1 PROJECT SUMMARY/ABSTRACT 2 Nearly 3 out of 4 adults in the United States (US) live with overweight or obesity (body mass index (BMI) of ≥ 25 3 kg/m2), with the highest rates among Blacks, rural residents, and lower socioeconomic groups. Obesity is 4 associated with cardiometabolic diseases like diabetes, heart disease and stroke, well as multiple cancers. Over 5 the past decade, trends in obesity have been generally stable for men, but increased significantly among women. 6 This is particularly true among Black women who have an obesity prevalence of 56.9% compared to 39.8% in 7 White women. Black women living in rural settings have higher rates of obesity compared to their same race/sex 8 peers in urban settings. Evidence-based interventions (EBIs) that promote weight loss, healthier diet and 9 physical activity are effective at slowing the conversion of pre-diabetes mellitus (pre-DM) and hypertension (HTN) 10 to diabetes and heart failure, respectively. However, these interventions are often underutilized by populations 11 at highest risk, including Black women living in the rural Deep South. The mission of the Deep South Center to 12 Reduce Disparities in Chronic Diseases is to promote health equity and reduce the burden of cardiometabolic 13 diseases across the Deep South. Consistent with the Center’s theme (applying a precision public health 14 approach across the care continuum to achieve health equity), this study leverages two EBIs led by our team 15 that have been previously culturally-adapted for the target population and achieved clinically-relevant weight loss 16 and other clinical outcomes (group-based weight loss intervention) along with improvements in diet and physical 17 activity (individual gardening intervention). Combining these EBIs addresses multiple domains (behavioral, 18 personal environment, sociocultural) and levels (individual, interpersonal, community) of influence on risk factors 19 for obesity and other cardiometabolic diseases prevalent in the Deep South. These interventions, delivered by 20 local lay staff and non-academic partners, have a high potential for sustainability; however, there is a need to 21 further evaluate the external validity and implementation-related barriers and facilitators to maximize reach, 22 adoption and implementation. We will employ a pragmatic, multilevel, cluster-randomized, type 1 hybrid 23 effectiveness-implementation trial. A total of 264 Black women (age >30 years) with overweight or obesity and 24 Pre-DM or HTN from 12 rural counties (6 Alabama, 6 Mississippi) will receive either the combined group weight 25 loss intervention (Journey to Better Health; JTBH) plus individual gardening intervention (Harvest for Health; 26 H4H) or the JTBH alone. The specific aims are to compare interventions on: (1) primary outcomes related to 27 implementation effectiveness (reach, adoption, maintenance of health behaviors), (2) secondary outcomes on 28 clinical effectiveness, and (3) cost effectiveness. Findings will inform discussions with coalition partners to 29 achieve our long-term goal of widely disseminating and sustaining multi-level interventions to reduce the multiple 30 chronic disease burden and health disparities in the Deep South.