Through a community-focused needs assessment conducted in rural Appalachia, we gauged perceptions of facilitators and barriers related to healthful eating and physical activity for young children and identified suggestions for improvement. Thirty-seven key informant interviews and three caregiver focus group sessions were coded and analyzed for key themes. Limited community resources emerged as a barrier to both healthful eating and physical activity. Suboptimal communication about existing opportunities was also identified. Community members reviewed the needs assessment data and implemented initiatives to address identified needs. The importance of Extension-facilitated needs assessments in rural settings to shape health initiatives to local contexts is highlighted.