Appalachian Diabetes Control and Translation Project

Building Capacity to Improve Health in Appalachia

View of mountaintops in Appalachian region

Residents in distressed Appalachian counties are more likely to have diabetes.

The Appalachian Region is an area of 205,000 square miles along the Appalachian Mountains, stretching from southern New York to northern Mississippi. It extends more than 1,000 miles across 420 counties in 13 states and is home to more than 25 million people.

Many people in Appalachia face serious health challenges that are influenced by factors such as a lack of economic stability and living in a rural location. Compared with the rest of the nation, they have significantly less access to health care, higher rates of substance use and mental health disorders, and higher rates of cancer and chronic diseases, including heart disease, stroke, and diabetes.

Health disparities are even worse in counties defined by the Appalachian Regional Commission as the most economically distressed based on unemployment rates, per capita income, and poverty rates.13

Diabetes in Appalachia

In a 2010 study, researchers found that residents in the 78 Appalachian counties classified as distressed were 1.4 times more likely to have diabetes than residents of non-Appalachian counties. Among adults aged 45 to 64, about 1 in 5 of those living in distressed counties had diabetes, compared to only 1 in 8 of those living in non-Appalachian counties.3

In 2011, CDC identified a 644-county area of the United States as the “diabetes belt.” At the time, about 11.7% of people living in this area had been diagnosed with diabetes, compared with only 8.5% of people living in other parts of the country. More than 33% of diabetes belt counties are in central and southern Appalachia.4

Appalachian Diabetes Control and Translation Project

The Appalachian Diabetes Control and Translation Project (ADCTP) was launched to help prevent and manage diabetes in distressed counties in Appalachia by supporting the development of community coalitions.

With support from DDT and the Appalachian Regional Commission, the Center for Rural Health at Marshall University built an infrastructure of diabetes coalitions called the Appalachian Diabetes Network, which serves more than 70 distressed counties in 9 states. Coalitions in the network are required to develop workplans, processes, and tools for reporting, managing, and evaluating their activities.


  • Scaling and Sustaining the National Diabetes Prevention Program (National DPP): In 2014, ADCTP helped diabetes coalitions deliver the National DPP lifestyle change program to prevent or delay type 2 diabetes among adults with prediabetes. ADCTP awarded $2,000 grants to promote prediabetes awareness and recruit participants to the lifestyle change program. By 2019, funded coalitions had helped enroll over 600 participants.
    • In 2020, Marshall University helped coalitions participate in a CDC-funded demonstration project to increase access to the National DPP lifestyle change program in Appalachia by getting more health care systems to cover the cost of the program. The project enrolled 170 participants from January 2020 through June 2021.
  • Increased Outreach Through Social Media: During the COVID-19 pandemic, coalitions expanded the reach of their efforts using social media to build knowledge about and access to quality preventive services, healthy foods, and physical activity.
  • Community Participation in Physical Activity and Healthy Eating: Coalitions focused on key diabetes risk factors, such as physical activity and diet, and expanded community involvement in local events. As a result of these efforts, the number of people participating in physical activity programs increased from 2,011 in 2011 to 60,418 in 2017. Participation in healthy eating programs increased from 7,032 to 37,227.
  • Increased Focus on Community Settings: By the end of 2017, 59 diabetes coalitions were working to redesign communities to help people be more physically active. Thirty-eight coalitions were focused on increasing healthier food choices for people facing hunger, with technical support from the Harvard Law Policy Group.

Success Stories

Mingo County, West Virginia

The Mingo County Diabetes Coalition worked with community members to develop community gardens, provide cooking classes, and sponsor team-based walking competitions that turned into monthly 5K runs and walks. The coalition brought together clinical partners, certified diabetes educators, and other practitioners to provide diabetes self-management education and support services recognized by the American Diabetes Association.

The coalition also secured funding to hire and train community health workers to make weekly home visits to help people with diabetes practice self-management skills, such as taking prescribed medications, checking their blood sugar levels, making healthy food choices, and increasing physical activity. After 12 months, 137 patients with diabetes had reduced their HbA1c level by an average of about 1.7%, and hospitalizations were down 30%.5

Community health workers are continuing to help their patients in Mingo County by sharing resources and encouraging them to participate in healthy community activities.6

Perry County, Kentucky

The Perry County Diabetes Coalition implemented a 6-week challenge for people with diabetes and prediabetes to help them improve their health. The challenge was to walk 150 minutes a week, eat 5 or more servings of fruits and vegetables each day, and consume 64 ounces or more of water each day.

The more goals participants reached, the more times they were eligible to win prizes. The Perry County Farmer’s Market and several local health clinics supported the challenge by “prescribing” Diabetes Dollars that patients could redeem at the farmer’s market for fresh produce.

  1. Wood L. Trends in National and Regional Economic Distress, 1960-2000 [PDF – 1.6 MB]. Appalachian Regional Commission; 2005.
  2. Halverson JA, Bichak G. Underlying Socioeconomic Factors Influencing Health Disparities in the Appalachian Region. Appalachian Regional Commission; 2008.
  3. Barker L, Crespo R, Gerzoff RB, Denham S, Shrewsberry M, Cornelius-Averhart D. Residence in a distressed county in Appalachia as a risk factor for diabetes, Behavioral Risk Factor Surveillance System, 2006-2007. Prev Chronic Dis. 2010;7(5):A104.
  4. Barker LE, Kirtland KA, Gregg EW, Geiss LS, Thompson T. Geographic distribution of diagnosed diabetes in the U.S.: a diabetes belt. Am J Prev Med. 2011;40(4):434–439.
  5. Crespo R, Hatfield V, Hudson J, Justice M. Partnership with community health workers extends the reach of diabetes educators. AADE in Practice. 2015;3(2):24–29.
  6. Crespo R, Christiansen M, Tieman K, Wittberg R. An emerging model for community health worker–based chronic care management for patients with high health care costs in rural Appalachia. Prev Chronic Dis. 2020;17:190316.