Background: Youth obesity remains a major public health concern in the United States, with high burdens in the Southeastern region. Tennessee consistently reports elevated youth obesity rates, yet the geographic distribution of youth obesity and its relationship with county-level factors are not well understood. This study examined spatial patterns of youth obesity across Tennessee counties and associations with social, behavioral, and demographic determinants.Methods: An ecological analysis was conducted using county-level data from Tennessee’s 95 counties. Youth obesity prevalence served as the outcome variable. Spatial patterns were evaluated using Global Moran’s I, Anselin Local Moran’s I, and Getis-Ord Gi* hotspot analysis. Ordinary least squares (OLS) regression was used as the primary multivariable model, with diagnostic tests assessing multicollinearity, heteroskedasticity, residual normality, and spatial dependence. All analyses were conducted using ArcGIS Pro and Python.Results: Youth obesity prevalence ranged from 23.9% to 55.5% across counties, revealing substantial geographic variation. Global Moran’s I indicated no significant statewide spatial autocorrelation; however, local analyses identified distinct clusters and hotspots in parts of West and East Tennessee. Bivariate correlations revealed strong interrelationships among socioeconomic indicators. In the multivariable OLS model, physical inactivity emerged as the only significant predictor of youth obesity (β = 1.02, p < 0.0004). Diagnostic tests showed no evidence of heteroskedasticity or spatial non-stationarity.Conclusion: Youth obesity in Tennessee displays localized geographic clustering and is strongly associated with county-level physical inactivity. These findings highlight the importance of spatially informed, place-based interventions that prioritize increasing physical activity, particularly in high-burden counties.