Permanent health education in the context of obesity: a scoping review

Magalhães, Carolina Gusmão; Ceccim, Ricardo Burg; Silva, Lígia Amparo Santos da; Santos, Verena Macedo; Pereira, Emile Miranda; Santos, Ana Artur Francisco Mussa; Xavier Júnior, Gesner Franscisco; Martins, Poliana Cardoso; Santana, Mônica Leila Portela de

doi:10.11606/s1518-8787.2023057004244

ABSTRACT

OBJETIVE

To map the international literature on Permanent Health Education initiatives to care for people with obesity.

METHODS

In total, six databases were searched without any language or publication period restriction according to the Joana Briggs Institute manual for evidence synthesis and the Prisma extension for scoping reviews (Prisma-ScR). Articles were independently analyzed by four reviewers and data, by two authors, which were then analyzed and discussed with our research team.

RESULTS

After screening 8,780 titles/abstracts and 26 full texts, 10studies met our eligibility criteria. We extracted data on methodologies, themes, definitions of obesity, outcomes, and gaps. Most initiatives came from North American countries without free or universal health systems and lasted a short period of time (70%), had multidisciplinary teams (70%), and addressed sub-themes on obesity approaches (90%). Results included changes in participants’ understanding, attitude, and procedures (80%) and gaps which pointed to the sustainability of these changes (80%).

CONCLUSION

This review shows the scarce research in the area and a general design of poorly effective initiatives, with traditional teaching methodologies based on information transmission techniques, the understanding of obesity as a disease and a public health problem, punctual actions, disciplinary fragmentation alien to the daily work centrality, and failure to recognize problems and territory as knowledge triggers and to focus on health care networks, line of care, the integrality of care, and food and body cultures.

Patient Care Team; Education, Continuing; Obesity Management; Review

INTRODUCTION

In recent decades, the phenomenon of obesity has taken the center of the debate on global health concerns due to its complex and multifactorial character. In a recent report, the Lancet Commission on obesity offers the concept of a global syndemic, tracing an association between three pandemics: obesity, malnutrition, and climate change, phenomena with common systemic factors and complex relations interacting with each other to contribute to anew narrative needed to accelerate the social movement of change¹1. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet. 2019;393(10173):791-846. https://doi.org/10.1016/S0140-6736(18)32822-8
https://doi.org/10.1016/S0140-6736(18)32... .

A global panorama of this magnitude invites policymakers, researchers, managers, and healthcare providers to think about new forms of care which are articulated in a network, structured in longitudinal lines, and based on the integrality of care and body and food cultures²2. Ceccim RBC, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004;14(1):41-65. https://doi.org/10.1590/S0103-73312004000100004
https://doi.org/10.1590/S0103-7331200400... , ³3. Burlandy L, Teixeira MRM, Castro LMC, Cruz MCC, Santos CRB, Souza SR, et al. Modelos de assistência ao indivíduo com obesidade na atenção básica em saúde no Estado do Rio de Janeiro, Brasil. CadSaude Publica. 2020;36(3):e00093419. https://doi.org/10.1590/0102-311x00093419
https://doi.org/10.1590/0102-311x0009341... . Guidelines to organize obesity care lines point to Permanent Health Education (PHE) actions, programs, and primary care policies as a powerful political-pedagogical strategy to change health care providers’ understanding, formulation, and thinking, turning territorial realities into beacons for critical, systemic, and transformative actions²2. Ceccim RBC, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004;14(1):41-65. https://doi.org/10.1590/S0103-73312004000100004
https://doi.org/10.1590/S0103-7331200400... .

Thus, this review aims to systematically map and summarize the evidence found in this area via the following research question (RQ): what has the international literature produced about permanent education initiatives so health care providers can care for people with obesity? It also explores the following sub-issues:(RQ1) What themes and methodologies do these initiatives use?; (RQ2) How do these studies conceptualize obesity?; (RQ3) What are the results of these initiatives?; and (RQ4) What gaps do these studies show?

METHODS

Protocol and Registration

The protocol of this review was elaborated according to Prisma-P⁶6. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;350:g7647. https://doi.org/10.1136/bmj.g7647
https://doi.org/10.1136/bmj.g7647... and the Joana Briggs Institute (JBI)⁷7. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scope reviews (version 2020). In: Aromataris E, Munn Z, editors. JBI Manual for evidence synthesis. Adelaide (AU): JBI; 2020 [cited 2021 June 16]. Chapter 11. Available from: https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews
https://jbi-global-wiki.refined.site/spa... recommendations, which were reviewed by our research team. Its final draft was registered on Open Science Framework on February 24, 2021(https://osf.io/g5jkh/).

Eligibility Criteria

Studies (which could have included articles from peer-reviewed journals, dissertations, theses, and reviews) dealing with permanent education initiatives for the primary care of people with obesity (overweight and obese) were assessed by this review. Language or year of publication restrictions were ignored to expand the number of retrieved studies. Quantitative, qualitative, and mixed studies were included to map different methodological approaches.

Studies which met the following criteria were excluded: participants who were not primarily healthcare providers; initiatives ignoring PHE, i.e., if they had no intention of educating professionals to work in health care networks; those outside primary care; and educational initiatives which dealt with issues other than obesity. Invitro studies with animals, texts, opinion papers, letters, conference summaries, and editorials were excluded because they failed to meet the objectives of this review.

Information Sources

At first, a limited search was conducted on two databases, Medline (PubMed) and CINAHL, followed by an analysis of the words contained in the title and abstract of the retrieved articles and of the terms in the indices and keywords used to describe the articles. To find as much relevant evidence as possible, our search for studies was comprehensive and systematic. Medline via PubMed, Embase, CINAHL, Scopus, Web of Science, and Lilacs were the databases selected for research. Nevertheless, Google Scholar and Open Gray were also searched for grey literature. Our search strategy was developed with descriptors which were synonymous to those in MeSH (PubMed), DeCS (Lilacs), and Emtree (Embase). Our search strategy was applied to these data bases by a reviewer and results, exported to Rayyan for duplicate removal and initial sorting. Reference lists with the included studies were evaluated. A wide consultation with specialists in the area was carried out to recover important studies which our searches failed to retrieve. Subsequently, the selected publications were exported to EndNote web. Our research team was assisted in this process by a librarian specialized in health (GFXJ). The search strategies developed for each database are included in an additional file ( Figure 1 ).

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Figure 1
Prisma diagram flow for this scoping review.

Sources of Evidence Selection

The entire selection was accompanied by two pilot tests. On the first stage, 25 titles/abstracts from sources of evidence were read and, on the second, five others, in full. Random sample were included in both sources. These studies were screened by our entire team according to our eligibility criteria, showing an agreement above 75%, as per the JBI Manual for Evidence Synthesis.⁷7. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scope reviews (version 2020). In: Aromataris E, Munn Z, editors. JBI Manual for evidence synthesis. Adelaide (AU): JBI; 2020 [cited 2021 June 16]. Chapter 11. Available from: https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews
https://jbi-global-wiki.refined.site/spa... Selections based on titles/abstracts and full texts were made in Rayyan by four independent reviewers (CGM, VMS, EMP, and AAFMS) and disagreements were resolved in pairs or by a third reviewer’s intervention. In the absence of additional information or data, the authors of the chosen studies were contacted.

Data Items and Data Charting Process

Data were summarized by the following characteristics: articles (country of origin, health system, funding, year of publication and authors); participants (demographic and sample size); educational initiatives (methodology, theme addressed, results achieved and gaps); and research (context, outcome and main results). The JBI Sumari software was used to map our findings.

The entire data extraction process was carried out by two independent reviewers (CGM and VMS), who discussed results and procedurally and simultaneously updated our data graph. To increase consistency among reviewers, a pilot source extraction test was performed with a random sample of four publications, about which reviewers showed an agreement above 75% on the mapped data. Any divergence was resolved by consensus or by the intervention of a third reviewer.

Result Synthesis

Results were synthesized by frequency and thematic analysis. Textual data were thematically analyzed by a reviewer and verified by a second one (CGM and MLPS) via ATLAS.ti. A tabular diagram, word cloud (Wordcloud.com), data graph, and narrative summary were elaborated by the authors according to Prisma ScR⁸8. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-73. https://doi.org/10.7326/M18-0850
https://doi.org/10.7326/M18-0850... recommendations, both in line and describing how results related to the questions and objectives of this review.

RESULTS (N = 10)

Sources of Evidence Selection

We retrieved 10,169 publications, one of which⁹9. Rueda-Clausen CF, Benterud E, Bond T, Olszowka R, Vallis MT, Sharma AM. Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care. Clin Obes. 2014;4(1):39-44. https://doi.org/doi:10.1111/cob.12038
https://doi.org/doi:10.1111/cob.12038... by a survey in our reference lists. We removed 1390 duplicates and evaluated 8,780 titles and abstracts and 26 full-text articles for eligibility. We neither found documents in the grey literature nor by consulting specialists. Subsequently, 10 studies, reported in 15 publications, met our eligibility criteria⁹9. Rueda-Clausen CF, Benterud E, Bond T, Olszowka R, Vallis MT, Sharma AM. Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care. Clin Obes. 2014;4(1):39-44. https://doi.org/doi:10.1111/cob.12038
https://doi.org/doi:10.1111/cob.12038... . Figure 1 shows the reasons for excluding full articles.

Sources of Evidence Characteristics

All studies were published after 2004 and originated in the United States of America (60%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , Canada (20%)¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... , Israel (10%)¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , and Iran (10%)¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... (Appendix S2). In total, eight publications were linked to three mixed studies¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , seven were quantitative studies¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , of which one was a dissertation¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... . Most were original studies (100%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... conducted in countries without universal health systems (60%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... which received public funding (30%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , appeared in journals whose central scope addressed training healthcare providers (30%)¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... , had quasi-experimental methods (60%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... aimed at primary care (80%)¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , and contained multidisciplinary groups (70%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... . Table 2 described the included studies.

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Table 1
Characteristics of the included studies (n = 10).

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Table 2
Thematic analysis results of the scoping review research questions

RQ1A. Permanent Health Education Initiatives themes

Most initiatives focused on self-reported approaches to obesity (80%)¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , including biomedical, psychological/behavioral, ecological, cultural, and environmental ones; and professional qualification strategies (40%)¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... . We must point out that twostudies¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... qualitatively assessed the involved healthcare providers’ current educational needs to build content panels for these initiatives, a participation strategy evinced in the PHE methodological principle. Table 3 shows a table with content frequency and thematic analysis.

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Table 3
Thematic analysis results of the research questions of this scoping review.

RQ1B. Methodology of Permanent Health Education Initiatives

Most studies showed the following methodological profile for their initiatives: oral exposure (60%)¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... and/or discussion (60%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... as teaching strategies; which lasted one day (70%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... and included individual (80%)¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... in-person participation (80%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... in a single meeting (50%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... . Some initiatives used data from participants’ reality, such as the prevalence of local obesity¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... and evaluations of medical records of patients with obesity¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... . Table 3 shows these data.

RQ2. Concept of Obesity

Most studies considered obesity as a problem (60%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... linked to world public health (30%)¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... and complex systems (10%)¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... which is common in primary care (10%)¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... . The other studies brought concepts such as world epidemic (20%)¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... ; prevalent chronic conditions (10%)¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... ; and risk factors for non-communicable chronic diseases (20%)¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... . Studies focused on explanatory models of obesity: (i) body mass indices (BMI) (40%)¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... ; (ii) the environment (20%)¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... ; (iii) culture (20%)¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... ; (iv) ecology (10%)¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... ; and (v) the perspective of a complex system, in which individual behaviors related to nutrition and physical activity interact with genetics, socioeconomic factors, among other factors (10%)¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... . Figure 2 shows a conceptual word cloud arrangement of these explanatory models.

Thumbnail

Figure 2
Obesity concept word cloud.

RQ3. Results of Permanent Health Education Initiatives

All initiatives showed results on participants’ conceptual, procedural, and attitudinal changes (100%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , evaluating them via pre-research (100%), immediate post-intervention (80%), and afterone¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , three¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , six¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... , and 12 months¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... . Table 3 offers a more detailed description.

RQ4. Gaps in Permanent Health Education Initiatives

Most initiatives showed gaps related to sustaining the conceptual, attitudinal, and procedural changes promoted by their courses (50%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... and teaching strategies (40%)¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... . Table 3 offers a more detailed description.

DISCUSSION

Regarding their general scope, results (n = 10) show a scarcity of research in the area and, consequently, novelty and importance for policymakers²⁴24. Ministério da Saúde (BR). Síntese de evidências para políticas de saúde: estimulando o uso de evidências científicas na tomada de decisão. Brasilia, DF; 2015. . The included studies showed initiatives to educate healthcare providers with methodological profiles focused on specific actions, technical and instrumental biases, and subthemes which addressed obesity (especially from a biomedical perspective— among others which often failed to dialogue with the problems of healthcare providers’ everyday life). Our sample addressed obesity as a public health problem, evincing a more quantitative bias between disease and risk factor. Initiative results showed changes in professionals’ concept and attitude toward obesity but only slightly altered the procedural field of caring for these patients, showing, in their gaps, the concern that future longitudinal research can investigate changes in long-term care practices.

Although widely used in its health services, we retrieved no study conducted in Latin America, in which PHE emerged in the 1980s as a methodological strategy at the initiative of the Pan American and World Health Organizations, structured in 2004 as a public policy for health training linked to national health services and disseminated throughout the Brazilian territory²⁵25. Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009. . Thus, it is necessary to consider the importance of encouraging the scientific dissemination of experiences in the everyday life of health services as evidence which can structure major scientific leaps in the area.

The fact that most studies come from the USA¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... endorses its pioneering and advancing spirit in scientific research on obesity handling and management. It historically adopted a mixed health system model, lacking universal health coverage and whose private sector lies higher than the public one. Moreover, it has institutionalized the issue of obesity – a process which corroborated, according to Poullain²⁶26. Poulain JP. Sociologia da obesidade. São Paulo: Senac São Paulo; 2013. , to place it as a world public health issue.

Such conditions signal a shift from the epistemological status of obesity to a more quantitative definition which suffers great interference from economic interests (private health insurance and food companies)²⁷27. Nestle M. Uma verdade indigesta: como a indústria alimentícia distorce a ciência do que comemos. São Paulo: Elefante; 2019. , ²⁸28. Peres J. Os bolsos gordos da ciência da obesidade. O Joio e o Trigo. 4 dez 2017 [cited 2021 Jun 16]. Available from: https://ojoioeotrigo.com.br/2017/12/os-bolsos-gordos-da-ciencia-da-obesidade/
https://ojoioeotrigo.com.br/2017/12/os-b... which outline the scope of such investigations, both assuming the hegemony of biomedical biases and the “warlike” logic of dealing with obesity, which, according to Foucault²⁹29. Foucault M. História da sexualidade. Vol. 1, A vontade de saber (1976). Rio de Janeiro: Graal; 1999. , controls body mass structure biopower techniques centered on the individualized body and considers it relevant to understand the tensions, logics, and interests around obesity to think of care strategies more focused on integrality, respect for individuality, and a critical position against the stigma it carries.

This review assumed a conceptual-methodological difference between continuing education (CE) and PHE. The first, the traditional resource in health, centers around updating knowledge, usually with a disciplinary focus based on transmission techniques, thus constituting a discontinuous training strategy with time breaks²⁵25. Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009. , ³⁰30. Miccas FL, Batista SH. Educação permanente em saúde: metassíntese. RevSaude Publica. 2014;48(1):170-85. https://doi.org/10.1590/s0034-8910.2014048004498
https://doi.org/10.1590/s0034-8910.20140... . PHE, on the other hand, proposes changing the conception and practices of health training and incorporating teaching and learning into the daily life of services, with practice as a source of knowledge and problems that increase teams’ critical thinking based on network, comprehensive care, and multiprofessional, interdisciplinary, and intersectoral approaches²2. Ceccim RBC, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004;14(1):41-65. https://doi.org/10.1590/S0103-73312004000100004
https://doi.org/10.1590/S0103-7331200400... , ⁵5. Ceccim RB, Ferla, AA. Educação permanente em saúde. In: Pereira IB, Lima JCF, organizadores. Dicionário de educação professional em saúde. 2. ed. rev. ampl. Rio de Janeiro: EPSJV; 2009 [cited 2020 Aug 16]. Availablefrom: http://www.sites.epsjv.fiocruz.br/dicionario/verbetes/edupersau.html
http://www.sites.epsjv.fiocruz.br/dicion... , ²⁵25. Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009. , ³⁰30. Miccas FL, Batista SH. Educação permanente em saúde: metassíntese. RevSaude Publica. 2014;48(1):170-85. https://doi.org/10.1590/s0034-8910.2014048004498
https://doi.org/10.1590/s0034-8910.20140... .In our analysis of the context of these actions, the included studies show initiatives which mainly relate to CE — punctual actions¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... , disciplinary fragmentation¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... ,andtraditional teaching methodologies based on transmission techniques¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... , even if some had moved toward PHE. This methodological design exposes a still present weakness in health education between what is desired and what is effectively done. It aims, for example, to offer something new using the same and exhausted strategies of knowledge mediation.

PHE presupposes the development of educational practices focusing on the resolution of concrete problems via team discussions based on the perspective of transforming work processes²2. Ceccim RBC, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004;14(1):41-65. https://doi.org/10.1590/S0103-73312004000100004
https://doi.org/10.1590/S0103-7331200400... , ⁵5. Ceccim RB, Ferla, AA. Educação permanente em saúde. In: Pereira IB, Lima JCF, organizadores. Dicionário de educação professional em saúde. 2. ed. rev. ampl. Rio de Janeiro: EPSJV; 2009 [cited 2020 Aug 16]. Availablefrom: http://www.sites.epsjv.fiocruz.br/dicionario/verbetes/edupersau.html
http://www.sites.epsjv.fiocruz.br/dicion... , ²⁵25. Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009. , ³⁰30. Miccas FL, Batista SH. Educação permanente em saúde: metassíntese. RevSaude Publica. 2014;48(1):170-85. https://doi.org/10.1590/s0034-8910.2014048004498
https://doi.org/10.1590/s0034-8910.20140... . Thus, four studies claimed, as their methodological strategies, to survey both participants’ problems as guidelines to build themes/contents for their PHEinitiatives¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... and data on the health service reality¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... and on advocacy resources in the care forobesity¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , a strategy based on what Ceccim²2. Ceccim RBC, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004;14(1):41-65. https://doi.org/10.1590/S0103-73312004000100004
https://doi.org/10.1590/S0103-7331200400... calls a four-way approach to training: teaching - care- management - social control, in which “each face involves a pedagogical call, an image of the future, an apolitical struggle, and a web of connections” (p.47). These strategies project participants’ critical approach to their realities, promoting the recognition of possibilities for emancipatory action in the face of the actual situations experienced in health services.

The contents of the initiatives dealt with approaches toobesity¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , most only discussed its biomedical perspective¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... ; professional qualification strategies¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... ; relations with PHE, including the strategic development of intervention plans¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... ; and obesity handling and management¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... . In general, initiatives mainly discussed continuous self-improvement in the search for professional and personal competence and only slightly consider the situations problematizing work to transform reality³³33. Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005;9(16):161-78. https://doi.org/10.1590/S1414-32832005000100013
https://doi.org/10.1590/S1414-3283200500... . The addressed sub-themes need to dialogue more with participants’ yearnings for change since they show a greater number of possible points of analysis when facing the same situation —obesity —, subsidizing the critical analysis of their realities to promote more critical, creative, and autonomous decision-making.

Educational actions in health human resources traditionally have methodological designs consisting of short actions¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... which favor individual participations¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... and teaching strategies mainly based on oral exposure¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... ; methodological conditions which, allied to institutional, political, ideological, and cultural ones, anticipate and determine the space within which training can operate its limits and possibilities: a simplified and instrumental vision of education; its low discrimination of problems to be overcome; and immediacy in projects with predetermined beginnings and ends²⁵25. Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009. , ³⁴34. Merhy EE. O desafio que a educação permanente tem em si: a pedagogia da implicação. Interface (Botucatu). 2005;9(16):172-4. https://doi.org/10.1590/S1414-32832005000100015
https://doi.org/10.1590/S1414-3283200500... ; results pointing to methodological designs far removed from what the National PHE Policy proposes in Brazil²⁵25. Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009. , ³²32. Ministério da Saúde (BR). Portaria Nº 198/GM/MS, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor, e dá outras providências. Brasília, DF; 2004. .

Studies conceptualized obesity as a problem¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... in global public health¹¹11. Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
https://doi.org/10.1186/1472-6920-5-4... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... which has a complex system¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... and is common in primary care¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... . Recognition as a public health issue, according to Poulain²⁶26. Poulain JP. Sociologia da obesidade. São Paulo: Senac São Paulo; 2013. , occurs after two conditions are met: theme institutionalization and the change in the epistemological status of obesity to a more quantitative definition — either as a risk factor¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... or a disease, consolidated by the use of BMI as an evaluation method¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... — in a process which medicalized obesity²⁶26. Poulain JP. Sociologia da obesidade. São Paulo: Senac São Paulo; 2013. , although limited, according to Gard & Wright³⁵35. Gard M, Wright J. The obesity epidemic: science, morality and ideology. London (UK): Routledge; 2005. .

Since the WHO³⁶36. World Health Organization. Obesity: preventing and managing the global epidemic: report of a WHO consultation. Geneva (CH): WHO; 2000. (WHO Technical Report Series; nº 894). used the term global “epidemic” (a concept which two studies¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... mention), obesity has gained prominence in the media and political debate, forming a true “warlike” scenario with considerable symbolic consequences and involving different agents which are motivated by different interests, offering questionable services, products, and information in the fight against the “enemy”¹1. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet. 2019;393(10173):791-846. https://doi.org/10.1016/S0140-6736(18)32822-8
https://doi.org/10.1016/S0140-6736(18)32... , ²⁶26. Poulain JP. Sociologia da obesidade. São Paulo: Senac São Paulo; 2013. . Although this narrative represents the current hegemonic discourse, according to the Lancet¹1. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet. 2019;393(10173):791-846. https://doi.org/10.1016/S0140-6736(18)32822-8
https://doi.org/10.1016/S0140-6736(18)32... report and authors from the Social and Human Sciences²⁶26. Poulain JP. Sociologia da obesidade. São Paulo: Senac São Paulo; 2013. , ³⁵35. Gard M, Wright J. The obesity epidemic: science, morality and ideology. London (UK): Routledge; 2005. , ³⁷37. Amparo-Santos L. Saúde, práticas corporais e obesidade na cultura contemporânea. In: Nascimento MC, Nogueira MI, organizadores. Intercâmbio solidário de saberes em sáude: racionalidades médicas e práticas integrativas e complementarers. São Paulo: Hucitec; 2013; p. 171-90. , it offers a limited understanding in the face of the phenomenon of obesity because it ignores its complexity, a condition only one study¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... signaled and valued by the systemic approach of PHE.

Regarding the results of these initiatives, all studies point to changes in participants. However, the most expressive are, according to the typology in Zabala⁴¹41. Zabala A. A prática educativa: como ensinar. 2. Ed. Porto Alegre: Artmed; 2010. , in their conceptual¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... and attitudinal content¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹⁵15. Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
https://doi.org/10.1186/1748-5908-9-78... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... , with lower expression in the procedural one¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , a great objective regarding primary care work collectives³¹31. Vasconcelos M, Grillo MJC, Soares SM. Práticas pedagógicas em atenção básica à saúde: tecnologias para abordagem ao indivíduo, família e comunidade. Belo Horizonte, MG: Editora UFMG; Nescon UFMG; 2009. . Moreover, some results describe the limits and potentialities of teaching strategies¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... , in which we find the success of those involving discussion and group work when we compared them to transmission strategies¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... . Thus, longitudinal studies may be a good strategy to promote more lasting changes also in the field of procedural contents installed in health services.

Also regarding results, two studies¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... highlighted that the use of strategies to understand cultural contexts (by race) within services provided significant conceptual and procedural changes for some participants, endorsing a premise of reorganizing their work process via the concept of territorialization⁴²42. Gondim GMM, Monken M, Rojas LI, Barcellos C, Peiter P. O território da saúde: a organização do sistema de saúde e a territorialização. In: Miranda AC, Barcellos C, Moreira JC, Momken M, organizadores. Território, ambiente e saúde. Rio de Janeiro: Fiocruz; 2008: p. 237-55. as an instrument to diagnose and analyze health situations in local planning. Finally, regarding the products of these actions, two studies¹²12. Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
https://doi.org/10.1016/j.jneb.2011.01.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... elaborated an individual intervention plan, a strategy qualifying social actors³³33. Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005;9(16):161-78. https://doi.org/10.1590/S1414-32832005000100013
https://doi.org/10.1590/S1414-3283200500... for strategic thinking/reasoning and the ability to contextualize projects for relevant healthcare problems⁴³43. Caleman G, Lima VV, Oliveira MS, Massaro A, Gomes R, Pereira MSF, et al. Projeto Aplicativo: termos de referência. São Paulo: Instituto Sírio-Libanês de Ensino e Pesquisa; Ministério da Saúde; 2016. (Projetos de Apoioao SUS). . The latter results are the most significant and desired for health services for their transformative power and association with the real needs of the monitored population.

Regarding gaps, six studies¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹³13. McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
https://doi.org/10.2105/AJPH.2012.300833... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁷17. Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
https://doi.org/10.1007/s40615-016-0231-... , ¹⁹19. Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
https://doi.org/10.1186/s12909-018-1380-... recorded the importance of further research designing longer and more targeted initiatives to assess the sustainability of conceptual, attitudinal, and procedural changes, considering that, even if these initiatives achieve individual learning, they fail to always translate themselves into organizational learning, i.e., the reorganization of collective work processes²⁵25. Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009. , ³³33. Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005;9(16):161-78. https://doi.org/10.1590/S1414-32832005000100013
https://doi.org/10.1590/S1414-3283200500... , a premise of the Brazilian National PHE Policy²⁵25. Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009. , ³²32. Ministério da Saúde (BR). Portaria Nº 198/GM/MS, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor, e dá outras providências. Brasília, DF; 2004. . Some studies¹⁰10. Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
https://doi.org/10.1016/j.jada.2003.12.0... , ¹⁴14. Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
https://doi.org/10.1002/chp.21141... , ¹⁶16. Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
https://doi.org/10.1097/PHH.000000000000... , ¹⁸18. Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
http://hdl.handle.net/10150/626636... indicate the possibility of surveying more powerful and cost-effective teaching strategies given the exhaustion of so many traditional and discontinued strategies aimed at transmission. In this sense, the PHE launches itself as a potential political-pedagogical practice that,

(…) at the same time as it disputes for the daily updating of practices according to the most recent theoretical, methodological, scientific, and technological contributions available, it is part of a necessary construction of relationships and processes which stem from within teams in a joint action – including their agents, organizational practices – involving the institution and/or the health sector and interinstitutional and/or intersectoral practices – linked to the policies in which the health acts are included³³33. Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005;9(16):161-78. https://doi.org/10.1590/S1414-32832005000100013
https://doi.org/10.1590/S1414-3283200500... (p.161).

Interpreting international production shows that obesity is a public health problem, and that health education rarely questions food versus body. Bio pedagogical studies on the stigma of obesity, the “invention” of the obesity epidemic, or those with a cultural and anthropological basis are absent in the training of healthcare providers toward a clinical/assisting approach to obesity. Most studies stem from countries without a universal health system, evincing that obesity has meanings in these countries unlike those of a “Brazilian-style” PHE. Thus, the great need to encourage the dissemination of research in the area and of considering the use of PHE as urgent.

The strengths of this review include its comprehensive bibliographical research in various electronic databases via a rigorous methodology suggested by JBI⁷7. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scope reviews (version 2020). In: Aromataris E, Munn Z, editors. JBI Manual for evidence synthesis. Adelaide (AU): JBI; 2020 [cited 2021 June 16]. Chapter 11. Available from: https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews
https://jbi-global-wiki.refined.site/spa... and Prisma-ScR⁸8. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-73. https://doi.org/10.7326/M18-0850
https://doi.org/10.7326/M18-0850... . Note also its novelty in view of the scarcity of publications in the national and international literature which focused on PHE focused on obesity care. Worldwide, the use of these syntheses is considered a priority to formulate well-informed and effective policies²⁴24. Ministério da Saúde (BR). Síntese de evidências para políticas de saúde: estimulando o uso de evidências científicas na tomada de decisão. Brasilia, DF; 2015. , ⁴⁴44. Lavis JN, Oxman AD, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP). Health Res Policy Syst. 2009;7 Suppl 1:I1. https://doi.org/10.1186/1478-4505-7-S1-I1
https://doi.org/10.1186/1478-4505-7-S1-I... .

Limitation

This study shows limitations regarding the scarcity of evidence, especially for Latin America and mainly for Brazil, regions which have consolidated PHE. Moreover, this scope review was a huge undertaking and our results include research only up to October 2020.

CONCLUSION

This scope review showed a scarcity of research in its area of interest and that most PHE initiatives for obesity care show a traditional teaching methodology centered on transmission of information techniques, punctual actions, and disciplinary fragmentation, unlike what PHE proposes. It also suggests that the concept of obesity is still mostly linked to a biomedical bias, although the literature has gradually included other causal approaches, and that short-term research fails to promote changes in the field of procedural content, making learning and organizational changes unfeasible. Future research should study continuous initiatives focused on professionals’ daily work, recognizing their problems as real and strategic knowledge triggers, considering the notion of network, line of care, integrality of care, and food and body cultures.

REFERENCES

¹
Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet. 2019;393(10173):791-846. https://doi.org/10.1016/S0140-6736(18)32822-8
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⁵
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⁷
Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scope reviews (version 2020). In: Aromataris E, Munn Z, editors. JBI Manual for evidence synthesis. Adelaide (AU): JBI; 2020 [cited 2021 June 16]. Chapter 11. Available from: https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews
» https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews
⁸
Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-73. https://doi.org/10.7326/M18-0850
» https://doi.org/10.7326/M18-0850
⁹
Rueda-Clausen CF, Benterud E, Bond T, Olszowka R, Vallis MT, Sharma AM. Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care. Clin Obes. 2014;4(1):39-44. https://doi.org/doi:10.1111/cob.12038
» https://doi.org/doi:10.1111/cob.12038
¹⁰
Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
» https://doi.org/10.1016/j.jada.2003.12.017
¹¹
Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
» https://doi.org/10.1186/1472-6920-5-4
¹²
Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
» https://doi.org/10.1016/j.jneb.2011.01.010
¹³
McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
» https://doi.org/10.2105/AJPH.2012.300833
¹⁴
Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
» https://doi.org/10.1002/chp.21141
¹⁵
Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
» https://doi.org/10.1186/1748-5908-9-78
¹⁶
Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
» https://doi.org/10.1097/PHH.0000000000000046
¹⁷
Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
» https://doi.org/10.1007/s40615-016-0231-2
¹⁸
Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
» http://hdl.handle.net/10150/626636
¹⁹
Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
» https://doi.org/10.1186/s12909-018-1380-2
²⁰
Asselin J, Osunlana AM, Ogunleye AA, Sharma AM, Campbell-Scherer D. Challenges in interdisciplinary weight management in primary care: lessons learned from the 5As Team study. Clin Obes. 2016;6(2):124-32. https://doi.org/10.1111/cob.12133
» https://doi.org/10.1111/cob.12133
²¹
Osunlana AM, Asselin J, Anderson R, Ogunleye AA, Cave A, Sharma AM, et al. 5As Team obesity intervention in primary care: development and evaluation of shared decision-making weight management tools. Clin Obes. 2015;5(4):219-25. https://doi.org/10.1111/cob.12105
» https://doi.org/10.1111/cob.12105
²²
Campbell-Scherer DL, Asselin J, Osunlana AM, Ogunleye AA, Fielding S, Anderson R, et al. Changing provider behaviour to increase nurse visits for obesity in family practice: the 5As Team randomized controlled trial. CMAJ Open. 2019;7(2):E371-E378. https://doi.org/10.9778/cmajo.20180165
» https://doi.org/10.9778/cmajo.20180165
²³
Ogunleye A, Osunlana A, Asselin J, Cave A, Sharma AM, Campbell-Scherer DL. The 5As team intervention: bridging the knowledge gap in obesity management among primary care practitioners. BMC Res Notes. 2015;8:810. https://doi.org/10.1186/s13104-015-1685-8
» https://doi.org/10.1186/s13104-015-1685-8
²⁴
Ministério da Saúde (BR). Síntese de evidências para políticas de saúde: estimulando o uso de evidências científicas na tomada de decisão. Brasilia, DF; 2015.
²⁵
Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009.
²⁶
Poulain JP. Sociologia da obesidade. São Paulo: Senac São Paulo; 2013.
²⁷
Nestle M. Uma verdade indigesta: como a indústria alimentícia distorce a ciência do que comemos. São Paulo: Elefante; 2019.
²⁸
Peres J. Os bolsos gordos da ciência da obesidade. O Joio e o Trigo. 4 dez 2017 [cited 2021 Jun 16]. Available from: https://ojoioeotrigo.com.br/2017/12/os-bolsos-gordos-da-ciencia-da-obesidade/
» https://ojoioeotrigo.com.br/2017/12/os-bolsos-gordos-da-ciencia-da-obesidade/
²⁹
Foucault M. História da sexualidade. Vol. 1, A vontade de saber (1976). Rio de Janeiro: Graal; 1999.
³⁰
Miccas FL, Batista SH. Educação permanente em saúde: metassíntese. RevSaude Publica. 2014;48(1):170-85. https://doi.org/10.1590/s0034-8910.2014048004498
» https://doi.org/10.1590/s0034-8910.2014048004498
³¹
Vasconcelos M, Grillo MJC, Soares SM. Práticas pedagógicas em atenção básica à saúde: tecnologias para abordagem ao indivíduo, família e comunidade. Belo Horizonte, MG: Editora UFMG; Nescon UFMG; 2009.
³²
Ministério da Saúde (BR). Portaria Nº 198/GM/MS, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor, e dá outras providências. Brasília, DF; 2004.
³³
Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005;9(16):161-78. https://doi.org/10.1590/S1414-32832005000100013
» https://doi.org/10.1590/S1414-32832005000100013
³⁴
Merhy EE. O desafio que a educação permanente tem em si: a pedagogia da implicação. Interface (Botucatu). 2005;9(16):172-4. https://doi.org/10.1590/S1414-32832005000100015
» https://doi.org/10.1590/S1414-32832005000100015
³⁵
Gard M, Wright J. The obesity epidemic: science, morality and ideology. London (UK): Routledge; 2005.
³⁶
World Health Organization. Obesity: preventing and managing the global epidemic: report of a WHO consultation. Geneva (CH): WHO; 2000. (WHO Technical Report Series; nº 894).
³⁷
Amparo-Santos L. Saúde, práticas corporais e obesidade na cultura contemporânea. In: Nascimento MC, Nogueira MI, organizadores. Intercâmbio solidário de saberes em sáude: racionalidades médicas e práticas integrativas e complementarers. São Paulo: Hucitec; 2013; p. 171-90.
³⁸
Ralston J, Brinsden H, Buse K, Candeias V, Caterson I, Hassell T, et al. Time for a new obesity narrative. Lancet. 2018;392(10156):1384-6. https://doi.org/10.1016/S0140-6736(18)32537-6
» https://doi.org/10.1016/S0140-6736(18)32537-6
³⁹
Yates-Doerr E. The weight of obesity.Berkeley, CA: University of California Press; 2015.
⁴⁰
Monaghan LF, Hollands R, Prtichard G. Obesity epidemic entrepreneurs: types, practices and interests. Body Soc. 2010;16(2):37-71. https://doi.org/10.1177/1357034X10364769
» https://doi.org/10.1177/1357034X10364769
⁴¹
Zabala A. A prática educativa: como ensinar. 2. Ed. Porto Alegre: Artmed; 2010.
⁴²
Gondim GMM, Monken M, Rojas LI, Barcellos C, Peiter P. O território da saúde: a organização do sistema de saúde e a territorialização. In: Miranda AC, Barcellos C, Moreira JC, Momken M, organizadores. Território, ambiente e saúde. Rio de Janeiro: Fiocruz; 2008: p. 237-55.
⁴³
Caleman G, Lima VV, Oliveira MS, Massaro A, Gomes R, Pereira MSF, et al. Projeto Aplicativo: termos de referência. São Paulo: Instituto Sírio-Libanês de Ensino e Pesquisa; Ministério da Saúde; 2016. (Projetos de Apoioao SUS).
⁴⁴
Lavis JN, Oxman AD, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP). Health Res Policy Syst. 2009;7 Suppl 1:I1. https://doi.org/10.1186/1478-4505-7-S1-I1
» https://doi.org/10.1186/1478-4505-7-S1-I1

Funding: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq - Process 408611/2017-0, regarding the acquisition of software for the data extraction stage).

Publication Dates

Publication in this collection
14 Apr 2023
Date of issue
2023

History

Received
24 Sept 2021
Accepted
28 Mar 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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» https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews

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Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-73. https://doi.org/10.7326/M18-0850
» https://doi.org/10.7326/M18-0850

[9] ⁹
Rueda-Clausen CF, Benterud E, Bond T, Olszowka R, Vallis MT, Sharma AM. Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care. Clin Obes. 2014;4(1):39-44. https://doi.org/doi:10.1111/cob.12038
» https://doi.org/doi:10.1111/cob.12038

[10] ¹⁰
Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion. J Am Diet Assoc. 2004;104(3):379-86. https://doi.org/10.1016/j.jada.2003.12.017
» https://doi.org/10.1016/j.jada.2003.12.017

[11] ¹¹
Katz S, Feigenbaum A, Pasternak S, Vinker S. An interactive course to enhance self-efficacy of family practitioners to treat obesity. BMC Med Educ. 2005;5(1):4. https://doi.org/10.1186/1472-6920-5-4
» https://doi.org/10.1186/1472-6920-5-4

[12] ¹²
Stark CM, Graham-Kiefer ML, Devine CM, Dollahite JS, Olson CM. Online course increases nutrition professionals’ knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity. J Nutr Educ Behav. 2011;43(5):316-22. https://doi.org/10.1016/j.jneb.2011.01.010
» https://doi.org/10.1016/j.jneb.2011.01.010

[13] ¹³
McPherson ME, Mirkin R, Heatherley PN, Homer CJ. Educating health care professionals in advocacy for childhood obesity prevention in their communities: integrating public health and primary care in the Be Our Voice project. Am J Public Health. 2012;102(8):e37-e43. https://doi.org/10.2105/AJPH.2012.300833
» https://doi.org/10.2105/AJPH.2012.300833

[14] ¹⁴
Sarayani A, Rashidian A, Gholami K, Torkamandi H, Javadi M. Efficacy of continuing education in improving pharmacists’ competencies for providing weight management service: three-arm randomized controlled trial. J Contin Educ Health Prof. 2012;32(3):163-73. https://doi.org/10.1002/chp.21141
» https://doi.org/10.1002/chp.21141

[15] ¹⁵
Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial. ImplementSci. 2014;9:78. https://doi.org/10.1186/1748-5908-9-78
» https://doi.org/10.1186/1748-5908-9-78

[16] ¹⁶
Mainor A, Leeman J, Sommers J, Heiser C, Gonzalez C, Farris RP, et al. A systematic approach to evaluating public health training: the obesity prevention in public health course. J Public Health ManagPract. 2014;20(6):647-53. https://doi.org/10.1097/PHH.0000000000000046
» https://doi.org/10.1097/PHH.0000000000000046

[17] ¹⁷
Vasudevan DA, Northrup TF, Mandayam S, Bamidele OO, Stotts AL. Impact of physician training on diagnosis and counseling of overweight and obese Asian patients. J Racial Ethn Health Disparities. 2017;4(3):322-8. https://doi.org/10.1007/s40615-016-0231-2
» https://doi.org/10.1007/s40615-016-0231-2

[18] ¹⁸
Joshua S. Enhancing culturally competent care for obesity among African immigrants [dissertation]. Tucson (AZ): The University of Arizona; 2017 [cited 2021 June 21]. Available from: http://hdl.handle.net/10150/626636
» http://hdl.handle.net/10150/626636

[19] ¹⁹
Sanchez-Ramirez DC, Long H, Mowat S, Hein C. Obesity education for front-line healthcare providers. BMC Med Educ. 2018;18(1):278. https://doi.org/10.1186/s12909-018-1380-2
» https://doi.org/10.1186/s12909-018-1380-2

[20] ²⁰
Asselin J, Osunlana AM, Ogunleye AA, Sharma AM, Campbell-Scherer D. Challenges in interdisciplinary weight management in primary care: lessons learned from the 5As Team study. Clin Obes. 2016;6(2):124-32. https://doi.org/10.1111/cob.12133
» https://doi.org/10.1111/cob.12133

[21] ²¹
Osunlana AM, Asselin J, Anderson R, Ogunleye AA, Cave A, Sharma AM, et al. 5As Team obesity intervention in primary care: development and evaluation of shared decision-making weight management tools. Clin Obes. 2015;5(4):219-25. https://doi.org/10.1111/cob.12105
» https://doi.org/10.1111/cob.12105

[22] ²²
Campbell-Scherer DL, Asselin J, Osunlana AM, Ogunleye AA, Fielding S, Anderson R, et al. Changing provider behaviour to increase nurse visits for obesity in family practice: the 5As Team randomized controlled trial. CMAJ Open. 2019;7(2):E371-E378. https://doi.org/10.9778/cmajo.20180165
» https://doi.org/10.9778/cmajo.20180165

[23] ²³
Ogunleye A, Osunlana A, Asselin J, Cave A, Sharma AM, Campbell-Scherer DL. The 5As team intervention: bridging the knowledge gap in obesity management among primary care practitioners. BMC Res Notes. 2015;8:810. https://doi.org/10.1186/s13104-015-1685-8
» https://doi.org/10.1186/s13104-015-1685-8

[24] ²⁴
Ministério da Saúde (BR). Síntese de evidências para políticas de saúde: estimulando o uso de evidências científicas na tomada de decisão. Brasilia, DF; 2015.

[25] ²⁵
Ministério da Saúde (BR). Política Nacional de Educação Permanente em Saúde. Brasilia, DF; 2009.

[26] ²⁶
Poulain JP. Sociologia da obesidade. São Paulo: Senac São Paulo; 2013.

[27] ²⁷
Nestle M. Uma verdade indigesta: como a indústria alimentícia distorce a ciência do que comemos. São Paulo: Elefante; 2019.

[28] ²⁸
Peres J. Os bolsos gordos da ciência da obesidade. O Joio e o Trigo. 4 dez 2017 [cited 2021 Jun 16]. Available from: https://ojoioeotrigo.com.br/2017/12/os-bolsos-gordos-da-ciencia-da-obesidade/
» https://ojoioeotrigo.com.br/2017/12/os-bolsos-gordos-da-ciencia-da-obesidade/

[29] ²⁹
Foucault M. História da sexualidade. Vol. 1, A vontade de saber (1976). Rio de Janeiro: Graal; 1999.

[30] ³⁰
Miccas FL, Batista SH. Educação permanente em saúde: metassíntese. RevSaude Publica. 2014;48(1):170-85. https://doi.org/10.1590/s0034-8910.2014048004498
» https://doi.org/10.1590/s0034-8910.2014048004498

[31] ³¹
Vasconcelos M, Grillo MJC, Soares SM. Práticas pedagógicas em atenção básica à saúde: tecnologias para abordagem ao indivíduo, família e comunidade. Belo Horizonte, MG: Editora UFMG; Nescon UFMG; 2009.

[32] ³²
Ministério da Saúde (BR). Portaria Nº 198/GM/MS, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor, e dá outras providências. Brasília, DF; 2004.

[33] ³³
Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005;9(16):161-78. https://doi.org/10.1590/S1414-32832005000100013
» https://doi.org/10.1590/S1414-32832005000100013

[34] ³⁴
Merhy EE. O desafio que a educação permanente tem em si: a pedagogia da implicação. Interface (Botucatu). 2005;9(16):172-4. https://doi.org/10.1590/S1414-32832005000100015
» https://doi.org/10.1590/S1414-32832005000100015

[35] ³⁵
Gard M, Wright J. The obesity epidemic: science, morality and ideology. London (UK): Routledge; 2005.

[36] ³⁶
World Health Organization. Obesity: preventing and managing the global epidemic: report of a WHO consultation. Geneva (CH): WHO; 2000. (WHO Technical Report Series; nº 894).

[37] ³⁷
Amparo-Santos L. Saúde, práticas corporais e obesidade na cultura contemporânea. In: Nascimento MC, Nogueira MI, organizadores. Intercâmbio solidário de saberes em sáude: racionalidades médicas e práticas integrativas e complementarers. São Paulo: Hucitec; 2013; p. 171-90.

[38] ³⁸
Ralston J, Brinsden H, Buse K, Candeias V, Caterson I, Hassell T, et al. Time for a new obesity narrative. Lancet. 2018;392(10156):1384-6. https://doi.org/10.1016/S0140-6736(18)32537-6
» https://doi.org/10.1016/S0140-6736(18)32537-6

[39] ³⁹
Yates-Doerr E. The weight of obesity.Berkeley, CA: University of California Press; 2015.

[40] ⁴⁰
Monaghan LF, Hollands R, Prtichard G. Obesity epidemic entrepreneurs: types, practices and interests. Body Soc. 2010;16(2):37-71. https://doi.org/10.1177/1357034X10364769
» https://doi.org/10.1177/1357034X10364769

[41] ⁴¹
Zabala A. A prática educativa: como ensinar. 2. Ed. Porto Alegre: Artmed; 2010.

[42] ⁴²
Gondim GMM, Monken M, Rojas LI, Barcellos C, Peiter P. O território da saúde: a organização do sistema de saúde e a territorialização. In: Miranda AC, Barcellos C, Moreira JC, Momken M, organizadores. Território, ambiente e saúde. Rio de Janeiro: Fiocruz; 2008: p. 237-55.

[43] ⁴³
Caleman G, Lima VV, Oliveira MS, Massaro A, Gomes R, Pereira MSF, et al. Projeto Aplicativo: termos de referência. São Paulo: Instituto Sírio-Libanês de Ensino e Pesquisa; Ministério da Saúde; 2016. (Projetos de Apoioao SUS).

[44] ⁴⁴
Lavis JN, Oxman AD, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP). Health Res Policy Syst. 2009;7 Suppl 1:I1. https://doi.org/10.1186/1478-4505-7-S1-I1
» https://doi.org/10.1186/1478-4505-7-S1-I1

Authors (year)	Country	Type of national health system	Funding source type	Journal discipline	Article type	Study design	Context/setting	Population
Whitaker et al. (2004)¹⁰	USA	No free or universal healthcare	Public-sponsored	Science of Nutrition	Original article	Quasi-experimental study	Kentucky 44th Annual Maternal and Child Health Conference	Nutritionists, nurses, and social workers
Katz et al. (2005)¹¹	Israel	Free and universal	Not reported	Training of healthcare providers	Original article	Mixed study	Primary care	Nutritionists, nurses, physicians, psychologists, physiotherapists, and physiologists
Stark et al. (2011)¹²	USA	No free or universal healthcare	Public-sponsored	Nutrition education	Original article	Quasi-experimental study	Primary care	Nutritionists
McPherson et al. (2012)¹³	USA	No free or universal healthcare	Not reported	Public health	Original article	Mixed study	Primary care	Nutritionists, nurses, and physicians
Sarayani et al. (2012)¹⁴	Iran	Free and universal	Not reported	Training of healthcare providers	Original article	Randomized clinical trial (RCT)	Community pharmacy	Pharmaceutical workers
Campbel-Scherer et al. (2014)¹⁵	Canada	Free and universal	Privately-sponsored	Scientific study of methods for health	Original article	Mixed study	Primary care	Nutritionists and physical educators
Mainor et al. (2014)¹⁶	USA	No free or universal healthcare	Public-sponsored	Public health	Original article	Quasi-experimental study	Primary care	Nutritionists, nurses, and physicians
Vasudevan et al. (2016)¹⁷	USA	No free or universal healthcare	Privately-sponsored	Health disparities based on race and ethnicity	Original article	Quasi-experimental study	Primary care	Physicians
Joshua (2017)¹⁸	USA	No free or universal healthcare	Non-sponsored	Not applicable (dissertation)	Original article	Quasi-experimental study	Primary care	Nurses and physicians
Sanchez-Ramirez et al. (2018)¹⁹	Canada	Free and universal	Non-sponsored	Training of healthcare professionals	Original article	Quasi-experimental study	Primary care	Nutritionists, nurses, physicians, and pharmaceutical, dental, and social workers

RQ1A. Themes of permanent education initiatives

Category		Conts (%)	Authors (year)
Approaches to obesity	Environmental approach	2 (20%)	Stark et al. (2011)¹²; Mainor et al. (2014)¹⁶
	Biomedical approach	5 (50%)	Katz et al. (2005)¹¹; Sarayani et al. (2012)¹⁴; Campbell-Scherer et al. (2014)¹⁵; Vasudevan et al. (2016)¹⁷; Joshua (2017)¹⁸
	Cultural/identity approach	2 (20%)	Campbell-Scherer et al. (2014)¹⁵; Joshua (2017)¹⁸
	Psychological/behavioral approach	4 (40%)	Katz et al. (2005)¹¹; Stark et al. (2011)¹²; Campbell-Scherer et al. (2014)¹⁵; Sanchez-Ramirez et al. (2018)¹⁹
	Ecological approach	1 (10%)	Stark et al. (2011)¹²
Professional qualification strategies	Curriculum and competency-based training	2 (20%)	Mainor et al. (2014)¹⁶; Joshua (2017)¹⁸
Professional qualification strategies	Strategic development of an intervention plan	2 (20%)	Stark et al. (2011)¹²; McPherson et al. (2012)¹³
Obesity management	Barriers and solutions in tackling obesity	1 (10%)	Whitaker et al. (2004)¹⁰
	Care for caregivers	1 (10%)	Campbell-Scherer et al. (2014)¹⁵
	Monitoring and evaluation of results in obesity management	1 (10%)	Stark et al. (2011)¹²
	Administrative and political factors whichinfluence obesity interventions	1 (10%)	Stark et al. (2011)¹²
	Prevention of obesity acrosspolicy	1 (10%)	McPherson et al. (2012)¹³
	Advocacy resources on obesity care	1 (10%)	McPherson et al. (2012)¹³
Sociohistorical overview of obesity	World obesity crisis	1 (10%)	Sanchez-Ramirez et al. (2018)¹⁹
Sociohistorical overview of obesity	The historical trajectory of care practices for people with obesity	1 (10%)	Sanchez-Ramirez et al. (2018)¹⁹
Professional work style	Interdisciplinary work in obesity care¹⁹	1 (10%)	Sanchez-Ramirez et al. (2018)¹⁹

RQ1B. Methodologies of permanent education initiatives

Category		Conts (%)	Authors (year)

Teaching strategy	Assigned readings	1 (10%)	Stark et al. (2011)¹²
	Round tables	1 (10%)	Mainor et al. (2014)¹⁶
	Audio-visual resources (film, documentary, webcast)	2 (20%)	Whitaker et al. (2004)¹⁰; Stark et al. (2011)¹²
	Sessions of skills development, training application	2 (20%)	Mainor et al. (2014)¹⁶; Vasudevan et al. (2016)¹⁷
	Support from teachers, feedback from experts, or tutoring with experienced providers	2 (20%)	McPherson et al. (2012)¹³; Sarayani et al. (2012)¹⁴
	Building interventions plans	2 (20%)	Stark et al. (2011)¹²; McPherson et al. (2012)¹³
	Assessment session - immediate post-intervention (after 3 and 6 months)	2 (20%)	Campbell-Scherer et al. (2014)¹⁵; Vasudevan et al. (2016)¹⁷
	Critical reviews of medical records or provider x patient/family interactions, simulated patients	2 (20%)	Sarayani et al. (2012)¹⁴; Vasudevan et al. (2016)
	Workshops	4 (40%)	Katz et al. (2005)¹¹; Stark et al. (2011)¹²; Campbell-Scherer et al. (2014)¹⁵; Sanchez-Ramirez et al. (2018)¹⁹
	Delivery of teaching material	3 (30%)	Sarayani et al. (2012)¹⁴; Campbell-Scherer et al. (2014)¹⁵; Vasudevan et al. (2016)¹⁷
	Case study/field history	5 (50%)	Whitaker et al. (2004)¹⁰; Katz et al. (2005)¹¹; Sarayani et al. (2012)¹⁴; Mainor et al. (2014)¹⁶; Sanchez-Ramirez et al. (2018)¹⁹
	Discussion panel (clinical reports and case presentation), discussion forums, and plenaries	6 (60%)	Whitaker et al. (2004)¹⁰; Katz et al. (2005)¹¹; Stark et al. (2011)¹²; Sarayani et al. (2012)¹⁴; Mainor et al. (2014)¹⁶; Sanchez-Ramirez et al. (2018)¹⁹
	Oral presentation (lectures and conferences)	6 (60%)	Katz et al. (2005)¹¹; Stark et al. (2011)¹²; Sarayani et al. (2012)¹⁴; Campbell-Scherer et al. (2014)¹⁵; Mainor et al. (2014)¹⁶; Sanchez-Ramirez et al. (2018)¹⁹
Length of permanent health education	Days (1 to 5)	7 (70%)	Whitaker et al. (2004)¹⁰; McPherson et al. (2012)¹³; Sarayani et al. (2012)¹⁴; Mainor et al. (2014)¹⁶; Vasudevan et al. (2016)¹⁷; Joshua (2017)¹⁸; Sanchez-Ramirez et al. (2018)¹⁹
	Weeks (06)	1 (10%)	Stark et al. (2011)¹²
	Semester	2 (20%)	Katz et al. (2005)¹¹; Campbell-Scherer et al. (2014)¹⁵
Types of participation	Individual	6 (60%)	Katz et al. (2005)¹¹; Stark et al. (2011)¹²; McPherson et al. (2012)¹³; Vasudevan et al. (2016)¹⁷; Joshua (2017)¹⁸; Sanchez-Ramirez et al. (2018)¹⁹
	Group	2 (20%)	Whitaker et al. (2004)¹⁰; Campbell-Scherer et al. (2014)¹⁵
	Mixed	2 (20%)	Sarayani et al. (2012)¹⁴; Mainor et al. (2014)¹⁶
Frequency of meetings	Single	5 (50%)	Whitaker et al. (2004)¹⁰; Sarayani et al. (2012)¹⁴; Vasudevan et al. (2016)¹⁷; Joshua (2017)¹⁸; Sanchez-Ramirez et al. (2018)¹⁹
	Daily	2 (20%)	McPherson et al. (2012)¹³; Mainor et al. (2014)¹⁶
	Weekly	1 (10%)	Stark et al. (2011)¹²
	Biweekly	1 (10%)	Campbell-Scherer et al. (2014)¹⁵
	Monthly	1 (10%)	Katz et al. (2005)¹¹
Teaching modality	In-person course	8 (80%)	Whitaker et al. (2004)¹⁰; Katz et al. (2005)¹¹; Sarayani et al. (2012)¹⁴; Campbell-Scherer et al. (2014)¹⁵; Mainor et al. (2014)¹⁶; Vasudevan et al. (2016)¹⁷; Joshua (2017)¹⁸; Sanchez-Ramirez et al. (2018)¹⁹
	Semi-in-person course	1 (10%)	McPherson et al. (2012)¹³
	Distance education	1 (10%)	Stark et al. (2011)¹²
Use of data from students’ reality		2 (20%)	Stark et al. (2011)¹²; Vasudevan et al. (2016)¹⁷
Use of professional development programs		2 (20%)	Stark et al. (2011)¹²; Campbell-Scherer et al. (2014)¹⁵
Qualitative assessment of the current educational needs of the involved healthcareproviders (real-life problems vs. previous knowledge and experience)		2 (20%)	Sarayani et al. (2012)¹⁴; Campbell-Scherer et al. (2014)¹⁵

RQ3. Results of permanent education initiatives

Category		Conts (%)	Authors (year)

Participants	Conceptual, procedural, and/or attitudinal changes on obesity care	10 (100%)	Whitaker et al. (2004)¹⁰; Katz et al. (2005)¹¹; Stark et al. (2011)¹²; McPherson et al. (2012)¹³; Sarayani et al. (2012)¹⁴; Campbell-Scherer et al. (2014)¹⁵; Mainor et al. (2014)¹⁶; Vasudevan et al. (2016)¹⁷; Joshua (2017)¹⁸; Sanchez-Ramirez et al. (2018)¹⁹
Initiative	Limits and potential of teaching strategies	3 (30%)	Katz et al. (2005)¹¹; Sarayani et al. (2012)¹⁴; Vasudevan et al. (2016)¹⁷
Initiative	High level of student satisfaction with the overall quality of the course	2 (20%)	Mainor et al. (2014)¹⁶; Joshua (2017)¹⁸
Products	Production of specific-action plans for students’ reality	2 (20%)	Stark et al. (2011)¹²; McPherson et al. (2012)¹³

RQ4. Gaps in permanent education initiatives

Category		Conts (%)	Authors (year)

Conceptual, attitudinal, and procedural change of course participants	Sustainability of conceptual, attitudinal, and procedural change of course participants	5 (50%)	Whitaker et al. (2004)¹⁰; Sarayani et al. (2012)¹⁴; Mainor et al. (2014)¹⁶; Vasudevan et al. (2016)¹⁷; Sanchez-Ramirez et al. (2018)¹⁹
	Ability to identify which element (strategy or content) induces course changes	1 (10%)	Stark et al. (2011)¹²
	Study the effect of the courseon the self-efficacy of healthcareproviders for continuing education	1 (10%)	Katz et al. (2005)¹¹
	Analysis of other factors whichinfluence learning	2 (20%)	Whitaker et al. (2004)¹⁰; Campbell-Scherer et al. (2014)¹⁵
Teaching strategies	Application of more powerful teaching strategies	1 (10%)	Whitaker et al. (2004)¹⁰
	Cost-benefit assessment of teaching strategies	2 (20%)	Sarayani et al. (2012)¹⁴; Mainor et al. (2014)¹⁶
	Compare various competency models for obesity management	1 (10%)	Joshua (2017)¹⁸
Course duration	Short-term for evaluating on patients and/or public policies	1 (10%)	McPherson et al. (2012)¹³

Line No.	Database search strategy Literature Search performed: October 21, 2020	Number of results
	1. Medline (PubMed)
#1	“Education, Continuing”[Mesh] OR (Continuing Education)	78,336
#2	“Inservice Training”[Mesh] OR (Inservice Training) OR (On-the-Job Training) OR (On the Job Training) OR (Training, On-the-Job) OR (Training, Inservice) OR (Orientation Programs, Employee) OR (Employee Orientation Program) OR (Orientation Program, Employee) OR (Program, Employee Orientation) OR (Programs, Employee Orientation) OR (Employee Orientation Programs) OR (Health Human Resource Training)	69,070
#3	“Education”[Mesh:NoExp] OR (Education)	1,792,949
#4	#1 OR #2 OR #3	1,800,195
#5	“Health Personnel”[Mesh] OR (Personnel, Health) OR (Health Care Providers) OR (Health Care Provider) OR (Provider, Health Care) OR (Providers, Health Care) OR (Healthcare Providers) OR (Healthcare Provider) OR (Provider, Healthcare) OR (Providers, Healthcare) OR (Healthcare Workers) OR (Healthcare Worker)	765,649
#6	“Obesity”[Mesh] OR (Obesity)	372,187
#7	“Overweight”[Mesh] OR (Overweight)	250,182
#8	#6 OR #7	387,011
#9	$4 AND #5 AND #8	3,032
	2. BVS
#1	(“Educação Continuada” OR “Education, Continuing” OR “Educación Continua” OR “Educação Contínua” OR “Educação Permanente” OR “Formação Continuada” OR “Capacitação em Serviço” OR “Inservice Training” OR “CapacitaciónenServicio” OR “Formationen interne” OR “Programas de Orientação ao Empregado” OR “Treinamento em Serviço” OR”Capacitação de Recursos Humanos em Saúde” OR “Health HumanResourceTraining” OR “Capacitación de Recursos Humanos enSalud” OR “FormationdesRessourcesenSantéHumaine” OR “Capacitação de Recursos Humanos Especializados” OR “Formação Profissional em Saúde” OR educação OR education OR educación)	-
#2	(“Pessoal de Saúde” OR “Prestadores de Cuidados de Saúde” OR “Profissionais da Saúde” OR “Profissionais de Saúde” OR “Profissional da Saúde” OR “Profissional de Saúde” OR “Trabalhador da Saúde” OR “Trabalhador de Saúde” OR “Trabalhadores da Saúde” OR “Trabalhadores de Saúde” OR “Health Personnel” OR “Health CareProviders” OR “HealthcareProviders” OR “HealthcareWorkers” OR “Personal de Salud” OR “Proveedores de Atención de Salud” OR “Trabajadores de laSalud” OR mh:m01.526.485*)	-
#3	(obesidade OR obesity OR obesidad OR “Tratamiento de la Obesidad” OR sobrepeso OR overweight OR sobrepeso)	-
#4	#1 AND #2 AND #3 (“Educação Continuada” OR “Education, Continuing” OR “Educación Continua” OR “Educação Contínua” OR “Educação Permanente” OR “Formação Continuada” OR “Capacitação em Serviço” OR “Inservice Training” OR “CapacitaciónenServicio” OR “Formationen interne” OR “Programas de Orientação ao Empregado” OR “Treinamento em Serviço” OR “Capacitação de Recursos Humanos em Saúde” OR “Health HumanResource Training” OR “Capacitación de Recursos Humanos enSalud” OR “FormationdesRessourcesenSantéHumaine” OR “Capacitação de Recursos Humanos Especializados” OR “Formação Profissional em Saúde” OR educação OR education OR educación) AND (“Pessoal de Saúde” OR “Prestadores de Cuidados de Saúde” OR “Profissionais da Saúde” OR “Profissionais de Saúde” OR “Profissional da Saúde” OR “Profissional de Saúde” OR “Trabalhador da Saúde” OR “Trabalhador de Saúde” OR “Trabalhadores da Saúde” OR “Trabalhadores de Saúde” OR “Health Personnel” OR “Health CareProviders” OR “HealthcareProviders” OR “HealthcareWorkers” OR “Personal de Salud” OR “Proveedores de Atención de Salud” OR “Trabajadores de laSalud” OR mh:m01.526.485*) AND (obesidade OR obesity OR obesidad OR “Tratamiento de laObesidad” OR sobrepeso OR overweight OR sobrepeso) AND ( db:(“LILACS” OR “IBECS” OR “BDENF” OR “INDEXPSI” OR “PERNAL” OR “BBO” OR “CUMED” OR “MedCarib” OR “PREPRINT-MEDRXIV” OR “BINACIS” OR “PREPRINT-SCIELO” OR “SES-SP” OR “colecionaSUS”))	127
	3. Embase (Emtree Descriptors)
#1	‘continuing education’/exp OR ‘continuing education’	50,656
#2	‘in service training’/exp OR ‘in service training’	17,282
#3	education:ti,ab,kw	644,878
#4	#1 OR #2 OR #3	2,242,533
#5	‘health care personnel’/exp OR ‘health care personnel’	1,615,480
#6	‘obesity’/exp OR obesity	631,624
#9	$4 AND #5 AND #6	2,099
	4. Cochrane
#1	MeSH descriptor: [Education, Continuing] explode all trees
#2	(“Continuing Education”):ti,ab,kw
#3	MeSH descriptor: [Inservice Training] explode all trees
#4	(“Inservice Training”):ti,ab,kw
#5	MeSH descriptor: [Education] this term only
#6	(“education”):ti,ab,kw
#9	MeSH descriptor: [Health Personnel] explode all trees
	(“Health Personnel”):ti,ab,kw
	MeSH descriptor: [Obesity] explode all trees	34 Reviews and 3,199 Trials
	5. CINAHL/Web of Science (WOS)/Scopus
	(“Education, Continuing” OR “Continuing Education” OR “Inservice Training” OR “Health Human Resource Training” OR education) AND (“Health Personnel” OR “Health Care Providers” OR “Healthcare Providers” OR “Healthcare Workers”) AND (obesity OR overweight)	CINAHL: 470
		WOS: 259
		Scopus: 1,000

Saúde Pública

Saúde Pública

Permanent health education in the context of obesity: a scoping review

ABSTRACT

OBJETIVE

METHODS

RESULTS

CONCLUSION

INTRODUCTION

METHODS

Protocol and Registration

Eligibility Criteria

Information Sources

Sources of Evidence Selection

Data Items and Data Charting Process

Result Synthesis

RESULTS (N = 10)

Sources of Evidence Selection

Sources of Evidence Characteristics

RQ1A. Permanent Health Education Initiatives themes

RQ1B. Methodology of Permanent Health Education Initiatives

RQ2. Concept of Obesity

RQ3. Results of Permanent Health Education Initiatives

RQ4. Gaps in Permanent Health Education Initiatives

DISCUSSION

Limitation

CONCLUSION

REFERENCES

Publication Dates

History