their work in practice.
Blackburn et al., 2015⁽²²22. Blackburn M, Stathi A, Keogh E, Eccleston C. Raising the topic of weight in general practice: perspectives of GPs and primary care nurses. BMJ Open. 2015;5(8):e008546. DOI: 10.1136/bmjopen-2015-008546⁾ England	Observational, descriptive n=34	Semi-structured interviews to explore points of view, opinions, and experiences of nurses for initiating discussions on weight control.	The following barriers were identified: limited understanding of obesity care, concern with the negative consequences of excess weight, and lack of time and resources to propose an effective alternative.
Yardley et al., 2014⁽²³23. Yardley L, Ware LJ, Smith ER, Williams S, Bradbury KJ, Arden-Close EJ, et al. Randomised controlled feasibility trial of a web-based weight management intervention with nurse support for obese patients in primary care. Int J Behav Nutr Phys Act [Internet]. 2014 [cited 2017 Mar 15];11:67. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4045942/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ England	Clinical trial, randomized, controlled n=179	The adult patients were divided into four intervention groups: normal care (n=43); a group that received regular nursing support (n=47); a group with web-based intervention only (n=45); and a group with web-based intervention and basic nursing support (n=44).	At 12 months, the mean weight loss was 2.44 kg in the normal care group; 2.5 kg in the group that received regular nursing support; 2.3 kg in the group with web-based intervention only; and 4.31 kg in the group with web-based intervention and basic nursing support group.
Döring et al., 2014⁽²⁴24. Döring N, Hansson LM, Andersson ES, Bohman B, Westin M, Magnusson M, et al. Primary prevention of childhood obesity through counselling sessions at Swedish child health centres: design, methods and baseline sample characteristics of the PRIMROSE cluster-randomised trial. BMC Public Health [Internet]. 2014 [cited 2017 Mar 15];14:335. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3995501/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ Sweden	Clinical trial, randomized n=43	Nursing intervention program with parents to prevent child obesity, starting when the child is 9-10 months old and ending at 4 years of age.	The BMI and waist measurement of the children at 4 years old were significantly reduced. The secondary results showed improvements in eating habits and physical activity of children and mothers.
Hansson et al., 2011⁽²⁵25. Hansson LM, Rasmussen F, Ahlstrom GI. General practitioners’ and district nurses’ conceptions of the encounter with obese patients in primary health care. BMC Fam Pract [Internet]. 2011 [cited 2017 Mar 15];12. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3050702/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ Sweden	Observational, phenomenological n=20	Semi-structured interviews to understand the views of physicians and nurses in relation to the care of people with obesity.	The general view of the team was that obesity should be prioritized in PHC, but they did not consider it the responsibility of this level of care, since they did not consider it to be a disease. Nevertheless, the team felt it was important for patients to receive personalized guidelines.
Phillips et al., 2014⁽²⁶26. Phillips K, Wood F, Kinnersley P. Tackling obesity: the challenge of obesity management for practice nurses in primary care. Fam Pract. 2014;31(1):51-9. DOI: 10.1093/fampra/cmt054⁾ Wales	Observational, descriptive n=18	Semi-structured interviews with nurses about good practices and barriers perceived by these professionals when dealing with obesity in PHC.	Nurses provided regular care to people suffering from obesity associated with other comorbidities. They had mixed opinions on how to approach the subject of obesity with people considered to be healthy.
Gorin et al., 2014⁽²⁷27. Gorin AA, Wiley J, Ohannessian CM, Hernandez D, Grant A, Michelle, et al. Steps to Growing Up Healthy: a pediatric primary care based obesity prevention program for young children. BMC Public Health [Internet]. 2014 [cited 2017 Aug 16];14(72): 90-7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3933325/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ USA	Clinical trial, n=150	Families with children from 2 to 4 years of age, that received brief counseling by physicians and nurses for 12 months (Group 1); monthly counseling and phone calls (Group 2); monthly counseling and home visits (Group 3).	The interventions led to a reduction in the percentile of children, with better results when the families received counseling and home visits.
Marcos et al., 2014⁽²⁸28. Marcos MLT, Rosich N, Royo JMP, Casas AG, Selva JPS, Rodríguez-Montes JA, et al. Eficacia de las estrategias de motivación en el tratamiento del sobrepeso y obesidad. Nutr Hosp [Internet]. 2014 [citado 2017 ago. 16];30(4):741-8. Disponible en: http://www.aulamedica.es/nh/pdf/7704.pdf http://www.aulamedica.es/nh/pdf/7704.pdf... ⁾ Spain	Multicenter trial, randomized n=696	A group of adults with obesity received counseling regarding change of habits in order to lose weight, from nurses with the support of a psychologist; the other group received routine monitoring.	The mean weight loss percentage was 1% for the control group and 2.5% in the intervention group; 18.1% of the control group reduced their weight by more than 5%, compared to 26.9% in the intervention group. After two years, the mean BMI of the control group dropped 0.9 kg/m²2. Brasil. Ministério da Saúde; Agência Nacional de Saúde Suplementar. Vigitel Brasil 2015. Saúde Suplementar: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico [Internet]. Brasília: MS; 2017. [citado 2017 mar. 14]. Disponível em: http://www.ans.gov.br/images/stories/Materiais_para_pesquisa/Materiais_por_assunto/2015_vigitel.pdf http://www.ans.gov.br/images/stories/Mat... , as opposed to 2.4 kg/m²2. Brasil. Ministério da Saúde; Agência Nacional de Saúde Suplementar. Vigitel Brasil 2015. Saúde Suplementar: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico [Internet]. Brasília: MS; 2017. [citado 2017 mar. 14]. Disponível em: http://www.ans.gov.br/images/stories/Materiais_para_pesquisa/Materiais_por_assunto/2015_vigitel.pdf http://www.ans.gov.br/images/stories/Mat... in the intervention group.
Redsell et al., 2011⁽²⁹29. Redsell SA, Atkinson PJ, Nathan D, Siriwardena NA, Swift JA, Glazebrook C. Preventing childhood obesity during infancy in UK primary care: a mixed-methods study of HCPs’ knowledge, beliefs and practice. BMC Fam Pract [Internet]. 2011 [cited 2017 Aug 16];12:54. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155826/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ England	Observational, mixed methods n=8	Semi-structured interviews with 12 physicians and six nurses to identify knowledge, beliefs, and practices in relation to child obesity.	The physicians were less confident to give advice on children’s nutrition than nurses, but they were more knowledgeable about the health risks of obesity.
Thabault et al., 2016⁽³⁰30. Thabault PJ, Burke PJ, Ades PA. Intensive behavioral treatment weight loss program in an adult primary care practice. J Am Assoc Nurse Pract. 2016;28(5):249-57.⁾ USA	Observational, descriptive n=38	Motivational interventions carried out by nurses with adults with obesity in relation to changes in eating habits and encouragement to exercise.	The interventions of the nurses resulted in actual weight loss (3.03 kg after four visits and 4.85 kg after eight visits); 39% of the adults lost 5% or more weight at the end of 12 weeks.
Derksen et al., 2012⁽³¹31. Derksen RE, Brink-Melis WJ, Westerman MJ, Dam JJ, Seidell JC, Visscher TL. A local consensus process making use of focus groups to enhance the implementation of a national integrated health care standard on obesity care. Fam Pract. 2012;29 Suppl1:i177-84.⁾ Holland	Observational, descriptive n=29 professionals n=24 users	Three focus groups with adults were created with semi-structured interviews with health professionals to understand experiences related to obesity prevention, diagnosis, treatment and relapse prevention.	The users felt that the professionals offered contradictory advice and recommendations which did not meet their needs, and did not provide support. Professionals felt lack of qualification to support and motivate adults since they did not consider obesity to be a chronic disease.
Isma et al., 2012⁽³²32. Isma GE, Bramhagen AC, Ahlstrom G, Ostman M, Dykes AK. Swedish Child Health Care nurses conceptions of overweight in children: a qualitative study. BMC Fam Pract [Internet]. 2012 [cited 2017 Aug 16];14(1):13-57. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3426496/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ Sweden	Observational, phenomenological n=18	Semi-structured interviews with nurses to identify their views on child overweight and obesity.	Overweight in younger children was overlooked by professionals and viewed as a consequence of their parents’ lifestyle, with not much importance attached to it in the preschool period.
Kelishadi et al., 2012⁽³³33. Kelishadi R, Malekahmadi M, Hashemipour M, Soghrati M, Soghrati M, Mirmoghtadaee P, et al. Can a trial of motivational lifestyle counseling be effective for controlling childhood obesity and the associated cardiometabolic risk factors? Pediatr Neonatol. 2012;52(2):90-7.⁾ Iran	Non-randomized clinical trial n=457	Interventions carried out by physicians and nurses with children and adolescents suffering from obesity associated with other comorbidities.	There was a significant decrease in the anthropometric and cardiometabolic risk measurements, as well as an increase in HDL-C. The prevalence of metabolic syndrome decreased by 20.8%.
Korhonen et al., 2014⁽³⁴34. Korhonen PE, Järvenpää S, Kautiainen H. Primary care-based, targeted screening programme to promote sustained weight management. Scand J Prim Health Care [Internet]. 2014 [cited 2017 Aug 16];32(1):30-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4137900/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ Finland	Longitudinal cohort study n=906	Assessment of interventions based on lifestyle advice given by a nurse over a period of three years, with people between 45 and 70 years of age with overweight and comorbidities.	Around 18% of the individuals lost at least 5% of their starting weight and managed to maintain the results for three years; 70% were able to stabilize their weight after the intervention.
Engström et al., 2013⁽³⁵35. Engström M, Skytt B, Ernesäter A, Fläckman B, Mamhidir AG. District nurses’ self-reported clinical activities, beliefs about and attitudes towards obesity management. Appl Nurs Res. 2013;26(4):198-203.⁾ Sweden	Observational, descriptive n=247	Questionnaires with nurses for describing self-reported clinical activities, opinions, and attitudes in relation to obesity management.	The nurses gave advice on physical activities (40.1%) and lifestyle changes (34.8%); 25% rarely/never carried out these activities, and 78.1% BMI or abdominal circumference assessments.
Ritten et al., 2016⁽³⁶36. Ritten A, Waldrop J, Kitson J. Fit living in progress--fighting lifelong obesity patterns (FLIP-FLOP): a nurse practitioner delivered intervention. Appl Nurs Res. 2016;30(1):119-24.⁾ USA	Observational, descriptive n=16	Adults received five home visits from a nurse every two weeks for three months, with behavioral interventions.	It was noted that the participants took greater responsibility for their health, physical activities, nutrition, spiritual growth, stress management and motivation to live healthily. Systemic blood pressure and BMI decreased significantly.
Gunther et al., 2012⁽³⁷37. Gunther S, Guo F, Sinfield P, Rogers S, Baker R. Barriers and enablers to managing obesity in general practice: a practical approach for use in implementation activities. Qual Prim Care. 2012;20(2):93-103.⁾ England	Observational, descriptive n=23	Semi-structured interviews with seven physicians, seven nurses and nine overweight adults to describe difficulties and ease in implementing obesity management recommendations.	The difficulties included stigma, previous treatment experiences, professionals not wanting to assume responsibility for obesity management, lack of care consistency, and limited skills of the professionals. Trust in the professional-patient relationship was considered to be easy.
Sousa et al., 2015⁽³⁸38. Sousa LAPA, Ascari RA, Ferraz L, Zanatta EA. Obesidade infantil: o olhar dos enfermeiros inseridos na atenção básica. Cult Cuidados [Internet] 2015 [citado 2017 ago. 16];19(41):147-56. Disponible en: https://rua.ua.es/dspace/bitstream/10045/46622/1/Cultura-Cuidados_41_17.pdf https://rua.ua.es/dspace/bitstream/10045... ⁾ Brazil	Observational, descriptive n=10	Semi-structured interviews with ten primary care nurses to obtain their views on child obesity.	The nurses had knowledge about changes in the nutritional profile of children, as well as the causes and consequences of obesity. They reported encouraging physical activities, moderate use of technologies, and nutritional education.
Ware et al., 2012⁽³⁹39. Ware LJ, Williams S, Bradbury K, Brant C, Little P, Hobbs FD, et al. Exploring weight loss services in primary care and staff views on using a web-based programme. Inform Prim Care. 2012;20(4):283-8.⁾ England	Observational, descriptive n=36	Focus groups to assess interventions by physicians, nurses and nursing aides over a period of six months, using in-person meetings, email or telephone calls to change behaviors.	Although considered an additional workload, the web program was viewed by the health professionals as a possibility for providing continuity of care.
Findholt et al., 2013⁽⁴⁰40. Findholt NE, Davis MM, Michael YL. Perceived barriers, resources, and training needs of rural primary care providers relevant to the management of childhood obesity. J Rural Health. 2013;29(1):17-24.⁾ USA	Observational, descriptive n=13	Semi-structured interviews with eight physicians and five nurses to understand the problems that affect child obesity management in a rural community.	They indicated the following barriers: time restrictions, limited knowledge, and lack of specialists and multidisciplinary care services. The professionals expressed interest in receiving training.
Little et al., 2016⁽⁴¹41. Little P, Stuart B, Hobbs FR, Kelly J, Smith ER, Bradbury KJ, et al. An internet-based intervention with brief nurse support to manage obesity in primary care (POWeR+): a pragmatic, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol. 2016;4(10):821-8.⁾ England	Controlled trial, randomized n=818	Online intervention with 24 web-based sessions, over a period of six months, on weight control associated with brief nursing support and phone calls.	The control group lost almost 3 kg in 12 months and 21% maintained a 5% weight reduction in the 12^th month. In the intervention group, there was an additional weight reduction of 1.5 kg and 29% maintained the weight in the 12^th month.

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[1] Corresponding author: Maria Cristina Pinto de Jesus. Rua José Lourenço Kelmer, S/N, Martelos. CEP 36036-330 – Juiz de Fora, MG, Brazil. mariacristina.jesus@ufjf.edu.br