Higher rates of obesity and sedentary behavior represent significant contributors to the greater prevalence of cardiovascular disease (CVD) morbidity and mortality observed in rural versus urban areas. Yet little research attention has been given to modifying these important influences on the urban/rural disparity in heart disease. Lifestyle interventions can produce weight reductions of sufficient magnitude to improve health, but the existing research is limited with respect to two critical factors: (a) the long-term maintenance of treatment effects and (b) translation and dissemination to underserved populations. In a series of effectiveness trials, our rural obesity research program has demonstrated the feasibility and effectiveness of delivering lifestyle programs through the existing infrastructure of the USDA Cooperative Extension Service (CES), which has more than 2,900 offices nationwide and whose mission includes improving nutrition and health. We have also demonstrated that we can improve the long-term effects of treatment via extended-care programs consisting of either face-to-face treatment sessions or individual telephone counseling. However, both of these options entail relatively high costs, which inhibit their adoption in rural communities. In a recently published pilot study, we demonstrated the effectiveness of a group-based telephone intervention for obese adults from rural areas. This highly innovative approach addresses barriers to access, provides group support in a confidential setting, and appears to be as effective as individual phone treatment. Group support may be especially important for rural residents who tend to be isolated, have heightened concerns about privacy, and report lower levels of quality of life. The next logical step in this lne of research is to conduct a randomized controlled trial to evaluate the long-term effects of this potentially more efficient mode of providing extended care for the management of obesity in rural communities. We propose to conduct a single-blind, randomized controlled "effectiveness" trial in obese adults (N=540) to evaluate the effects of extended-care programs delivered via INDIVIDUAL or GROUP telephone counseling, compared to a health education control (CTRL) condition, on long-term (22 month) changes in body weight. Our principal hypothesis is that both the INDIVIDUAL and GROUP interventions will produce greater weight reductions at 22 months than the CTRL condition. We will evaluate the proportion of participants in each condition who demonstrate clinically significant weight losses (>5% of initial body weight) at long-term follow-up. We also will examine the effects of treatment on CVD risk factors, and we will evaluate the costs and cost effectiveness of the interventions.
The study will fill a critical gap in knowledge regarding the translation and dissemination of research from efficacy studies to best practices in community settings. By determining the effects and cost effectiveness of telephone-based INDIVIDUAL and GROUP extended-care programs, the study will have important public health implications with respect to the implementation of lifestyle interventions for the long-term management of obesity and obesity-related risk factors for cardiovascular disease in underserved rural settings.