Discussion
obesity, cancer, inflammation, Styku, adiposity, ’ within behavior, dietary behavior, weight loss
OBESITY, CARCINOGENESIS, CANCER, AIDS, INFLAMMATION, RECRUITMENT, ADIPOSITY, EVENTS
Our results indicate that it was feasible to conduct a 15-week randomized controlled weight loss study among rural residents who were overweight/obese. We also found that it was feasible for rural residents to participate in a 15-week telephone-based weight loss intervention. Although efforts were taken to retain participants (e.g., in-person assessment at a community center close to participants, gift card incentives, and offering the active control group the same lifestyle manual and Fitbit as the weight loss group at the end of the study), we observed some dropouts in both groups. However, the dropout rate of our study was less than 20%, indicating that this study design is feasible for this population [Rural residents, who experience disparities in obesity and cancer incidence and mortality, are a vulnerable population that can benefit from weight loss interventions. Most weight loss programs have focused on health-promoting resources available in urban areas [The disruption in daily life during the pandemic may have contributed to the low adherence to the weight loss intervention. Since the pandemic started, loss of daily routine, lack of access to groceries, stockpiling with highly processed foods, irregular eating due to stress, and financial burden related to unemployment from COVID-19 had negative impacts on health behaviors [Due to the impact of the COVID-19 pandemic, we encountered some challenges in recruitment and retention, in addition to delays in receiving equipment and supplies. As we were unable to attend community events, our recruitment solely depended on Facebook advertising, flyers, and mailed postcards to participants from a previous study. Among individuals who met the eligibility criteria and were interested in the study, there was a two-week waiting period before the scheduled baseline in-person sessions. The two-week period allowed us to obtain medical clearance for those with medical conditions, however, it resulted in a high no-show rate of 31.7%. Common reasons for no-shows included sick/medical-issue, COVID or COVID-related issues, or family emergencies, all of which were reasonable due to the unprecedented pandemic disruption. Future studies may consider kick-off sessions to engage and motivate individuals, improve connections with potential participants and the community centers, and reduce the no-show rate.This study has several limitations. It was a relatively small, homogenous sample of 40 participants who were all White and mostly women, in rural Ohio. Our findings may not generalize to more diverse populations in different geographic areas. Additionally, we found individuals who enrolled in our study had a lower BMI compared to individuals who were interested but not enrolled. Therefore, our study sample may not represent the general populations in rural areas. Moreover, some participants experienced cellphone reception issues that impeded them from receiving phone calls or group messages. With the new federal infrastructure investment in the next few years, especially the improvement of internet services, future studies may consider utilizing video-conferencing or other telehealth approaches to deliver remotely accessible weight loss programs for this population.Our study has several strengths. First, to tailor the weight loss intervention to rural populations, the weekly sessions specifically focused on optimizing accessible resources, improving self-efficacy, and promoting social support to help rural populations overcome barriers, with the goal of increasing physical activity, improving healthy diet, and maintaining a healthy weight. Most of the participants lived in rural areas inundated by quick-service restaurants. Consequently, health coaches routinely provided strategic guidance to help participants successfully manage their dietary behavior and environment. For example, one participant reported that she had to frequently resort to fast-food restaurants, simply because there was no other option. As a substitution for the typical high-calorically dense meal choices, the coach suggested ordering a side salad and a 4-piece chicken nugget (about 500 kcal total) when necessary and combining this with the mindful eating and planning skills developed through the counseling sessions.The importance of identifying the ‘active ingredients’ within behavior change interventions, is critical to advancing their dissemination and implementation. BCTs are the “observable, replicable, and irreducible components of interventions designed to alter or redirect causal processes that regulate behavior” [Additionally, our study included an in-house registered dietitian available to provide valuable guidance for the weight loss intervention group upon request on an as-needed basis. We noticed that many participants were not familiar with macronutrients. Besides individual nutrition counseling, the dietitian offered supplementary educational and visual aids to illustrate the macronutrient content of commonly consumed foods and to facilitate improvement in dietary decision-making. This was crucial for the rural population to improve their awareness, self-efficacy, and planning for healthy diet. We also provided the active control group with AICR physical activity and dietary guidelines, as well as the exercise manual and online exercise videos (Lastly, we were, to date, the first study to use a novel, portable 3D body scanner, Styku S100 (Styku LLC, Los Angeles, CA), to assess body composition, including fat mass and fat percentage, in rural community settings. Measures of body composition, especially body fat, are relevant to assessing cancer risk, as adiposity deposition is associated with inflammation and carcinogenesis [In conclusion, our pilot study provided important data and valuable experiences in conducting a telephone-based weight loss intervention among rural populations with overweight/obesity. In our study, a 15-week study to promote physical activity, healthy eating, we demonstrated that conducting a study to promote a healthy diet is feasible among rural Ohio residents. We also demonstrated that it was feasible for rural adults with overweight/obesity to participate in a 15-week telephone-based weight loss intervention. Further studies should refine strategies to improve the uptake of the weight loss intervention, as well as evaluate the effect size of the telephone-based intervention to serve as preliminary data for a large-scale, randomized controlled trial to quantify the therapeutic effect of weight loss interventions and cancer risk in rural populations.