Findings Challenges | 2018 Annual Report

Executive Summary IntroductionFindingsState Rankings Successes Challenges Health Equity International ComparisonCore MeasuresBehaviors Community & Environment Policy Clinical Care OutcomesSupplemental MeasuresBehaviors Community & Environment Policy Clinical Care OutcomesState Summaries
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2018 Annual Report 2018 Annual Report - Executive Summary
Obesity Prevalence Exceeds 30 Percent of Adults 
In the past year, obesity increased 5 percent from 29.9 percent to 31.3 percent of adults. This is the percentage of adults with a body mass index of 30.0 or higher based on reported height and weight. Obesity is a leading cause of preventable life-years lost and contributes to chronic illnesses such as heart disease, type 2 diabetes, stroke, cancer and hypertension. Contributing factors include poor diet, physical inactivity, social and physical environment, genetics and medical history. 
Nationally, there are disparities in obesity by age, race/ethnicity, urbancity, education and income. 
Obesity is highest among adults aged 45 to 64 at 35.6 percent. Adults aged 65 and older are at 28.5 percent, and adults aged 18 to 44 are at 26.7 percent.
Asian adults have the lowest prevalence of obesity at 11.2 percent, followed by adults identifying as other race at 26.9 percent, white at 29.3 percent, Hispanic at 32.4 percent, Hawaiian/Pacific Islander at 32.5 percent, multiracial at 32.8 percent, American Indian/Alaska Native at 38.7 percent and black at 39.0 percent.
Rural adults have a higher prevalence of obesity at 34.8 percent compared with suburban (30.6 percent) and urban (30.3 percent) adults. 
Obesity prevalence decreases with each increasing level of education and income:
Adults aged 25 and older with a college degree have a lower prevalence of obesity at 23.2 percent than all other education levels: less than a high school education (37.4 percent), high school education (36.1 percent) and some college (34.8 percent).
Adults aged 25 and older with annual household incomes less than $25,000 have a higher prevalence of obesity (38.0 percent) than adults aged 25 and older with incomes $25,000-$49,999 (34.2 percent), $50,000-$74,999 (33.0 percent) and $75,000 or more (27.2 percent).
Obesity in West Virginia (38.1 percent) is nearly double the prevalence in Colorado (22.6 percent). In the past year, obesity prevalence increased significantly in Iowa (+4.4 percentage points) and Oklahoma (+3.7 percentage points) (Figure 12). While obesity decreased in a few states in the past year, none of the decreases were significant.
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Since 2012, obesity prevalence has increased significantly in 23 states (Figure 13). The largest increases occurred in Iowa (+7.4 percentage points), Alaska (+6.8 percentage points), West Virginia (+5.7 percentage points), Oklahoma (5.4 percentage points) and North Dakota (+5.3 percentage points) (Figure 14). The smallest increases occurred in Montana (+0.7 percentage points), Utah and Virginia (+0.8 percentage points), Michigan (+1.0 percentage points), and New York and Washington (+1.2 percentage points). Obesity prevalence has not decreased in any state since 2012.
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Increasing Mortality Rates Contributing to Premature Death
Drug Deaths
The United States is in a drug crisis with fatal consequences. Since 2015, drug deaths increased 25 percent from 13.5 to 16.9 deaths per 100,000 population. This is the age-adjusted number of deaths due to drug injury of any intent (unintentional, suicide, homicide or undetermined) per 100,000 population (three-year average). More than 63,000 drug overdose deaths occurred in 2016, with more than 42,000 involving opioids.
Nationally, the drug death rate differs by sex, age and race/ethnicity (Figure 15).
Males have a higher rate of drug deaths at 21.7 per 100,000 than females at 12.2 deaths per 100,000. 
White adults have the highest rate of drug deaths at 18.9 per 100,000, followed by adults identifying as American Indian/Alaska Native at 14.3 per 100,000 and black at 13.5 per 100,000. The drug death rate among Asian and Hispanic adults is much lower at 2.8 per 100,000 and 8.1 per 100,000, respectively.
Adults aged 45 to 54 have the highest rate at 30.9 deaths per 100,000 when compared with other 10-year age groups between ages 15 and 74.
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The drug death rate also varies by state. It is 6.1 times higher in West Virginia, the least healthy state for this measure at 41.4 deaths per 100,000 population, compared with Nebraska, the healthiest state for this measure at 6.8 deaths per 100,000 population.
Since 2015, the drug death rate has significantly increased nationally as well as in 31 states and the District of Columbia (Figure 16). The largest increases occurred in New Hampshire (+17.4 deaths per 100,000), Ohio and Massachusetts (+11.5 deaths per 100,000), and Maryland (+10.5 deaths per 100,000) and Maine (+9.7 deaths per 100,000) (Figure 17). Non-significant decreases occurred in Nevada (-1.4 deaths per 100,000), Montana (-0.8 deaths per 100,000) and Nebraska (-0.5 deaths per 100,000).
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Since 2007, the drug death rate increased significantly nationally, in the District of Columbia and in all but one state, Montana. The largest increases occurred in West Virginia (+26.8 deaths per 100,000), New Hampshire (+22.1 deaths per 100,000), Ohio (+21.2 deaths per 100,000), Delaware (+15.9 deaths per 100,000) and Pennsylvania (+15.8 deaths per 100,000) (Figure 18). The smallest increases occurred in Texas (+1.7 deaths per 100,000), Montana and Washington (+2.2 deaths per 100,000), Oregon (+2.5 deaths per 100,000), and Nebraska and California (+2.9 deaths per 100,000).
Suicide
Since 2012, suicide increased 16 percent from 12.0 to 13.9 deaths per 100,000 population. This is the age-adjusted number of deaths due to intentional self-harm per 100,000 population. This is a supplemental measure that is not included in the overall state rankings calculation, but an important measure that is contributing to the increase in premature death.
The suicide rate differs by sex, age and race/ethnicity (Figure 19).
The suicide rate is much higher among males at 22.2 deaths per 100,000 compared with females at 6.2 deaths per 100,000.
Suicide rates are highest among whites at 15.7 deaths per 100,000, followed by American Indian/Alaska Natives at 13.4 deaths per 100,000.
In the 10-year age ranges, the suicide rate is highest among adults aged 45 to 54 at 19.7 deaths per 100,000 and among adults aged 85 and older at 19.0 deaths per 100,000.
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The suicide rate also varies by state. It is 3.5 times lower in New Jersey, the healthiest state for this measure at 7.5 deaths per 100,000 population, compared with Montana, the least healthy state for this measure at 26.0 deaths per 100,000.
Since 2012, the suicide rate increased in all but three states. The largest increases occurred in West Virginia (+6.0 deaths per 100,000), Oklahoma (+5.8 deaths per 100,000), New Hampshire (+5.6 deaths per 100,000), Alaska (+5.3 deaths per 100,000), and Vermont and North Dakota (+4.8 deaths per 100,000) (Figure 20). Rates decreased in Hawaii (-1.1 deaths per 100,000), Florida (-0.3 deaths per 100,000) and Mississippi (-0.2 deaths per 100,000).
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Occupational Fatalities
Occupational fatalities decreased from 5.3 deaths per 100,000 workers in 2007 to 3.7 deaths per 100,000 workers in 2015. But occupational fatalities have increased significantly since 2015, rising from 3.7 to 4.4 deaths per 100,000 workers this year. This is the number of fatal occupational injuries in construction, manufacturing, trade, transportation, utilities and professional and business services per 100,000 workers (three-year average). The leading causes of death were transportation incidents, violence, homicide, suicide, falls and contact with equipment. Violence accounts for the greatest increase since 2017.
Five times more occupational fatalities occurred in Wyoming (12.5 deaths per 100,000 workers), the least healthy state for this measure, compared with New York (2.5 deaths per 100,000 workers), the healthiest state for this measure. Since 2015, occupational fatalities increased significantly in Alaska (+5.2 deaths per 100,000 workers), South Carolina (+1.8 per 100,000 workers) and Georgia (+1.3 deaths per 100,000 workers) (Figure 21). The occupational fatality rate also increased by more than 1.0 death per 100,000 workers in Mississippi (+1.9 deaths per 100,000 workers) and Montana (+1.2 deaths per workers), but those increases were not significant. Rates decreased in 10 states, but none significantly. The largest decreases occurred in North Dakota (-3.1 deaths per 100,000 workers) and Louisiana (-1.3 deaths per 100,000 workers).
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Premature Death
In the past year, premature death significantly increased 3 percent from 7,214 to 7,432 years lost before age 75 per 100,000 population. This is the number of years of potential life lost before age 75 per 100,000 population. After decreasing for several decades, the premature death rate has increased for the fourth consecutive year (Figure 22). The top five causes of premature death in the United States are cancer, unintentional injuries, heart disease, suicide and perinatal deaths. Nearly half of U.S. premature deaths are due to tobacco use, lack of physical activity and poor diet. 
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The number of years lost before age 75 is two times higher in West Virginia, the least healthy state for this measure at 11,136 years lost before age 75, than in Minnesota, the healthiest state for this measure at 5,653 years lost before age 75. Premature death significantly increased in 23 states in the past year and significantly declined in just Washington, where there was a decline of 154 years lost before age 75 per 100,000 population (Figure 23). States with the largest increases include West Virginia (+658 years lost per 100,000), Maryland (+542 years lost per 100,000), Ohio (+506 years lost per 100,000), New Hampshire (+495 years lost per 100,000) and Iowa (+479 years lost per 100,000) (Figure 24). Premature death decreased, but not significantly, in Wyoming (-494 years lost per 100,000), Montana (-329 years lost per 100,000), Nebraska (-191 years lost per 100,000) and North Dakota (-178 years lost per 100,000). Since 2014, premature death increased nationally and in 40 states (Figure 25). No state experienced a decrease during this period.
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Cardiovascular Death Rates Move in Wrong Direction
In the past three years, cardiovascular deaths significantly increased 2 percent from 250.8 to 256.8 deaths per 100,000 population. This is the third consecutive year in which the cardiovascular death rate increased nationally (Figure 26). This is the age-adjusted number of deaths due to all cardiovascular diseases including heart disease and stroke per 100,000 population (three-year average). An estimated 92.1 million U.S. adults have at least one type of cardiovascular disease. The two most common types, heart disease and stroke, are the leading and fifth-leading causes of death, respectively, in the U.S., accounting for 635,000 and 142,000 deaths in 2016.
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Cardiovascular death rates vary by sex and race/ethnicity (Figure 27).
Cardiovascular death rates are significantly higher among males (310.3 per 100,000) than females (212.7 per 100,000).
Cardiovascular death rates are significantly higher among black adults (327.6 per 100,000) than adults identifying as American Indian/Alaska Native (178.6 per 100,000), Asian (147.2 per 100,000), Hispanic (186.2 per 100,000) and white (253.4 per 100,000).
Cardiovascular death rates also vary by state. The rate is 1.9 times higher in Mississippi (356.0 per 100,000 population), the least healthy state for this measure, than in Minnesota (190.3 per 100,000 population), the healthiest state for this measure. 
Since 2015, cardiovascular death rates increased significantly in 26 states (Figure 28), led by Nevada (+19.4 deaths per 100,000), Utah (+17.3 deaths per 100,000), Vermont (+17.2 deaths per 100,000), Arkansas (+16.8 deaths per 100,000) and Oklahoma (+16.4 deaths per 100,000) (Figure 29). The cardiovascular death rate decreased significantly only in California (-2.5 deaths per 100,000) and not significantly in New Jersey (-0.5 deaths per 100,000).
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Mixed Findings With Cancer Deaths 
Since 1990, U.S. cancer deaths have dropped significantly from 199.0 to 189.8 deaths per 100,000 population (Figure 30). This is the age-adjusted number of deaths due to all causes of cancer per 100,000 population (three-year average). Over the same time period, however, cancer death rates have significantly increased in 12 states and not changed significantly in 19 states (Figure 31). Yet cancer deaths have significantly declined in 19 other states. Cancer remains the second-leading cause of death, and it is estimated that in 2018 there will be more than 1.7 million new cases of cancer and 609,000 deaths as a result.
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Rates are age adjusted to mid-year population estimates. Depending upon the method of population adjustment, the change over time in cancer death rates may differ.
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States with the largest increases in the cancer death rate since 1990 are Oklahoma (+23.7 deaths per 100,000), Kentucky (+23.3 deaths per 100,000), Mississippi (+22.5 deaths per 100,000), West Virginia (+18.8 deaths per 100,000) and Arkansas (+17.7 deaths per 100,000) (Figure 32). States with the largest decreases in the cancer death rate are Maryland (-34.3 deaths per 100,000), New Jersey (-31.6 deaths per 100,000), New York (-27.9 deaths per 100,000), Massachusetts (-25.7 deaths per 100,000) and Connecticut (-25.0 deaths per 100,000).
Rates are age adjusted to mid-year population estimates. Depending upon the method of population adjustment, the change over time in cancer death rates may differ. 
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Cancer deaths differ by sex and race/ethnicity (Figure 33). 
The cancer death rate is significantly higher among males (227.8 deaths per 100,000) than females (161.9 deaths per 100,000).
Cancer deaths are higher among black adults (217.1 deaths per 100,000) than adults identifying as American Indian/Alaska Native (126.0 deaths per 100,000), Asian (116.6 deaths per 100,000), Hispanic (131.7 deaths per 100,000) and white (190.8 deaths per 100,000).
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Frequent Mental, Physical Distress Rising
Frequent Mental Distress
In the past two years, frequent mental distress increased 7 percent from 11.2 percent to 12.0 percent of adults. This is the percentage of adults who reported their mental health was not good 14 or more days in the past 30 days. This measure represents the percentage of the population experiencing persistent and likely severe mental health issues.
There are significant differences in frequent mental distress by state, gender, race/ethnicity, urbanicity, education and income.
The prevalence of frequent mental distress is 1.9 times higher in West Virginia (17.3 percent), the least healthy state for this measure, than in Minnesota (9.2 percent), the healthiest state for this measure. 
Females have a higher prevalence of frequent mental distress (14.3 percent) than males (10.4 percent).
Frequent mental distress prevalence is higher among multiracial adults (20.8 percent) and American Indian/Alaska Native adults (18.7 percent) compared with adults identifying as Asian (7.7 percent), other race (13.5 percent), black (13.2 percent), Hawaiian/Pacific Islander (12.6 percent), Hispanic (11.6 percent) and white (12.5).
Rural adults have a higher prevalence of frequent mental distress (12.0 percent) than suburban (10.0 percent) and urban (10.7 percent) adults.
Frequent mental distress decreases with each increasing level of education and income:
Adults aged 25 and older with less than a high school education have a higher prevalence of frequent mental distress (17.2 percent) than adults aged 25 and older with a high school education (13.2 percent), some college (12.8 percent) and college graduates (7.1 percent).
Adults aged 25 and older with household incomes less than $25,000 have a higher prevalence of frequent mental distress (20.1 percent) than adults aged 25 and older with incomes $25,000-$49,999 (11.6 percent), $50,000-$74,999 (10.0 percent) and $75,000 or more (6.5 percent).
In the past two years, frequent mental distress increased significantly in New Mexico (+2.5 percentage points), Vermont (+2.4 percentage points), Indiana (+2.3 percentage points), Kansas (+1.7 percentage points) and Nebraska (+1.6 percentage points). Delaware (+2.6 percentage points) as well as South Dakota and Oklahoma (each +2.5 percentage points) had similar increases, but they were not significant (Figure 34). Six states had non-significant decreases in frequent mental distress.
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Frequent Physical Distress
In the past two years, frequent physical distress increased 5 percent from 11.4 percent to 12.0 percent of adults. This is the percentage of adults who reported their physical health was not good 14 or more days in the past 30 days. Those who report frequent poor physical health days are at higher risk of mortality, increased health care use and lower health-related quality of life.
Frequent Physical Distress varies by state, gender, race/ethnicity, urbanicity, education and income.
The prevalence of frequent physical distress is 2.0 times higher in West Virginia (18.8 percent), the healthiest state for this measure, than in Minnesota (9.2 percent), the least healthy state for this measure. 
Females have a higher prevalence of frequent physical distress (13.7 percent) than males (10.9 percent).
Frequent physical distress prevalence is higher among American Indian/Alaska Native (21.5 percent) adults compared with adults identifying as Asian (6.6 percent), black (12.7 percent), Hawaiian/Pacific Islander (10.3 percent), Hispanic (11.3 percent), multiracial (15.7 percent), other race (13.9 percent) and white (12.7).
Rural adults have a higher prevalence of frequent physical distress (18.1 percent) than suburban (14.0 percent) and urban (15.3 percent) adults.
Frequent physical distress decreases with each increasing level of education and income:
Adults aged 25 and older with less than a high school education have a higher prevalence of frequent physical distress (22.6 percent) than adults aged 25 and older with a high school education (15.4 percent), some college (13.8 percent) and college graduates (6.9 percent).
Adults aged 25 and older with household incomes less than $25,000 have a higher prevalence of frequent physical distress (24.2 percent) than adults aged 25 and older with incomes $25,000-$49,999 (13.2 percent), $50,000-$74,999 (9.5 percent) and $75,000 or more (6.0 percent).
Since 2016, the prevalence of frequent physical distress increased significantly in Pennsylvania (+2.2 percentage points), Michigan (+1.8 percentage points) and Kansas (+1.3 percentage points). Alaska (+2.9 percentage points), Louisiana (+2.1 percentage points) and South Dakota (+2.0 percentage points) had similar increases, but they were not significant (Figure 35). Fourteen states had non-significant decreases.
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Chlamydia Rates Increase
Since 2009 the number of new cases of chlamydia per 100,000 population increased 35 percent from 367.5 to 497.3 cases per 100,000 population, and 4 percent since 2017 from 478.8 cases per 100,000 population. Chlamydia is the most commonly reported sexually transmitted infection in the U.S., with more than 1.7 million cases reported in 2017. The incidence of chlamydia is higher among black adults at 1,168.7 cases per 100,000 compared with adults identifying as American Indian/Alaska Native (684.8 cases per 100,000), Asian (120.6 cases per 100,000), Hispanic/Latino (372.8 cases per 100,000), multiracial (146 cases per 100,000), Native Hawaiian/Pacific Islander (623.6 cases per 100,000) and white (203.3 cases per 100,000).
Chlamydia rates are 3.0 times higher in Alaska, the least healthy state for this measure at 771.6 per 100,000 population, than in New Hampshire, the healthiest state for this measure at 260.6 per 100,000 population. The District of Columbia has the highest rate at 1,083.4 per 100,000 population. In the past year, the states with the largest increases in chlamydia incidence were Mississippi (+91.9 cases per 100,000), Delaware (+75.0 cases per 100,000), Nevada (+51.4 cases per 100,000), Maryland (+51.1 cases per 100,000) and Virginia (+48.7 cases per 100,000) (Figure 36). The states with the largest decreases in chlamydia incidence in the past year were North Carolina (-69.8 cases per 100,000), Vermont (-33.5 cases per 100,000), Hawaii (-16.2 cases per 100,000), Louisiana (-15.9 cases per 100,000) and West Virginia (-6.6 cases per 100,000).
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