<p>Risk factors for type 2 diabetes (T2D) and cardiovascular diseases (CVD) are increasingly apparent in adolescence, and those in rural communities are disproportionately impacted. Intensive health behavior and lifestyle treatment (IHBLT) interventions have been shown to reduce risk factors for T2D and CVD; yet, for adolescents living in rural communities, these types of interventions are difficult to access and may be less effective due to unique barriers faced by rural adolescents. Tailoring IHBLT to the local rural context, particularly in ways that consider current and historical structural drivers of inequity, offers strong potential to address this need. Guided by the Practical, Robust Implementation and Sustainability Model with an equity focus, we co-created an adapted version of an IHBLT program, Health Without Barriers, for rural families with adolescents ages 11–19&#xa0;years, emphasizing access for families living on a low-income, for adolescents whose caregivers prefer a language other than English (Spanish), and for adolescents with historically marginalized racial and ethnic identities. The aims of the current project were to (1) illustrate how participatory co-creation with community members can be systematically implemented—through an extensive initial information gathering phase coupled with iterative adaptation and additional information gathering—to make local and cultural adaptations to IHBLT, and (2) evaluate the feasibility and acceptability of those adaptations using multiple methods (self-report survey data, program attendance, and focus groups) among rural families with adolescents (<i>n</i> = 29 adolescents and <i>n</i> = 22 caregivers) who participated in the adapted IHBLT. Findings have implications for other research teams and practitioners looking to increase access and efficacy of IHBLT for the prevention and treatment of T2D and CVD in diverse and underserved rural populations.</p>