Obesogenic Environment Features and Childhood Overweight/Obesity Across the Urban–Rural Continuum: Development of a Revised Childhood Obesogenic Environment Index

Background: Environmental factors such as food access, walkability, and recreation opportunities are associated with childhood obesity risk and urban–rural obesity disparities. Although the Childhood Obesogenic Environment Index (COEI) was previously developed to characterize obesogenic environments across US counties, limited research has examined how combinations of obesogenic environment features relate to childhood overweight/obesity rates across the urban–rural continuum. The purpose of this study was to assess associations between obesogenic environments and childhood overweight/obesity rates and to develop a revised COEI composed of variables associated with childhood overweight/obesity rates. Methods: Data from 3140 US counties were analyzed using 10 environment variables associated with childhood obesity estimates. Counties were classified by Rural-Urban Continuum Codes (RUCC) and Census divisions. Regressions identified best-fit models nationally and by RUCC level, and beta coefficients from the national model were used to develop a weighted COEI. Results: The national and all rurality-stratified models were significant ( p < 0.001), although associations between individual obesogenic environment variables and childhood overweight/obesity rates varied across RUCC classifications. The revised weighted COEI demonstrated a modestly stronger association with childhood overweight/obesity rates than the original index ( r = 0.25 vs. r = 0.22) while remaining correlated with the original measure ( r = 0.80, p < 0.001). The revised COEI varied significantly by rurality and Census division ( p < 0.001), with the highest COEI scores concentrated in rural counties. Conclusions: Obesogenic environment features appear to operate differently across geographic contexts, highlighting the importance of place-based approaches to childhood obesity prevention.