The search was conducted between June 2023 and September 2023 in four databases: PubMed, Google Scholar, Embase, and Web of Science. The search strategy utilized the following combination of keywords: “rural” AND “obesity interventions” OR “weight loss interventions” OR “obesity randomized controlled trials” OR “school-based obesity interventions” OR “lifestyle interventions” OR “obesity telehealth interventions.” Additionally, reference lists of narrative and systematic reviews were examined for additional primary research studies. Articles were eligible for inclusion if they were published in English in a peer-reviewed scientific journal within the last 5 years and explicitly studied an intervention designed to prevent or treat obesity. Articles were excluded if they reported descriptive data, conference abstracts, case reports, or did not include weight-related outcomes.

A 2018 study by Vogeltanz-Holm and Holm [18] evaluated the findings from a 3-year elementary school-based obesity prevention program in eight rural schools in North Dakota, USA (see Table 1). The program was an enhanced version of the Coordinated Approach to Child Health Program (CATCH) trial, which was the largest, most comprehensive school-based obesity prevention program conducted in 1991 to 1994 [19]. The enhanced CATCH program integrated realistic and cultural perspectives of students and their communities, specifically for students living in American Indian reservation communities that were tribal homes. Pre- and post-assessment of the 308 students (66% White and 34% American Indian) showed significant, but clinically modest decreases in percentile BMI from 71.2 to 68.8% (z = 3.05, p = 0.002, d = 0.14). Additional comparisons with an age-matched enrolled in a cohort from the National Health and Nutrition Examination Survey (NHANES) found the percentage of program students with obesity at the end of the study was significantly less than in the NHANES children (12.7% vs 20.7%; z = 2.74, p = 0.006, d = 0.32)27.

A 2019 study by Hao et al. [20] in Benxi City, Liaoning Province, in Northeast China randomized rural elementary school students in 4th through 6th grades to a 2-month exercise intervention (girls, n = 25; boys, n = 32), a nutrition education intervention (girls, n = 27; boys, n = 33), an exercise plus nutrition education intervention (girls, n = 25; boys, n = 31), and a control (girls, n = 27; boys, n = 29). Changes in absolute BMI, nutrition knowledge, and daily energy intake were assessed post-intervention and at 12-month follow-up. All three intervention arms decreased absolute BMI post-intervention in boys and girls compared to baseline values (mean change in BMI girls’ exercise group: − 0.7; boys’ exercise group: − 0.7; girls’ nutrition group: − 0.8; boys’ nutrition group: − 07; girls’ exercise + nutrition group: − 0.9; boys’ exercise + nutrition group: − 1.3; p < 0.05), and values remained significant at 12-month follow-up for boys and girls, with the exception of girls in the nutrition only group 28. Also, nutrition knowledge increased for girls and boys in the nutrition and exercise plus nutrition interventions at post-intervention and remained significant at 12-month follow-up. Similarly, energy intake decreased for girls and boys in the nutrition and exercise plus nutrition interventions at post-intervention and remained significant at 12-month follow-up. While this study documents improvements in knowledge and weight loss among children, measuring absolute BMI is not recommended for growing children. BMI for children and adolescents must take into account age and sex to account for fluctuations in body fat.

A 2019 cluster randomized trial by Lin et al. [21] assessed the effectiveness of an 8-week program in eight elementary schools in rural Taiwan. Four schools (n = 92 children) were randomized to the Mission X: Train Like an Astronaut Challenge, which was an international fitness challenge developed by the National Aeronautics and Space Administration (NASA) and consisted of 24 challenges for children aged 8–12 years. The four remaining schools were randomized to the control group (n = 109 children). Children in the intervention group demonstrated significant increases in nutrition knowledge (+ 0.62 vs. + 0.17, p = 0.044) and active lifestyle knowledge (+ 0.91 vs. + 0.25, p = 0.002) compared to the control group. Mean BMI-for-age did not change pre- and post-intervention; however, the prevalence of obesity and overweight decreased from 52 to 49% in the intervention group and increased from 34 to 35% in the control group. This trial demonstrates that this free, online training program associated with space exploration may be an effective approach to improving nutrition and physical activity knowledge in children at rural elementary schools; additional research with a longer study duration is needed to examine effects on body weight outcomes.

Two school-based lunch interventions aimed to reduce energy consumption, decrease sodium and sugar intake, and increase fruit and vegetable intake. A 2018 cluster randomized trial by Hawkins et al. [22] examined a 28-month obesity prevention program that focused on modification of the school environment (e.g., five fruits and vegetables per day, meet guidelines for the National School Lunch Program) in rural Louisiana, USA. Utilizing digital photography of foods methods, a change in reduced energy consumption was observed at 28 months in the intervention group (− 75.6 ± 27.4 kcal/lunch, p = 0.02) compared to the control (p = 0.02). Similarly, sodium consumption (− 153.5 ± 66.9 mg/lunch, p = 0.03) and added sugar (− 3.5 ± 1.6 teaspoon/lunch, p = 0.05) were lower at 28 months in the intervention group compared to the control group [22]. A different 2019 pilot study by Askelson et al. [23] utilized behavioral economics to improve the lunchroom environment for students in six middle schools in rural IA, USA throughout the school year. Schools implemented changes in the lunchroom for stand-alone carts with whole fruit; signs to promote fruits, vegetables, and milk; and facts about fruits and vegetables. From fall to spring, five of the six schools documented increased total servings of fruits and three schools increased total servings of vegetables and milk [23].

Finally, a 2019 paper by Sanchez-Lopez et al. [24] described the methodology of a 16-week cluster-randomized controlled trial with eight preschools in rural and urban Spain. Approximately 900 children aged 4 to 6 years were enrolled in one of three groups: MOVI-da10-Enriched intervention (n = 3), MOVI-da10-Standard (n = 2), or the control group (n = 3). The MOVI-da10-Enriched intervention paired 10-min physical activity breaks (e.g., coordination exercises, basic motor skills) with curricular content (e.g., counting, letters) to create a high cognitive demand [25]. The MOVI-da10-Standard intervention also included 10-min physical activity breaks; however, these breaks were considered low cognitive demand activities that did not include curricular content or high cognitive demand activities [25]. Primary outcome measures include body weight, BMI, blood pressure, physical fitness, and executive function. If the interventions improve body composition, blood pressure, physical fitness, and cognition, the findings have implications for school-based interventions in preschool children.

Historically, lifestyle interventions demonstrate improvements in diet, physical activity, smoking status, and sedentary behavior [26,27,28,29], which in turn, lead to improvements in body weight and BMI [30]. Evidence from rural lifestyle interventions are limited, but emerging data suggest that existing programs can be adapted to meet the unique needs of rural populations.

The 2019 Strong Hearts, Healthy Communities cluster randomized trial by Folta et al. [31] was designed to address healthy eating and physical activity to prevent cardiovascular disease among rural women in MT, USA (12 towns) and NY, USA (4 towns; see Table 2). Women in eight towns (n = 101) were randomized to participate in the lifestyle intervention, which included twice weekly exercise and nutrition classes for 24 weeks. The remaining eight towns (n = 93) were randomized to an attention control arm consisting of six didactic healthy lifestyle classes. Post-intervention, the lifestyle intervention group increased fruit and vegetable consumption (difference, 0.6 cup equivalents per day; 95% CI 0.1 to 1.1, p = 0.026) and vegetable intake alone (difference, 0.3 cup equivalents per day; 95% CI 0.1 to 0.6, p = 0.016) compared to the control arm 39. No significant differences were observed in physical activity measured via accelerometry; however, the intervention group self-reported a greater increase in metabolic equivalent (MET) walking minutes per week compared to the control group. No other differences were observed between groups.

A 2020 cluster randomized controlled trial by Katzmarzyk et al. [32] tested the effectiveness of a high-intensity lifestyle intervention at 18 primary care clinics in rural LA, USA. The two-year trial, entitled Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL, NCT02561221), randomized nine clinics to the intervention, which included both in-person visits and telephone visits with health coaches, and nine clinics to usual care. A total of 607 participants (n = 362 intervention, n = 351 usual care) had weight loss data at 24 months. Participants in the high-intensity lifestyle group lost significantly more weight (change in body weight percentage, − 4.99%; 95% CI, − 6.02 to − 3.96%) than participants in the usual care group (− 0.48%; 95% CI, − 1.57 to 0.61%), with a mean percentage difference of − 4.51% (95% CI, − 5.93 to − 3.10%) between the groups (p < 0.001) [32]. A similar cluster randomized controlled trial by Befort et al. 41 in 2021 compared the Medicare Intensive Behavioral Therapy for Obesity fee-for-service model to in-clinic group visits, in-clinic individual visits, and telephone-based group visits. Named the Rural Engagement in Primary Care for Optimizing Weight Reduction (REPOWER) trial [33] (NCT02456636), a total of 36 primary care practices in Kansas and Iowa participated in the lifestyle intervention. Findings at 24-month follow-up showed mean weight loss was –4.4 kg (95% CI, –5.5 to –3.4 kg) for in-clinic group visits, –3.9 kg (95% CI, –5.0 to − 2.9 kg) for telephone group visits, and –2.6 kg (95% CI, –3.6 to –1.5 kg) for in-clinic individual visits. Comparisons found in-clinic group visits but not telephone group visits resulted in greater weight loss at 24 months when compared to the individual in-clinic visits.

Interestingly, data from both the PROPEL and REPOWER trials were pooled to examine the results of the five weight loss interventions across the 54 rural primary care clinics [34]. At 24 months, weight loss was − 4.80 (95% confidence interval (CI), − 5.96 to − 3.64) for the PROPEL in-clinic/telephone arm compared to − 0.50 kg (− 1.77 to 0.76) for the PROPEL usual care. In the REPOWER trial, weight loss at 24 months was − 4.79 kg (− 5.83 to − 3.75) for the REPOWER in-clinic group arm, − 4.30 kg (− 5.35 to − 3.26) for the REPOWER telephone group arm, and − 3.05 kg (− 4.10 to − 2.01) for the REPOWER in-clinic individual arm. Findings from this pooled analysis show weight loss is achievable in rural areas with high-intensity lifestyle counseling in-person or by telephone to produce clinically significant weight loss [34].

Lastly, a 2022 non-randomized, controlled study by Koeder et al. [35] compared a 1-year lifestyle intervention program to control condition with adults in rural Germany. The lifestyle intervention consisted of 14 seminars and eight workshops focused on a healthy, plant-based diet, physical activity, stress management, and community support. Participants in the lifestyle intervention arm also participated in two one-on-one coaching sessions. From baseline to one year, participants in the intervention group showed significant reductions in body weight (− 3.9 kg; CI, − 4.9, − 2.9 vs − 0.4; CI, − 1.6, 0.8) and BMI (− 1.3; CI, − 1.6, − 1.0 vs − 0.1; CI, − 0.5, 0.3) compared to the control arm.