April 2019

PREPARED BY: 

East Tennessee State University and

NORC at the University of Chicago 

An initiative to identify and explore Appalachian communities with better-than-expected health outcomes

ISSUE BRIEF

Health Disparities Related to 

Obesity in Appalachia

Practical Strategies and

Recommendations for Communities

Photo: Ryan Parker on Unsplash
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities i

ACKNOWLEDGMENTS 

Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation (RWJF) is the nation’s largest philanthropy dedicated to health. 

For more than 40 years, RWJF has supported research and programs targeting some of the nation’s most 

pressing health issues. RWJF provided funding for this research project as part of its Culture of Health 

Initiative.

Appalachian Regional Commission

The Appalachian Regional Commission (ARC) provided funding, leadership, and project management for 

the project. ARC is an economic development agency of the federal government and 13 state 

governments focusing on 420 counties across the Appalachian Region. ARC’s mission is to innovate, 

partner, and invest to build community capacity and strengthen economic growth in Appalachia to help

the Region achieve socioeconomic parity with the nation. Julie Marshall, PhD, Senior Economist, 

Division of Research and Evaluation, served as the Project Director, with support from Kostas Skordas, 

Director, Division of Research and Evaluation. 

Foundation for a Healthy Kentucky

The Foundation for a Healthy Kentucky served as the grantee and fiscal agent for the project. Funded by 

an endowment, the nonpartisan Foundation’s mission is to address the unmet health needs of Kentuckians 

by developing and influencing policy, improving access to care, reducing health risks and disparities, and 

promoting health equity. Since the Foundation opened its doors in 2001, it has invested more than $27 

million in health policy research, advocacy, and demonstration project grants across the Commonwealth.

Research Team

Kate Beatty, PhD, and Nathan Hale, PhD, at the Center for Rural and Appalachian Health in the College 

of Public Health at East Tennessee State University (ETSU), along with researchers at NORC at the 

University of Chicago’s Walsh Center for Rural Health Analysis, led the development of this brief. The 

NORC team included Michael Meit, Megan Heffernan, Michelle Dougherty, Luciana Rocha, and Kelsey 

Ruane. Additional contributors from ETSU included Ginny Kidwell. 
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities ii

TABLE OF CONTENTS

Why Address Obesity in Appalachia?.....................................................................................1

Assessing Community Need for Obesity Prevention Programs............................................3

Practical Strategies and Recommendations...........................................................................4

Recommendation #1: Establish Healthy Behaviors Among Children and Youth to Prevent 

Childhood Obesity ....................................................................................................................5

Recommendation #2: Increase Availability of Affordable Healthy Foods and Beverages in 

Communities .............................................................................................................................8

Recommendation #3: Create Safe Communities That Support Physical Activity ................9

Recommendation #4: Increase Physical Activity and Healthy Eating Among Adults........11

Strategies and Recommendations for Funders ....................................................................13
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 1

Creating a Culture of Health in Appalachia: Disparities and Bright Spots is a health research 

initiative sponsored by the Appalachian Regional Commission (ARC) and the Robert Wood Johnson 

Foundation (RWFJ), and administered by the Foundation for a Healthy Kentucky. This multipart research 

initiative has produced an interactive website, HealthinAppalachia.org, along with three reports: 1) Health 

Disparities in Appalachia,

1 2) Identifying Bright Spots in Appalachian Health: Statistical Analysis,

2 and 

3) Exploring Bright Spots in Appalachian Health: Case Studies.

3

Obesity, which is both a chronic disease and a risk factor for other chronic diseases, contributes to higher 

rates of premature mortality in Appalachia. Drawing on research presented in the health disparities and

Bright Spot reports, this brief focuses on promising practices, intervention strategies, and policies aimed 

at reducing health disparities related to obesity. This brief:

■ summarizes statistics on obesity and related disease in Appalachian communities,

■ discusses key strategies and resources for preventing and reducing obesity, and

■ provides recommendations for community leaders, funders, and policymakers.

This brief discusses four recommendations in detail:

1. Establish healthy behaviors among children and youth to prevent childhood obesity.

2. Increase the availability of affordable healthy foods and beverages in communities.

3. Create safe communities that support physical activity.

4. Increase physical activity and healthy eating among adults.

WHY ADDRESS OBESITY IN 

APPALACHIA? 

Chronic diseases, such as obesity, are a primary driver of

poor health, disability, and death in the United States.4

While obesity represents a distinct chronic condition, it is 

also a contributing factor for other chronic conditions, 

such as diabetes and cardiovascular disease. Obesityrelated chronic conditions remain a significant driver of 

health care costs, with estimates ranging from 10% to 21% 

of all health care spending in the United States (2000–

2005).

5,6

The Creating a Culture of Health in Appalachia

initiative has documented key health challenges and 

opportunities in Appalachia. The initiative’s reports offer a 

basis for understanding and addressing health in the 

Region and for identifying factors that support a culture of 

health in Appalachian communities. 

A striking portrait of obesity and obesity-related chronic 

conditions emerged in these reports. Findings suggest that

obesity and obesity-related chronic illnesses are higher in 

the Appalachian Region and contribute to a greater loss 

of life compared to the rest of the United States.

Figure 1: 

Figure 1: Prevalence of Adult Obesity in 

Appalachia, 2012

Image source: Health Disparities in Appalachia. 

https://www.arc.gov/assets/research_reports/Health_Disparitie

s_in_Appalachia_August_2017.pdf. 

Data source: County Health Rankings & Roadmaps, 2016 

edition. University of Wisconsin Population Health Institute 

supported by the Robert Wood Johnson Foundation.

http://www.countyhealthrankings.org/rankings/data .
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 2

Obesity in Appalachia 

Data from 2015–2016 show that nearly 39.8% of the adult population (93.3 million) in the United States 

is considered obese.7 The Health Disparities in Appalachia report provides a more nuanced picture of 

obesity by examining county-level obesity rates across the United States. These data were derived from

2012 estimates,

* and important differences in obesity were noted in Appalachia compared to the rest of 

the country. Findings from that report show the prevalence of obesity in Appalachian counties is higher 

than in non-Appalachian counties (31% versus 27.1%). The proportion of obese adults was higher across 

all five Appalachian subregions than what is observed in the rest of the country, with Central Appalachia 

(34.7%) and North Central Appalachia (33.4%) having the highest percentages (Figure 2). 

Obesity-Related Chronic Conditions 

While obesity itself is considered a chronic condition, it is also a driver of other chronic conditions more 

proximally associated with disability and death in the United States. Cardiovascular disease, stroke, and 

diabetes are important obesity-related chronic conditions that are also far more common in the 

Appalachian Region than in the rest of the country. Heart disease mortality in Appalachian counties is 

18% higher than in non-Appalachian counties. In Central Appalachian counties, economically distressed 

Appalachian counties,

8 and rural Appalachian counties, cardiovascular disease mortality is markedly 

higher than in non-Appalachian counties. While the geographic distribution within Appalachia may vary, 

stroke and diabetes-related mortality are also disproportionately high in Appalachian counties compared 

to elsewhere. Previous research suggests that 33% of “diabetes belt” counties are in Central and Southern 

Appalachian counties.9 Together, these findings suggest that residents of Appalachia die more 

frequently from obesity-related chronic conditions than those living outside the Region.

 *Across the United States, obesity prevalence has increased since 2012; therefore, the percentage of obese adults in Appalachia 

has likely increased as well. 

Figure 2: Percentage of Obese Adults by Appalachian Subregion (2012)

Image source: Health Disparities in Appalachia. 

https://www.arc.gov/assets/research_reports/Health_Disparities_in_Appalachia_August_2017.pdf. 

Data source: County Health Rankings & Roadmaps, 2016 edition. University of Wisconsin Population 

Health Institute supported by the Robert Wood Johnson Foundation.

http://www.countyhealthrankings.org/rankings/data.
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 3

Risk Factors Contributing to Obesity

While obesity is a complex condition with multiple contributing factors, physical inactivity is a key 

determinant of obesity and related chronic conditions. Residents of Appalachia are more likely to be 

physically inactive, relative to those living outside of Appalachia. Across the Region, 28.4% of the 

population report NOT being physically active compared to 22.6% of adults among non-Appalachian

counties. Physical inactivity was highest among residents of Central Appalachia (33.8%), those residing 

in the rural counties of Appalachia (31.8%), and among economically distressed counties in the Region

(33.9%).

ASSESSING COMMUNITY NEED FOR OBESITY

PREVENTION PROGRAMS 

Obesity and obesity-related diseases are particularly prevalent throughout Appalachia, and understanding 

to what extent obesity affects a community is an important first step in determining how to target limited 

resources. Assessing community needs can help community leaders, funders, and policymakers determine 

which of the recommendations presented in this brief have the greatest potential to reduce obesity rates.

Conducting a Needs Assessment

Needs assessments are formative research activities that can help communities understand important 

cultural norms and attitudes that may affect efforts to decrease obesity. They can help community leaders, 

funders, and policymakers understand the prevalence and nature of obesity in a particular community, 

including which populations are at a disproportionately high risk of obesity and obesity-related diseases. 

Conducting a needs assessment will also help leaders take stock of which programs and policies are 

already addressing obesity and the extent to which they are working successfully.

The Centers for Disease Control and Prevention (CDC) provide a guide to how to conduct a community 

needs assessment, which includes data sources and strategies. Communities may also consider the 

following local sources of data:

10

■ Civic and non-profit organizations, for lists of current projects, more information about who 

and how many individuals are served, and plans for the future

■ Community colleges/local universities, for academic research related to the community

■ Faith-based groups, for membership numbers and community needs

■ Health departments/healthcare providers, for local prevalence rates

■ Libraries, for local history/information unique to the county

Quantitative data in conjunction with qualitative data from community forums and focus groups can 

reveal how changes in nutrition, physical activity, and obesity rates have occurred over time and what 

current barriers exist to creating change. Identifying and mapping community assets are equally important 

to recognizing challenges, and enable community leaders to take stock of existing resources. Additional 

resources for conducting community needs assessments, including asset mapping, are provided on the 

next page.
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 4

Using State- and County-Level Data to Prioritize Resources

To target limited resources appropriately, community leaders, funders, and policymakers may consider 

leveraging data from state and national surveys to understand how access to healthy foods and physical 

activities varies across counties. For example, in 2016 the Appalachian Regional Healthcare System

conducted a health needs assessment using multiple data sources, including the U.S. Census and state 

vital statistics data. For additional data, policymakers may also consider using County Health Rankings to 

understand how obesity, access to exercise and healthy food, and physical inactivity varies across 

counties. The USDA’s Food Environment Atlas also offers data on factors such as food prices, food and 

nutrition services, proximity to fast food, and diet quality. Health coalitions may be able to offer 

additional data. North Carolina’s Eat Smart Move More Campaign offers a number of data resources that 

can be used to target program planning. HealthinAppalachia.org provides a comprehensive overview of 

health in the Appalachian Region using 41 county-level measures, including the prevalence of obesity and 

physical inactivity.

Additional Resources for Assessing the Need in Your Community

Conducting a needs 

assessment

This Community Tool Box11 provides an overview of needs 

assessments.

Conducting a Community Health Assessment12 provides helpful 

tools and examples for identifying and analyzing data for a needs 

assessment.

Conducting Rural Health Research, Needs Assessment, and 

Program Evaluation13 is a collection of resources that 

communities can use to develop and refine their own research.

Discovering Community Power: A Guide to Mobilizing Local 

Assets and Your Organization’s Capacity14 is a workbook that 

provides guidance for systematically identifying community 

assets.

Using state- and county-level 

data to prioritize resources

HealthData.gov15 is a searchable warehouse of health data.

Based on assessment of community needs, policymakers, funders, and community leaders should 

consider which recommendations and associated strategies below would best suit their communities. 

Many effective models for reducing obesity presented in this brief were part of multipronged efforts that 

combined community-based intervention with policy changes and health communications. To

successfully reduce obesity rates, community leaders, funders, and policymakers should work together to 

select a set of strategies that complement each other.

PRACTICAL STRATEGIES AND RECOMMENDATIONS 

Reducing the prevalence of obesity in Appalachia could help decrease the prevalence of chronic diseases, 

such as heart disease and diabetes. This section presents successful or promising policies, programs, and 

initiatives that aim to prevent or reduce obesity. We also provide examples of intervention strategies 

taking place in the Appalachian Region. Recommendations for reducing obesity and promoting healthy 

lifestyles include both system-level changes targeting organizational structure and policy, and individuallevel change that focuses on health behavior. 
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 5

RECOMMENDATION #1: ESTABLISH HEALTHY 

BEHAVIORS AMONG CHILDREN AND YOUTH TO 

PREVENT CHILDHOOD OBESITY

It is critical to establish healthy behaviors among children and adolescents to help reduce rates of 

childhood obesity. Early care and education settings and schools are uniquely positioned to influence a 

child’s eating and physical activity habits at a critical time in their development. Policymakers, 

community organizations, and funders must work collaboratively to ensure healthy habits are established 

among children.

Support Early Childhood Education Interventions

According to the Centers for Disease Control and Prevention (CDC), young children who are overweight 

in kindergarten are four times more likely than those who are not overweight to be obese by the time they 

have reached eighth grade.16 Interventions to prevent obesity must begin as early as possible and continue 

as children age. Early Care Education (ECE) settings include child care centers, day care homes, and 

Head Start and pre-kindergarten programs. ECE facilities can implement practices that address nutrition, 

infant feeding, physical activity, and screen time in order to develop healthy eating and activity habits

among young children. CDC has developed a framework for obesity prevention, tailored to ECE settings, 

called the Spectrum of Opportunities. The Quick Start Action Guide provides guidance on the Spectrum 

of Opportunities framework and action steps on how to institute system-level changes to a state’s ECE 

system. In 2012, CDC funded a six-year program, the Early Childcare and Education Obesity Prevention 

Program, which included the development of the National Early Care and Education Learning 

Collaborative (ECELC).

17 Across 10 states, Nemours Children’s Health System provided practical 

training and technical assistance on how to make changes within their ECE program to support healthy 

eating and physical activity.18 According to one ECELC project coordinator, “In Kentucky, many 

stakeholders have been hesitant to address obesity prevention practices and policies that impact the 

operations of nearly 3,000 licensed child care centers and certified homes. [Through this] project, we have 

been able to shift statewide attitudes so that more stakeholders are valuing and prioritizing childhood 

obesity prevention efforts.”18Community organizations, ECE providers, and policymakers can reference 

CDC’s 2016 Early Care and Education (ECE) State Indicator Report, which shows how states have 

incorporated the Spectrum of Opportunities into their ECE obesity prevention efforts. Finally, states can 

apply for funds from the Child and Adult Care Food Program (CACFP)19 to provide nutritious meals and 

snacks for the people they serve. The CACFP website describes key funding opportunities, state policy 

levers, and system supports for accessing healthy food at after-school care centers, childcare centers, and 

daycare centers. 

Increase Availability of Healthy Foods and Beverages in Schools 

A focus on providing healthy food and beverages to children in schools has increased over the past 

decade. The U.S. Department of Agriculture (USDA) Food and Nutrition Service (FNS) administers 

several child nutrition programs, including the National School Lunch Program, School Breakfast 

Program, Child and Adult Care Food Program, Summer Food Service Program, Fresh Fruit and 

Vegetable Program, and Special Milk Program.20 In 2012, USDA updated nutrition standards for the 

National School Lunch Program and School Breakfast Program to require schools to increase availability 

of fruits, vegetables, whole grains, and fat-free and low-fat fluid milk in school meals, along with other 

changes. Additionally, since the 2014–2015 school year, all foods sold at school during the school day are 

required to meet USDA nutrition standards.21
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 6

To help schools comply with new nutrition standards, 

several initiatives aim to increase the availability of 

healthy foods and beverages in schools, including Salad 

Bars to School and Farm to School. Salad Bars to 

School is a unique public-private partnership that

promotes and sponsors salad bars in schools. Research 

has shown that students who have access to a school 

salad bar eat more fruits and vegetables and add more 

variety to their diets.22 CDC created an Action Guide on 

promoting and supporting school salad bars, which can 

be used as a reference by stakeholders in the 

Appalachian Region. USDA’s Farm to School program 

awards grants to different types of organizations 

(schools, school districts, nonprofit organizations, etc.) 

to plan, implement, and/or provide training on farm-toschool activities. The Appalachian Sustainable 

Agriculture Project’s (ASAP) Growing Minds Farm to School Program in Haywood County, North 

Carolina, began in 2002, making it one of the first farm-to-school programs in the country. Growing 

Minds now works with schools in 60 Appalachian counties, helping them provide farm-to-school 

experiences to their students. Growing Minds provides seeds for school gardens, mini-grants, lesson 

plans, and recipes, and also manages a database of children’s literature focused on local food and farms.

A critical aspect of improving healthy behaviors in the school setting is limiting consumption of sugarsweetened beverages (SSBs). This can be achieved by increasing access to healthier beverages and 

disincentivizing or eliminating the option of sugary beverages, such as soda. An example of an innovative 

Appalachian intervention is the “Sodabriety” 30-day challenge, which was implemented in two high 

schools in Pike County, Ohio. A teen advisory council designed the intervention, including promotional 

campaigns and facts during daily announcements. Results showed that student participation in the 

challenge reduced both daily consumption of SSBs and increased water consumption.23

Promote Physical Activity Among Children and Youth 

The most effective strategy for promoting physical activity 

among youth is ensuring children have opportunities for 

physical activity before, during, and after school. Children can 

experience substantial health benefits if they meet the 

Physical Activity Guidelines,

24 which recommend that schoolaged youth (ages 6 through 17 years) do moderate- and 

vigorous-intensity physical activity for at least 60 minutes 

each day.25 CDC recommends the Comprehensive School 

Physical Activity Program approach, which encourages 

schools to promote physical activity before, during, and after 

school, while also incorporating staff involvement and family 

and community engagement. 

Growing Minds Farm to School Program helps schools 

provide farm-to-school experiences for their students.

© Appalachian Sustainable Agriculture Project

© CDC
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 7

Several policies and strategies can help schools achieve the goals established in the Comprehensive 

School Physical Activity Program, such as the following:

26

■ Design an enhanced school-based physical education program.

27

■ Incorporate physical activity opportunities into regular classroom activities.

■ Establish formal policies or agreements, such as joint use agreements, to allow schools to use 

nearby fields and parks for before-, during-, and after-school physical activity opportunities.

Additional Resources for Establishing Healthy Behaviors Among Children and Youth 

Early childhood 

education setting 

Institute of Medicine (IOM) report on Early Childhood Obesity 

Prevention Policies28

CDC report on licensing and administrative regulations29 to support 

obesity prevention in ECE settings

CDC report on increasing access to drinking water and other healthier 

beverages30 in early care and education settings 

National Center for Healthy Safety in Child Care and Early Education – 

Achieving a State of Healthy Weight Report31

Access to healthy foods 

and beverages in schools

An overview32 of achievements of USDA’s Fiscal Year 2015 and 2016 

Farm to School Grantees 

CDC Healthy Schools project offers guidelines on implementing school 

health guidelines33

A Guide to Smart Snacks in School34

Increasing access to drinking waters in schools35

Information on model wellness policy language36 to increase water 

access in schools 

Physical activity Comprehensive School Physical Activity Program (CSPAP) – step-bystep guide37 for schools and school districts to develop, implement, 

and evaluate comprehensive school physical activity programs

Increasing Physical Education and Physical Activity: A Framework for 

Schools38

A guide39 for sharing physical activity resources through joint 

agreements

A checklist40 for developing joint use agreements 
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 8

RECOMMENDATION #2: INCREASE AVAILABILITY OF 

AFFORDABLE HEALTHY FOODS AND BEVERAGES IN 

COMMUNITIES 

To support individual behavior change, the environment in which a person lives must promote healthy 

eating through the availability of affordable healthy foods and beverages. Increasing access to affordable 

healthy foods can be achieved through both community-based and policy-based strategies. 

Community-Based Strategies 

Bringing affordable, healthy food options 

into communities throughout Appalachia 

requires collaboration between local 

farmers, community leaders, nonprofits, 

and funders. For example, a community 

can establish a farmers market or 

community and school gardens. Farmers 

markets can apply to become authorized to 

accept Supplemental Nutrition Assistance 

Program (SNAP) and Women, Infants, and 

Children (WIC) benefits. SNAP offers 

nutritional assistance to low-income 

citizens, and WIC offers nutritional 

assistance, formula, breastfeeding 

assistance, and supplies to low-income mothers and their children. Both programs serve vulnerable 

populations and are a vital tool for increasing access to nutritious foods. The Kanawha Valley Local Food 

Project is an initiative of the West Virginia Food and Farm Coalition that helps establish farmers markets

and make them accessible to people of all incomes, including SNAP and WIC recipients.

41

Other nonprofit organizations and funders can use charitable donations to provide food to those in need 

throughout their communities, while also encouraging healthy eating behaviors. As highlighted in the 

Bright Spot case studies report, in Madison County, North Carolina, the School Health Advisory Council 

(SHAC) launched a food truck program that provides free fruits and vegetables to county residents.3

Similarly, the Healthy Living Mobile Market is a vehicle operated jointly by the Madison County Health 

Department and the YMCA that delivers free fruits and vegetables to low-income residents around the 

county.42 Additionally, the Madison County extension office operates a food hub program that helps 

small-scale local farmers bring their products to market, and also provides a place where low-income 

families can obtain high-quality organic produce at low prices. 

Policy-Based Strategies 

Policies that encourage and incentivize participation in programs that increase access to healthy foods and 

beverages are critical. Policies can be targeted at different groups, including farmers, retailers, and 

consumers. Incentives for farmers include implementing a farm-to-food bank tax credit, which provides 

an incentive through a tax credit for farmers if they donate their products to local food banks. This 

legislation was passed in West Virginia, modeled after previous legislation in Kentucky.43 West Virginia 

also passed legislation that established a single statewide permitting process for farmers market vendors.

44

The YMCA of Western North Carolina’s Healthy Living Mobile Market 

provides free food distribution to underserved counties as a way to 

encourage healthy eating.

© YMCA
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 9

Research has shown that offering incentives to SNAP and WIC participants, such as coupons that double 

the value of their dollars if spent on fruits and vegetables, can increase fruit and vegetable consumption.45

The Pennsylvania Fresh Food Financing Initiative offers a model for public-private partnerships for 

increasing access to healthy food. The program created incentives for supermarkets and grocery stores to 

serve rural and underserved communities, and was effective at providing healthy food and reducing 

incidence of diet-related diseases.46

Access to supermarkets and grocery stores with healthy food options is often limited in Appalachia, 

particularly in rural areas. Zoning and tax policies can be implemented to encourage grocery stores to 

locate in specific areas.

47 However, in order to increase consumption of healthy foods, comprehensive 

strategies are likely necessary to address other influences on purchasing, including marketing and pricing 

of healthy food.48 Organizations such as schools, universities, and healthcare facilities can also create 

organizational policies that promote healthy beverages rather than sugary beverages. For example, the 

University of Michigan Health System stopped selling sugary beverages in its health centers, 

administrative buildings, and medical school.49 Some localities have enacted a sugar-sweetened beverage 

tax to disincentivize consumption of sugary drinks. Public health advocates in West Virginia have 

supported an increase on the sugar-sweetened beverages tax that was implemented in 1951. They hope the 

tax will help prevent the continued rise in diabetes and obesity rates in West Virginia, and generate

revenue to fund health care and obesity programs for low-income individuals.50 For other jurisdictions 

interested in pursuing this policy, Change Lab Solutions has developed a Legal and Practical Guide for 

Designing Sugary Drink Taxes.

51 

RECOMMENDATION #3: CREATE SAFE 

COMMUNITIES THAT SUPPORT PHYSICAL ACTIVITY 

Ensuring that communities encourage physical activity is critical for reducing obesity among all age 

groups. Strategies discussed in this section focus on changes to the physical environment that facilitate 

higher levels of activity among people of all ages. Research demonstrates that an environment with 

barriers to safe exercise will decrease the likelihood that a child will choose physical activity over indoor 

activity, such as watching television or playing video games. To reverse this trend, many states and 

localities invest in public trails, parks, and recreational facilities. A national study of U.S. adults found 

that access to public parks and trails was associated with higher levels of physical activity among people 

of all age groups.52 Changes in access to transportation and public land such as parks will be crucial in 

maintaining an environment that is conducive to walking, biking, and playing outside. 

Community organizations, funders, and policymakers can work together to change local environments to 

create opportunities for physical activity. Changes can include creating or improving walking trails, 

building exercise facilities, or providing access to existing facilities.53 For localities that cannot set aside 

public funds for maintaining parks and recreational centers, private grants are available. For example,

Investing in Kentucky’s Future (IKF) was a $3 million grant that implemented various health programs 

across seven communities.54 Recipients could use their grants for a wide range of preventive health 

initiatives, such as building parks, increasing access to fruits and vegetables, and integrating mental 

healthcare into schools. Clinton County, Kentucky, used its funding to build walking trails to schools and 

add exercise equipment to public parks. A program evaluation of IKF by the Foundation for a Healthy 

Kentucky showed changes in health behavior, including increased physical activity.55

Making an environment more conducive to physical activity can change the way people travel to work 

and school. The Safe Routes to School Program56 modifies current infrastructure and offers education and 

incentives for children to walk or bike to school. By making travel safer for students, communities can 
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 10

increase their physical activity on the way to school. Meigs County, Tennessee, was able to open a 

walking trail to its elementary school through an Appalachian Diabetes Control and Translation Project 

(ADCTP) grant. States and cities can also adopt a “complete streets” approach, which can include 

developing bike trails, safe routes to walk or bike to school, and widening roads to make more room for 

pedestrians and cyclists. The North Carolina Department of Transportation adopted a complete streets 

policy in 2009, which built and enhanced bike and pedestrian trails across the state. This project included 

improving roads and trails so that children can walk or bike to school. 

Public parks and recreational facilities offer another opportunity to foster increased physical activity and 

social cohesion. Creating and maintaining public facilities ensures that children have safe places to be 

outside and gives the community at large a place to meet and hold events. Research has shown that 

creating a public place to exercise improved all measures of physical activity, including aerobic exercise 

and general energy expenditure.57 Examples from other cities show that people will use parks if they are 

properly maintained. The Exploring Your Own Backyard58 project, which takes place along the 

Cumberland River in Kentucky and Tennessee, offers a broad range of recreational opportunities for 

children, including hiking, biking, and kayaking.59 The program is funded through federal grants and 

community partnerships, which could be similarly leveraged in other Appalachian counties.

Additional Resources for Creating Safe Communities That Support Physical Activity

Create safe routes to school Smart Growth America offers guidelines60 and a model for 

complete streets policy.

Department of Transportation offers a complete guide61 that 

includes evaluation materials and implementation 

considerations. 

Maintain public parks and 

recreation facilities 

An Action Guide62 from the CDC and Partnership for Prevention 

details the implementation process of constructing and 

maintaining public land.

National Recreation and Park Association tracks grant 

availability63 for maintaining parks and recreational centers.

The Appalachian Diabetes Control and Translation Project 

(ADCTP)64 offers information on and funding resources for 

infrastructure change.
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 11

RECOMMENDATION #4: INCREASE PHYSICAL 

ACTIVITY AND HEALTHY EATING AMONG ADULTS 

The first three recommendations have focused on strategies that support communities that promote 

healthy behaviors, which are critical first steps to improving outcomes related to obesity and related 

diseases. However, in order to reduce the prevalence of obesity in Appalachia among adults, individual 

behaviors must change. The following strategies can stand alone, though they can also be combined into 

comprehensive behavioral interventions. We discuss several strategies that have been recommended as 

effective interventions by the Community Preventive Services Task Force65(CPSTF), a resource for 

selecting evidence-based interventions for improving health and preventing disease.

Worksite Wellness Programs 

The average employee spends more than one-third of their day at the workplace. Given the major role that 

work plays in an individual’s life, worksite wellness programs can significantly improve employees’ 

behavioral health and overall quality of life. Establishing a multicomponent worksite obesity prevention 

program is one intervention included in CDC’s Health Impact in Five Years (HI-5) initiative.66 Employers 

may implement worksite obesity prevention programs separately or as part of a comprehensive wellness 

program. The typical worksite wellness program includes—but is not limited to—weight control 

interventions, physical activity opportunities, access to private breastfeeding areas, smoking cessation 

programs, and stress management resources. Designing and implementing a worksite wellness program 

can be done through organizational policies and programs, or by supporting legislation such as tax 

incentives for businesses to design one. The Kentucky Department for Public Health used a health impact 

assessment to analyze the impact of a worksite wellness tax credit on several outcomes, including obesity 

rates, social cohesion, and job creation in the state.67 Following the assessment, a worksite wellness tax 

credit was introduced in the state legislature.68

Community-Wide Campaigns to Increase Physical Activity 

Community-wide campaigns to increase physical activity using highly visible, multicomponent strategies

are a vital tool for reducing obesity through behavioral changes.

69 Successful community-wide campaigns 

involve collaboration between different sectors, such as medicine, early childhood professionals, social 

services, and educators. Ideal components of a community-led program are detailed in the CDC’s Guide 

to Strategies to Increase Physical Activity in the Community.

70 An example from the Bright Spot case 

studies report is Step Up Sequatchie: Improve Your Health One Step at a Time in Sequatchie County, 

Tennessee.

3This project includes community-led programs that educate people and provide resources on 

healthy eating and physical activity, in addition to smoking cessation. Volunteers have sponsored multiple 

health screening events and teamed up with the University of Tennessee to improve exercise facilities and 

physical education offerings in schools. This multifaceted project strengthened the reach of each 

intervention, reflecting a desire to create an overall culture of health that emphasizes sufficient physical 

activity and healthy habits. 

Social Support Interventions in Community Settings 

A large body of evidence suggests a positive association between increased social support and physical 

activity.71 Interventions that focus on building, strengthening, and maintaining social networks can

motivate people to engage in more physical activity. The increased community support and availability of 

information is what makes these programs successful. Examples include setting up a buddy system, 

making contracts with others to complete specified levels of physical activity, or setting up walking or 
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 12

other groups to provide friendship and support.72 Social support interventions can take place within a 

community or can be offered through health care systems. Western Maryland Health System (WMHS), a 

comprehensive health organization serving counties in Maryland, West Virginia, and Pennsylvania,

secured more than 12 partnerships with local organizations as diverse as the Allegany County Board of 

Education, the Country Club Mall, and the YMCA. Two “mall movers” walking groups encourage 

community-wide organized physical activity, social support, and enhanced access to local facilities.

73

WMHS was able to prove to private organizations and insurance providers that the program increased 

physical activity, and successfully secured grants to fund future programs. These programs can be 

replicated in communities, particularly those with local health providers directly involved in their 

communities. Many counties profiled in the Bright Spot case studies report prioritize community 

development and participation, indicating that fostering social support is a promising strategy that can be 

replicated in other Appalachian communities. 

Technology-Supported Multicomponent Coaching or Counseling Interventions

The Community Preventive Services Task Force (CPSTF) found compelling evidence that the use of 

technology such as activity monitors was helpful in increasing physical activity. These interventions 

expand access to support and professional advice through technology such as computers, videoconferencing, digital assistance, or mobile applications.

74 The technological aspect makes social support 

and expertise available to people regardless of their location or work schedule. These interventions could 

be integrated with current worksite wellness programs and be part of a larger multicomponent coaching 

intervention. In 2013, IBM provided all employees with a Fitbit to track their progress. The program 

included activity challenges where employees could earn points.75 It also included a social media 

component where employees could seek advice and help with other users online. The technology and/or 

online community aspect of this program could be integrated into new or existing community wellness 

programs. 

An example of multicomponent health coaching can be seen in Fit for Life, a program sponsored by 

Trinity Hospital in Tuscarawas County, Ohio. The goal of the program is to provide an innovative multiagency means to reduce the number of overweight and obese men and women in Tuscarawas County and 

surrounding counties of Carroll, Guernsey, and Harrison. The initiative offers “fit for life” classes, health 

risk assessment, and more for the community and workplace.76 Although the program started as a private

hospital initiative, the success of the first round convinced funders to expand the program to businesses as 

well. 

Additional Resources for Behavioral Health Interventions

Worksite wellness 

programs

The CDC’s Worksite Scorecard77 includes examples of worksite programs 

and a tool to evaluate existing programs. 

Multicomponent 

wellness campaigns 

The CDC guide78 to Strategies to Increase Physical Activities in the 

Community offers guidance on best practices and potential strategies. 
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 13

STRATEGIES AND RECOMMENDATIONS FOR 

FUNDERS

Funders throughout the Region have the opportunity to invest in initiatives and activities to improve 

outcomes related to obesity and related diseases across Appalachia. Below, we describe strategies for 

funders and how they can make a difference in reducing health disparities related to obesity in the 

Appalachian Region. 

 Leverage existing assets

Funders can leverage existing programs, practices, and policies by promoting the replication and 

adoption of successful programs and strategies. Appalachian communities have many assets that 

should be recognized and promoted. Community members are often connected through volunteering 

and coalition building. They also build strong social connections through faith- and community-based 

organizations, schools, local businesses, and shared culture and history. Funders can expand 

programs such as healthy mobile markets and fresh food financing to additional communities.

 Strengthen community implementation capacity

Funders can strengthen community implementation capacity in Appalachian communities. 

Opportunities to increase capacity include 1) enhancing individual-level knowledge and skills that 

facilitate community action, and 2) fostering organizational and systems-level capacity. Examples of 

organizational and systems-level capacity include engaging in community visioning and strategic 

planning, building networks and engaging community stakeholders, writing grants, and engaging in 

local and regional policy advocacy, such as creating incentives for local farms to distribute locally or 

developing joint use agreements with schools.

 Focus on cross-sector collaboration through philanthropic strategies

Funders can help facilitate collaboration between community members, the public, and privatesector individuals, which is critical to addressing obesity within the Region. Through a coordinated 

use of resources, leadership, and action, communities can work together towards a common goal, 

using multiple perspectives and different areas of expertise. Government, the health care system, 

schools, private businesses, and community organizations all have critical roles in this 

effort. Funders can also play a role in helping key players collaborate through the funding of regional 

conferences or technical assistance.

 Build the Appalachian evidence base

The Bright Spot case studies report identified examples of promising practices to improve outcomes 

related to obesity and related diseases in Appalachian communities. However, these programs and 

their outcomes are often not well documented. For long-term changes to occur, successful programs 

need to be evaluated rigorously and shared widely. Funders should encourage evaluation among 

their grantees to ensure program effectiveness is measured and documented. Evaluation, along with 

increased efforts to document local successes, will provide a more robust evidence base for 

Appalachian-specific programs and policies to improve outcomes related to obesity and related 

diseases. One tool to assist grantees is the Rural Health Promotion and Disease Prevention 

Toolkit, which has a module devoted to evaluation. Also, the Rural Health Information (RHI) Hub

has tools for dissemination that can help grantees and funders identify ways to highlight their work 

related to obesity and obesity-related diseases.
Health Disparities Related to Obesity in Appalachia | Practical Strategies and Recommendations for Communities 14

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