The most rural (noncore) counties had higher (worse) average childhood obesogenic environment index scores compared to their metropolitan or micropolitan counterparts. By region, the South had the highest (worst) observed obesogenic environment index scores compared to the West, Midwest, and Northeast regions. Southern noncore counties had the greatest obesogenic environment burden; whereas, Northeast metropolitan counties had the lowest burden.

This study identified several key environmental variables that may play a significant role in childhood obesity. A number of these variables may prove problematic in the rural environment particularly as existing literature shows that rural populations are at an increased risk for childhood obesity. In some rural areas, agricultural work may facilitate healthy eating and physical activity among children and farming families, but in most cases, additional environmental improvement efforts will be useful. Indeed, documented resource limitations in rural areas such as access to healthful foods and opportunities for physical activity may contribute to geographic disparities in childhood obesity. These barriers to healthy living, however, may be overcome through a number of different public health policies and initiatives.

Aspects of the physical environment could be modified to promote physical activity and increase access to exercise opportunities. For example, public health, planning, and other government agencies could improve walkability and pedestrian and bicycle safety through improvements to infrastructure (e.g., traffic calming measures, sidewalks). Rural schools may adopt programming such as Safe Routes to School which increases safety surrounding schools to encourage active travel to/from school. Further, physical activity-related policies such as shared use agreements that increase accessibility of school recreation facilities and playgrounds to the public could be a viable method to increase access to exercise opportunities.

Features of the physical environment can also be modified to increase the availability of healthy food options. For example, policy makers could work to improve the food environment through food outlet zoning. Unhealthy food outlets – fast food restaurants, convenience stores, etc. – may cluster around schools and negatively influence student diets. Such efforts could reduce the prevalence of food swamps which have been linked to higher obesity rates. Additionally, rural public health agencies could work to improve childhood obesity rates through partnerships with fellow public agencies, schools, and local grocery stores and restaurants. For example, public health agencies could sponsor farmers markets to promote healthful and affordable food options. Moreover, fostering relationships between farms and schools and local businesses could bring healthier food choices into schools and restaurants. These efforts to increase access to healthy food options could contribute to reducing the number of food deserts in rural areas.

The foundation of our obesogenic environment index was variables that represent resource availability. It is important to note that counties that have fewer total resources to promote healthy eating and physical activity (e.g., lower access to grocery stores, poorer walkability) do not necessarily have higher childhood obesity prevalence or vice versa. Other key area-level drivers of childhood obesity including socioeconomic status, lack of health insurance, and proportion of racial/ethnic minorities may interact with an area's physical environment to determine obesity outcomes. Additional research is needed to explore the additive and multiplicative interaction between the obesogenic environment and other area-level sociodemographic factors that predict childhood obesity.