PROJECT SUMMARY/ABSTRACT Obesity increases risk for 13 types of cancer and now affects over 40% of the U.S. adult population, with even higher prevalence among rural Americans. Most worrisome, the prevalence of class 3 obesity (BMI ≥ 40), which contributes the highest cancer risk, is increasing at a rate 3 times higher in rural communities compared to urban areas. Rural residents often lack access to weight control programs and food and physical activity resources that promote healthy lifestyles, especially in small or remote rural areas. It is paramount that obesity treatment be offered in rural primary care, especially to reach those who have Class 3 obesity and/or co- morbid medical conditions who carry the highest obesity-related cancer risk. Medical management by a primary care provider (PCP) during behavioral weight loss is essential to address co-morbid medical conditions, evaluate obesogenic medications, and explore options for guideline-recommended pharmacotherapy and surgical treatment. However, there has been a missed opportunity in primary care- based obesity treatment trials for capitalizing on guideline-based medical management. The current trial builds on lessons learned in our recently completed RE-POWER trial conducted in rural primary care clinics, which demonstrated significantly greater weight loss with in-clinic group visits versus individual visits, and highlighted the need for medical management by the local PCPs. RE-TOOL (Rural Engagement in TelemedTeam for Options in Obesity Treatment SoLutions) is a cluster RCT (n = 16 clinics and 560 participants) designed to enhance sustainable access to obesity treatment in rural communities. TelemedTeam is a novel team-based telemedicine approach that pairs intensive telemedicine group visits with quarterly individual team-based clinic visits that simultaneously engage the patient, the local PCP, and the lifestyle coach to help activate the patient. This novel collaborative telemedicine solution combines the benefits of group-based treatment with home- based telemedicine delivery, and critically, integrates team-based care in local rural clinics to capitalize on the importance of medical management and access to local support and resources. The primary hypothesis is that TelemedTeam will result in greater % weight loss at 24 months compared to Enhanced Usual Care consisting of quarterly PCP visits only. Secondary outcomes include the proportion achieving ≥5% and 10% weight loss, diet quality, physical activity, quality of life, and medical treatment process outcomes. Exploratory analyses will assess reach, adoption, and implementation and investigate rural sociocultural and spatial predictors of treatment effects.

PROJECT NARRATIVE Higher prevalence of obesity increases risk of cancer in rural populations who often lack access to weight control programs, have fewer food and physical built environment resources that promote healthy lifestyles, and limited availability of evidence-based treatment. This study will assess the effectiveness of TelemedTeam, a two-year team-based telemedicine intervention that pairs intensive group telemedicine visits with a lifestyle coach and quarterly team-based clinic visits with the patient, PCP, and telemedicine lifestyle coach. This novel collaborative telemedicine solution combines the benefits of group-based treatment, home-based telemedicine delivery and team-based care integration in local rural clinics, capitalizing on the importance of medical management, and local resources and support networks.