Four measures reflect behaviors that are potentially modifiable through a combination of personal, community and clinical interventions: the prevalence of smoking, the prevalence of obesity, the percentage of the population that binge drinks and high school graduation. These items are determinants that measure behaviors and activities having an immediate or delayed effect on health and are prominently included in these rankings. However, the selection of these four does not imply that they are the only underlying behaviors that need to be addressed in a comprehensive public health effort. For example, the American Academy of Family Physicians suggests that to improve health, individuals should:

• Avoid any form of tobacco,
• Eat a healthy diet,
• Exercise regularly,
• Drink alcohol in moderation, if at all,
• Avoid use of illegal drugs,
• Practice safe sex,
• Use seat belts (and car seats for children) when riding in a car or truck,
• Avoid sunbathing and tanning booths,
• Keep immunizations up-to-date, and
• See a doctor regularly for preventive care.

Additional suggestions for individual initiatives are in Healthy People in Healthy Communities, A Community Planning Guide Using Healthy People 2010, published by the U.S. Department of Health and Human Services, Washington, D.C., available at http://www.healthypeople.gov/Publications/HealthyCommunities2001/default.htm. The impact of changing behaviors is huge. CDC estimates that if tobacco use, poor diet and physical inactivity were eliminated, 80 percent of heart disease and stroke, 80 percent of Type 2 diabetes and 40 percent of cancer would be prevented.

Prevalence of Smoking measures the percent of the population over age 18 that smokes tobacco products regularly. The information is obtained from the Behavioral Risk Factor Surveillance System (BRFSS) and measures the percentage of the population that has smoked at least 100 cigarettes and currently smokes regularly.

The prevalence of smoking in the population has an adverse impact on overall health by causing increased cases of respiratory diseases, heart disease, stroke, cancer and other illnesses (http://www.cdc.gov/tobacco/). It is a lifestyle behavior that an individual can directly influence with support from the community and, as required, clinical intervention.

The 2009 ranks, based on 2008 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention), can be found at www.americashealthrankings.org/measure/2009/smoking.aspx. The national average is 18.3 percent of the population, a significant decrease of 1.5 percent from the rate last year. This means that over 40 million American adults smoke on a regular basis. Cigarette smoking is estimated to be responsible for about one in five deaths annually, or about 443,000 deaths per year . The proportion of the population that smokes varies from a low of 9.3 percent in Utah to more than 25 percent in Kentucky, Indiana and West Virginia. The prevalence of smoking decreased significantly in Wyoming, from 22.1 percent to 19.3 percent of the population, and in Ohio, from 23.1 percent to 20.1 percent of the population. If all states were to accomplish a smoking rate equal to the best state (Utah), the number of smokers in the United States would be halved.

Since the 1990 Edition, the prevalence of smoking decreased in the United States by 11.2 percent. Rhode Island, Virginia, Maryland, Florida, Delaware and Vermont each lowered the prevalence of smoking since 1990 by 14 percent or more. Every state experienced a decrease since the 1990 Edition. Missouri had the smallest decrease in percentage of the population and continues to hover around one-quarter of the population smoking on a regular basis. Due to the limits of the BRFSS, caution must be used in comparing changes in prevalence of smoking in states with small populations.

Prevalence of Binge Drinking measures the percentage of the population who binge drink. Binge drinking is defined as males having five or more drinks and females having four or more drinks on one occasion. Binge drinking has an adverse effect on health due to increased injuries and deaths, increased aggression, damage to the fetus and liver diseases along with other health concerns (http://www.cdc.gov/alcohol/).

Prevalence of Binge Drinking is measured over a two-year span to increase the reliability of the estimates and to allow better state-to-state comparisons. The measure reflects the impact of excessive alcohol on increased motor vehicle deaths, liver damage and unintentional injuries.

The 2009 ranks, based on 2007 and 2008 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention) are at www.americashealthrankings.org/measure/2009/binge.aspx. The prevalence of binge drinking varies from less than 10 percent in Tennessee, West Virginia and Utah

Mensah, George A., Associate Director for Medical Affairs, CDC "Global and Domestic Health Priorities: Spotlight on "Chronic Disease", National Business Group on Health Webinar, May 23, 2006. Centers for Disease Control and Prevention. Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses-United States, 2000-2004. Morbidity and Mortality Weekly Report [serial online]. 2008;57(45):1226-1228 to more than 20 percent in Iowa, North Dakota and Wisconsin. The national average is 15.7 percent of the adult population who binge drinks and has varied from 14.3 percent to 16.8 percent of the population over the last seven years. The largest decrease in the last year was in West Virginia where the prevalence of binge drinking decreased from 10.5 percent to 9.3 percent of the population, however this decline may not be statistically significant. New Mexico also declined in overall ranking in the last year, but its notable gain is the decline in binge drinking from 15.4 percent in 2002 to 11.9 percent of the population in 2009. Even though the definition of binge drinking has changed during this time span, the state has shown consistent declines in the last seven years. The largest increase in the last year was in Kentucky, but it also may not be statistically significant in that it increased from 8.4 percent to 10.1 percent of the population and just returned to historical levels.

Prevalence of Obesity is the percentage of the population estimated to be obese, defined as having a body mass index (BMI) of 30.0 or higher. BMI is equal to your weight in pounds divided by your height in inches squared and then multiplied by 703. CDC has a calculator for BMI at http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm. Weight status is determined per Table 14. Obesity is known to contribute to a variety of diseases, including heart disease, diabetes and general poor health (http://www.cdc.gov/nccdphp/dnpa/obesity/). The data are collected by each state as part of the Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention.

The 2009 ranks, based on 2008 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention), are at www.americashealthrankings.org/measure/2009/obesity.aspx. The average for the United States is 26.6 percent of the adult population, up from 26.3 percent of the population in 2008 and substantially more than double the rate of 11.6 percent of the population in 1990. In the United States, this means that more than one-in-four are obese - that is 56 million adults with a body mass index of 30.0 or higher. If the population of the United States could return to the weight status of 1990, there would be 25 million fewer obese individuals - more than the entire population of the second most populous U.S. state, Texas.

The prevalence of obesity ranges from 19.1 percent of the population in Colorado to over 30 percent of the population in Kentucky, South Carolina, Oklahoma, Tennessee, West Virginia, Alabama and Mississippi. In the last year, no state experienced a significant change in obesity, however over the last five years, obesity has significantly increased in 80 percent of all states. There has been no significant decline in obesity in the last five years. Since 1990, the prevalence of obesity increased in all states. The largest increases have been in Alabama, Tennessee and Oklahoma.

High School Graduation estimates the percentage of incoming ninth graders who graduate within four years and are considered regular graduates. The National Center for Education Statistics collects the enrollment and completion data and, now, as part of the No Child Left Behind initiative, estimates the graduation rate for each state. The rate is the number of graduates divided by the estimated count of freshmen four years earlier. This average freshman enrollment count is the sum of the number of 8th graders five years earlier, the number of 9th graders four years earlier (because this is when current year seniors were freshmen) and the number of 10th graders three years earlier divided by three. Enrollment counts include a proportional distribution of students not enrolled in a specific grade.

Data are not adjusted for the presence or quality of basic health and consumer health education in the curriculum, for continuing education programs nor for other non-traditional learning programs. Also, individual states are increasingly altering graduation requirements, which may affect their reported number of regular graduates, their graduation rate and the comparability of these rates across time.

Education is a vital contributor to health as consumers must be able to learn about, create and maintain a healthy lifestyle and understand and participate in their options for care.

The 2009 ranks, based on 2005 to 2006 data (National Center for Education Statistics, Washington, D.C., U.S. Department of Education), are at www.americashealthrankings.org/measure/2009/graduation.aspx. The rate varies from 87.5 percent of incoming ninth graders who graduate within four years in Wisconsin to 55.8 percent in Nevada. The national average is 73.4 percent, down 1.3 percent from 74.7 percent in the 2008 Edition. Graduation rates have stagnated in the last five years with around 73 percent of incoming ninth graders graduating within four years. Arizona`s rate returned back to more historical levels dropping from 84.7 percent to 70.5 percent of incoming ninth graders who graduate within four years. Utah, California and Virginia indicated a drop of five percent or more in the last year.

Five measures are used to represent the community and the environment: the violent crime rate, the occupational fatalities rate, the percentage of children in poverty, the incidence of infectious disease and the exposure to air pollution. Measures of community and environment reflect the reality that the daily conditions in which we live our lives have a great effect on achieving optimal individual health. The presence of pollution, violence, illegal drugs, infectious disease and unsafe workplaces are detrimental. In addition, studies indicate that the general socio-economic conditions and the level of education have a significant relationship to the healthiness of a community`s residents.

These determinants measure both positive and negative aspects of the community and environment of each state and their effects on the population`s health. Again, there are many additional efforts of communities that improve the overall health of a population but are not directly reflected in these five measures. Each community has its strengths, challenges and resources and should undertake a careful planning process to determine what action plans are best for them.

Violent Crime measures the effect of criminal behavior on a population`s health. It represents factors such as illegal drug use and various social ills. Violent crime measures the annual number of murders, rapes, robberies and aggravated assaults per 100,000 population. Violent crime reflects an aspect of current U.S. lifestyle and is an indicator of health risk and death.

The 2009 ranks, based on 2008 data (Crime in the United States: 2008. Washington, D.C., Federal Bureau of Investigation), are at www.americashealthrankings.org/measure/2009/crime.aspx. The violent crime rate is dependent upon many factors, not just population; thus when taking action to combat crime, each state must consider its specific circumstances.

The violent crime rate varies from less than 175 offenses per 100,000 population in Maine, Vermont, New Hampshire and North Dakota to more than 700 offenses per 100,000 population in South Carolina, Nevada, Tennessee and Delaware. The national average is 455 offenses per 100,000 population, down 12 offenses per 100,000 population from the prior year and down 154 offenses per 100,000 population from the 1990 Edition. Crime peaked in 1993 and 1994 at 758 offenses per 100,000 population and has since dropped by 40 percent.

The largest reported decreases in violent crime from the 2008 Edition occurred in Louisiana where reported offenses decreased by 74 offenses per 100,000 population and in South Carolina where reported offenses decreased by 58 offenses per 100,000 population. The largest reported increases occurred in Connecticut, from 256 to 298 offenses per 100,000 population, and in South Dakota, from 169 to 201 offenses per 100,000 population.

This is the tenth year that the national violent crime rate is lower than the 1990 Edition. However, several states experienced significant increases since 1990, led by Delaware, Alaska and Tennessee with increases of 271 offenses, 197 offenses and 188 offenses per 100,000 population, respectively. New York, California and Florida reduced violent crime the most since the 1990 Edition, decreasing from 1,007 to 398 offenses per 100,000 population, from 918 to 504 offenses per 100,000 population, and from 1,024 to 689 offenses per 100,000 population, respectively.

Occupational Fatalities represents the impact of hazardous jobs on the population. Occupational injuries would be a preferred measure; however, there is not a uniform reporting system used by all 50 states. Due to the different industry mixes in each state, occupational fatalities are adjusted to more accurately reflect the actual safety differences between the states.

Occupational fatalities are measured over a three-year span because of their low incidence rate. The industry adjustment is based on the ratio of workers in the following industries: construction, manufacturing, trade, transportation, utilities, professional and business services as defined by the North American Industry Classification System (NAICS).

The 2009 ranks, based on 2006 to preliminary 2008 data (Census of Fatal Occupational Injuries, Bureau of Labor Statistics, U.S. Department of Labor, Washington, D.C.), are at www.americashealthrankings.org/measure/2009/WorkFatalities.aspx. Scores vary from 3.1 deaths per 100,000 workers in Massachusetts and Minnesota to over 10 deaths per 100,000 workers in Wyoming and Alaska. The national norm is 4.8 deaths per 100,000 workers, down from 5.2 deaths per 100,000 workers in the 2008 Edition. The occupational fatalities rate decreased the most in the last year in Florida, by 1.3 deaths per 100,000 workers. The rate did not significantly increase in any state.

Children in Poverty measures the percentage of related persons under age 18 living in a household that is below the poverty threshold. The poverty threshold established by the U.S. Census Bureau for a household of four people which includes two children living in the lower 48 states is approximately $22,050 in household income.

The 2009 ranks, based on 2008 data (March 2009 Current Population Survey, Washington, D.C., U.S. Census Bureau), are at www.americashealthrankings.org/measure/2009/ChildPoverty.aspx. The percentage of children in poverty ranged from less than 10 percent of persons under age 18 in New Hampshire, Utah, Alaska and Vermont to a high of more than 25 percent in New Mexico and Arizona. The national average is 19.0 percent, up 1.0 percent from the 2008 Edition and up 3.2 percent from the low of 15.8 percent of persons under age 18 reported in the 2002 Edition. It is only 1.6 percent below the 1990 Edition. In the past year, the percentage of children in poverty increased in 35 of 50 states, though no individual changes are statistically significant. Since 1990, the percentage of children in poverty has increased in 17 of 50 states. Children in poverty increased by five percent or more in Rhode Island, Arizona and Delaware, while during the same time period, it decreased by ten percent or more in Louisiana and Mississippi.

Infectious Disease includes the occurrence of Acquired Immune Deficiency Syndrome (AIDS), tuberculosis and hepatitis (A and B) as representative of all major infectious diseases in a state. It is a running three-year average.

It should be noted that this measure is neither age nor race adjusted, and, as reporting comes from each individual state health department, the level of accuracy may differ from state to state. Despite these drawbacks, the data remains the best available.

The 2009 ranks, based on 2006 to 2008 data (Mortality and Morbidity Weekly Reports, Centers for Disease Control and Prevention), are at www.americashealthrankings.org/2008/disease.aspx. AIDS cases in 2008 were not available as the data collection system for this measure is being revised. The incidence of infectious disease per 100,000 population varies from a reported low of less than five cases in North Dakota, Wyoming, Montana, Idaho and Vermont to a reported high of more than 30 cases in New York, Maryland and Florida. The national average is 19.1 cases per 100,000 population, down from 20.1 cases per 100,000 population in the 2008 Edition and down considerably from 40.7 cases per 100,000 population in the 1990 Edition.

In Georgia, reported infectious disease decreased by 4.8 cases per 100,000 population and continues a five-year decline in the state. No state had a considerable increase. Since the 1990 Edition, Oregon, Alaska, Arizona and Washington have seen the greatest decreases in reported cases with more than 70 fewer cases per 100,000 population and all show a gradual, continued decline in infectious disease rates. None of the states have experienced increases in the incidence of infectious disease since the 1990 Edition.

Air Pollution measures the fine particulates in the air we breathe. The fine particulates, too small to see individually but appearing as haze in the air, can enter the deepest portions of the lungs. Air pollution has been shown to have an adverse effect on health, including decreased lung function, aggravated asthma, development of chronic bronchitis, irregular heartbeat, nonfatal heart attacks, and premature death in people with heart or lung disease. See www.epa.gov/air/particlepollution/health.html for more information.

Air Pollution was a new measure in the 2008 Edition. It is the population-weighted average exposure to particulates 2.5 micron and smaller for each county reporting within a state. Air pollution is monitored in many counties where population density is significant and/or where there have been pollution concerns in prior years. Population weighting of the county data adjusts the information to reflect the actual number of people potentially exposed to the particulate. In counties where pollution data is not available, the population was assumed to be exposed to the background level of particulate in the air quality control region and/or state. Background levels are estimated to be the average of the lowest measures in each region or state for each of the last three years. The data is collected by the EPA and available at http://www.epa.gov/air/data/. (Due to modification in the method used to estimate particulate exposure in background areas, the data for the 2008 Edition is restated in this report.)

The 2009 ranks, based on 2006 to 2008 data (U.S. Environmental Protection Agency, Washington, D.C. and the U.S. Census Bureau, Washington, D.C.), are at www.americashealthrankings.org/measure/2009/air.aspx. Air pollution varies from a low of 4.8 micrograms of fine particulate per cubic meter in Hawaii to 13.9 micrograms of fine particulate per cubic meter in California, Delaware, Georgia and Pennsylvania. The average for reporting counties in the United States is 11.7 micrograms of fine particulate per cubic meter, down slightly from 12.2 micrograms in 2008 and 12.8 micrograms five years ago in the 2004 Edition.

Three measures are used to represent public and health policies and programs: public health funding, immunization coverage and lack of health insurance. These measures are indicative of the availability of resources and the extent of the program`s reach to the public.

Every state has many excellent and effective public health programs, too numerous and individualized to list, that contribute to the overall health of the population but are not explicitly included in these rankings. Contact your state public health officials to obtain additional information about programs in your state that are enacted to optimize individual and community health. Each state summary lists the Web site for that state`s health department. Individuals can also see the spectrum of options available to states and communities by visiting www.thecommunityguide.org, a Web site that provides a systemic review of programs and evidence-based recommendations for health and community officials.

Lack of Health Insurance measures the percentage of the population not covered by private or public health insurance. Individuals without health insurance have greater difficulty accessing the health care system, frequently are not able to participate in preventive care programs and can add substantially to the cost of health care due to delayed care and emergency department treatment.

The 2009 ranks, based on 2008 data (March 2009 Current Population Survey, Washington, D.C., U.S. Census Bureau), are at www.americashealthrankings.org/measure/2009/insurance.aspx.

The rate of uninsured population ranged from 5.4 percent in Massachusetts to over 20 percent in Texas, New Mexico and Florida. The national average is 15.3 percent (46.3 million people) uninsured . If the United States as a whole could emulate the best state, the number of uninsured would decrease by over 25 million people or more than the population of Texas, the second most populous state in the United States.

In the last year, the two-year average rate of uninsured population decreased in 16 states, led by Massachusetts with a significant decline of 2.5 percent. The rate of uninsured population increased in 32 states, including an increase of 1.0 percent or more in Rhode Island and Alaska. Over a five-year period, Washington and Massachusetts have experienced a significant decrease in the uninsured rate and Tennessee and South Carolina (as well as the United States as a whole) have experienced a significant increase.

Public Health Funding measures the dollars per person that are spent on public or population health through funding from Centers for Disease Control and Prevention, Health Resources Services Administration and the state. This does not include spending from other sources such as county or city governments. High spending on these health programs are indicative of states that are proactively implementing preventive and education programs targeted at improving the health of at-risk populations within a state. Recent research has shown that an investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annually within five years. This is a

The 2009 ranks, based on 2006 and 2007 data (Trust for America`s Health, Washington, D.C.) are at www.americashealthrankings.org/measure/2009/PH_Spending.aspx. It ranges from more than $150 per person in Vermont, Alaska and Hawaii to less than $40 per person in Wisconsin, Indiana, Nevada and Ohio. The average funding in the United States is $94 per person, up from $88 per person last year and $76 per person two years ago.

Immunization Coverage is the percentage of children ages 19 to 35 months who have received the suggested early childhood immunizations listed in the table below. Early childhood immunization has been shown to be a safe and cost-effective manner of controlling diseases within the population.

Immunization Coverage

The 2009 ranks, based on 2008 data (National Immunization Program, Centers for Disease Control and Prevention), are at www.americashealthrankings.org/measure/2009/immunize.aspx. It ranges from immunization coverage of 85.0 percent in New Hampshire to less than 70 percent in Montana, Idaho and Wyoming. Compared to coverage in the prior year, coverage for the complete series of immunizations in the United States decreased from 80.1 percent to 78.2 percent of children ages 19 to 35 months. In the last year, immunization coverage dropped significantly in Connecticut from 89.3 percent to 72.5 percent of children ages 19 to 35 months and in Maryland from 92.4 percent to 82.6 percent of children ages 19 to 35 months. (The latter is less troubling since 2008 data was reported to be unusually high compared to prior years.) In the last 14 years, coverage in the United States increased from 55.1 percent to 78.2 percent of children ages 19 to 35 months who received the complete set of immunizations. The rate peaked in 2005 and 2006 at almost 81 percent of children receiving a full set of immunizations. The recent decline is not significant at the 95 percent confidence level, yet is still troubling in its direction.

The Guide to Community Preventive Services has numerous proven methods to increase the rate of vaccinations in a community that include ways to increase the demand in the community, improving access and system-based or provider-based innovations. See their suggestions at http://www.thecommunityguide.org/vaccines/index.html.

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[1] U.S. Bureau of the Census; Income, Poverty and Health Insurance Coverage in the United States : 2008, September 2009.

return of $5.60 for every $1 invested (http://healthyamericans.org/reports/prevention08/Prevention08.pdf).

Preventive and curative care must be delivered in an effective, appropriate and timely manner. In the 2009 Edition, three measures are included in this section: Prenatal Care, Primary Care Physicians and Preventable Hospitalizations. Prenatal Care has been included since the 1990 Edition and Primary Care Physicians and Preventable Hospitalizations were added in the 2007 Edition.

Prenatal Care is a measure of both access to and frequency of prenatal care based on the Adequacy of Prenatal Care Utilization (APNCU) Index developed by Kotelchuck. This index considers two aspects of prenatal care: the month it was initiated and the number of visits occurring after initiation. The 1990 through 2004 Editions of the report defined Prenatal Care using the Kessner Index, a measure highly correlated to Kotelchuck; however, it does not consider both initiation and frequency of visits. The introduction of a new birth certificate, the information of record from which the APNCU is derived, is an additional complication to the data. The adoption of the new birth certificate is gradual across the system and directly comparing the APNCU from the different certificates is not valid. Therefore, starting with this Edition, the APNCU index only compares a state to another state using the same birth certificate. While this does allow a score to be calculated among peer states, it doesn`t allow for ranking the states for this measure.

Prenatal care is not adjusted for age or race.

The 2009 Edition is based on 2006 data (National Center for Health Statistics. Adequacy of Care by State, United States, Hyattsville, Md.) and can be found at www.americashealthrankings.org/measure/2009/prenatal.aspx.

Primary Care Physicians is a measure of access to primary care for the general population as measured by number of primary care physicians per 100,000 population. Primary care physicians provide a combination of direct care to the patient and, as necessary, counsel the patient in the appropriate use of specialists and advance treatment locations.

The 2009 ranks, based on 2007 data (American Medical Association, Physician Characteristics and Distribution in the United States, 2009 Edition, Chicago, Ill. Data used with permission), are at www.americashealthrankings.org/measure/2009/PCP.aspx. Primary care physicians include all those who identify themselves as Family Practice physicians, General Practitioners, Internists, Pediatricians, Obstetricians or Gynecologists.

The number of Primary Care Physicians per 100,000 population will change because of changing state population, physician retirements, new physicians, and physicians moving between states and specialties. Primary Care Physicians range from 190.0 physicians per 100,000 population in Massachusetts to 78.1 physicians in Idaho. The national average is 120.6 physicians per 100,000 population, essentially unchanged in the last few years.

Preventable Hospitalizations is a measure of the discharge rate from hospitals for ambulatory care-sensitive conditions. Ambulatory care-sensitive conditions are those "for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease ." These hospitalizations can often be reduced by strong outpatient care systems and include conditions such as adult asthma, bacterial pneumonia, congestive heart failure, chronic obstructive pulmonary disease, diabetes, low birth weight, urinary tract infection and other conditions. It is not adjusted by characteristics of the population served, such as age or health status.

These discharges are also highly correlated with general admissions and reflect the tendency for a population to overuse the hospital setting as a site for care.

The 2009 ranks, based on 2006 data (The Dartmouth Atlas of Health Care, The Dartmouth Institute for Health Policy and Clinic Practice, Lebanon, N.H.), are at www.americashealthrankings.org/measure/2009/preventable.aspx. The rate of preventable hospitalizations ranges from a low of under 50 discharges per 1,000 Medicare enrollees in Washington, Oregon, Hawaii and Utah to over 100 discharges per 1,000 Medicare enrollees in West Virginia, Kentucky and Mississippi. The national average is 74.2 discharges per 1,000 Medicare enrollees, down from 78.4 discharges last year. Four of five states had a significant improvement in this measure in the last year. In the last eight years, the national discharge rate declined from 82.5 to 74.2 discharges per 1,000 Medicare enrollees, a notable improvement in this metric that reflects improving clinical care and follow-up for preventable hospitalizations.

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http://www.qualityindicators.ahrq.gov/

Health outcomes include the length of life, the disparity among outcomes in a state and the quality of life. These seven measures represent the burden placed on the overall health of a population by death, disparity and depressed quality of life. Measures range from counting days in which people feel their normal activities are limited due to poor health to disease-specific mortality and years of potential life lost.

Poor Mental Health Days is the average number of days in the previous 30 days that a person could not perform work or household tasks due to mental illness. The data is collected by the Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention and rely on the accuracy of each respondent`s estimate of the number of limited activity days lost in the previous 30 days.

Poor mental health days highlight the fact that good health outcomes preclude days in which mental health prohibits an individual from accomplishing everyday activities.

The 2009 ranks, based on 2008 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention), are at www.americashealthrankings.org/measure/2009/MentalDays.aspx. The number of poor mental health days in the previous 30 days ranges from an average of 2.2 days in North Dakota to 4.0 or more days in Oklahoma, Alabama, Mississippi, West Virginia and Kentucky. The average number of poor mental health days in the previous 30 days for the United States is 3.4 days, essentially unchanged from the prior eight editions. Kentucky had a significant increase of 0.9 days in the previous 30 days, returning it to more historical values. Florida had a significant increase of 0.5 days, rising to 3.7 days in the previous 30 days, and continues to trend upward over the last ten years.

Poor Physical Health Days is the average number of days in the previous 30 days that a person could not perform work or household tasks due to physical illness. The data are collected by the Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention and rely on the accuracy of each respondent`s estimate of the number of limited activity days lost in the previous 30 days.

Poor physical health days highlight that good health outcomes preclude days in which physical health prohibits an individual from accomplishing everyday activities.

The 2009 ranks, based on 2008 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention), are at www.americashealthrankings.org/measure/2009/PhysicalDays.aspx. The number of poor physical health days in the previous 30 days ranges from an average of 2.7 days in Nebraska, 2.8 days in North Dakota, 2.9 days in Connecticut and Minnesota and 5.5 days in West Virginia. The average number of poor physical health days in the previous 30 days for the United States is 3.6 days, and it has remained the same for the last six years.

Geographic Disparity measures the variation in the age-adjusted mortality rate among counties within a state. Ideally, health and mortality should be equal among the populations of every county within a state and not vary based upon the physical location where a person lives. Many things may differ among counties, including natural features such as altitude, latitude, moisture and temperature and man-made features such as land use, population density, roads and communications. But even with all these variations, health should still be equal.

Geographic Disparity was a new measure in the 2008 Edition. It indicates the amount of variation among the counties of a state. It is the standard deviation of the three-year average, age-adjusted all-cause mortality rate for all counties within a state divided by the three-year age-adjusted all-cause mortality rate for the state. The lower the percent, the closer each county is to the state average and the more uniform the mortality rate is across the state. For counties with fewer than 20 deaths in the three year period (about 20 to 30 counties in the United States each year), the county was assumed to have an age-adjusted death rate equal to the state`s age-adjusted death rate and thus has no effect on the geographic disparity of the state.

The 2009 ranks, based on 2004 to 2006 data (Centers for Disease Control and Prevention), are at www.americashealthrankings.org/measure/2009/disparity.aspx. It varies from a low geographic disparity of less than 6 percent in Connecticut, New Hampshire and Delaware to a high geographic disparity of more than 20 percent in Florida and South Dakota. For the United States as a whole, the geographic disparity among all counties is 17.1 percent, up slightly from 16.8 percent in the 2008 Edition and on a consistently upward trend since the 2004 Edition, the first year it was calculated.

Infant Mortality represents many factors surrounding birth, including but not limited to: the health of the mother, prenatal care, quality of the health services delivered to the mother and child and infant care. In addition, high infant mortality rates are often considered preventable and, thus, can be influenced by various educational and care programs.

The 2009 ranks, based on a two-year average using 2005 and 2006 data (National Center for Health Statistics, Washington, D.C. Some data is provisional), are at www.americashealthrankings.org/measure/2009/IMR.aspx. Infant mortality varies greatly among states, from less than 5.0 deaths per 1,000 live births in Washington and Utah to more than 10.0 deaths per 1,000 live births in Mississippi. The national average is 6.8 deaths per 1,000 live births. The data has not been updated since the 2008 Edition.

States with a low number of births will experience more fluctuations in the two-year average infant mortality rate than states with a higher number of births.

Cardiovascular Deaths is measured using a three-year average, age- adjusted death rate due to heart disease, strokes and other cardiovascular disease. The effect of cardiovascular disease on health was measured using mortality data due to the improved accuracy of the data and the ability to adjust for age and race.

The use of mortality data does not reflect the full impact of cardiovascular disease as data indicates that even though mortality rates are declining, more individuals are living with cardiac disease as new procedures prolong the lives of these individuals.

The 2009 ranks, based on 2004 to 2006 data (Centers for Disease Control and Prevention), are at www.americashealthrankings.org/measure/2009/CVD.aspx. This measure varies from a low of 212.6 deaths from cardiovascular disease per 100,000 population in Minnesota to over 350 deaths per 100,000 population in Alabama, Oklahoma and Mississippi. The national average is 287.9 deaths per 100,000 population, down from 298.2 deaths per 100,000 population last year and 405.1 deaths per 100,000 population in 1990.

In the last year, 38 of 50 states had a significant decline in cardiovascular deaths led by declines in Oklahoma from 371.0 deaths to 354.4 deaths per 100,000 population and in Tennessee from 353.8 deaths to 338.1 deaths per 100,000 population. No state experienced an increase. All states have had a significant decline in cardiovascular deaths since the 2007 Edition and the nation overall has experienced a steady decline since the 1990 Edition.

Cancer Deaths is measured using a three-year average, age-adjusted death rate due to cancer. The effect of cancer on health was measured using mortality data due to the improved accuracy of the data and the ability to adjust for age.

The 2009 ranks, based on 2004 to 2006 data (Centers for Disease Control and Prevention), are at www.americashealthrankings.org/measure/2009/cancer.aspx. The rate varies from less than 150 cancer deaths per 100,000 population in Utah to over 220 deaths per 100,000 population in West Virginia, Louisiana and Kentucky. The national average is 192.6 deaths per 100,000 population, a decrease of 0.8 deaths per 100,000 population from the 2008 Edition and a decrease of only 4.9 deaths per 100,000 population from the 1990 Edition. Cancer deaths peaked in 1996 when the national rate was 205.5 deaths per 100,000 population, but unlike cardiovascular deaths, there has not been a significant decline in cancer deaths over the last 20 years.

In the last five years, cancer deaths have declined significantly in about half of the states led by declines in Virginia, Alaska, New Jersey, Nevada and New York.

Premature Death measures the loss of years of productive life due to death before age 75 as defined by Centers for Disease Control and Prevention`s Years of Potential Life Lost (YPLL-75). Thus, the death of a 25-year-old would account for 50 years of lost life, while the death of a 60-year-old would account for 15 years.

The 2009 ranks, based on 2006 data (Centers for Disease Control and Prevention), are at www.americashealthrankings.org/measure/2009/PrematureDeath.aspx. The age-adjusted data vary from less than 6,000 years lost per 100,000 population in Minnesota, New Hampshire and Vermont to more than 10,000 years lost per 100,000 population in Mississippi, Louisiana and Alabama. The national average is 7,511 years lost before age 75 per 100,000 population, which is 21 years more than the 2008 Edition. Premature death has essentially plateaued in the last decade and hovers around 7,500 years lost before age 75 per 100,000 population.

The core measures used in the Rankings are a small fraction of those measures available to the public and public health officials. The America`s Health Rankingsâ„¢ Web site contains additional measures that are useful in understanding the health of your state and provide information for more in-depth analysis.

Table ttt contains a brief definition of the supplemental measures and a link to the data.

Cholesterol Check: The National Cholesterol Education Program (NCEP) recommends that adults aged 20 years or older have their cholesterol checked every 5 years. A simple blood test can measure total cholesterol levels, including LDL (low-density lipoprotein, or "bad" cholesterol), HDL (high-density lipoprotein, or "good" cholesterol), and triglycerides. More than 107 million people are considered to have high cholesterol, of which 38 million are over 240 mg/dL, a level which puts them are a higher risk for heart disease.

These data are collected through the Behavioral Risk Factor Surveillance System by Centers for Disease Control and Prevention. A table of the percentage of adults receiving a blood cholesterol check within the last five years is at www.americashealthrankings.org/measure/2009/CholesterolTest.aspx. Factors that influence individuals receiving a blood cholesterol check include access, cost, education and motivation.

The National Heart, Lung and Blood Institute at the National Institute of Health provides additional background information on cholesterol and actions you can take to manage high cholesterol at http://www.nhlbi.nih.gov/health/public/heart/index.htm#chol.

Dental Visit: Oral health is a vital part of a comprehensive preventive health program. The Division of Oral Health at the CDC notes, "There are threats to oral health across the lifespan. Nearly one-third of all adults in the United States have untreated tooth decay. One in seven adults aged 35 to 44 years has gum disease; this increases to one in every four adults aged 65 years and older. In addition, nearly a quarter of all adults have experienced some facial pain in the past six months. Oral cancers are most common in older adults, particularly those over 55 years who smoke and are heavy drinkers."

These data are collected through the Behavioral Risk Factor Surveillance System by Centers for Disease Control and Prevention. A table of the percentage of adults visiting a dental office within the last year is at www.americashealthrankings.org/measure/2009/dental.aspx. Factors that influence individuals receiving dental include access, cost, education and motivation.

Additional information on oral health can be obtained from the Division of Oral Health, Centers for Disease Control and Prevention (http://www.cdc.gov/OralHealth) and from the American Dental Association (http://www.ada.org/public/index.asp). Both web sites address questions about personal oral health and community programs to improve overall oral health, such as water fluoridation.

Physical Activity: Regular physical activity is one of the most important things you can do for your health. It can help :

• Control your weight

• Reduce your risk of cardiovascular disease

• Reduce your risk for type 2 diabetes and metabolic syndrome

• Reduce your risk of some cancers
  

• Strengthen your bones and muscles

• Improve your mental health and mood
  

• Improve your ability to do daily activities and prevent falls, if you're an older adult

• Increase your chances of living longer

These data are collected through the Behavioral Risk Factor Surveillance System by Centers for Disease Control and Prevention. A table of the percentage of adults who have participated in any physical activities in the last 30 days is at www.americashealthrankings.org/measure/2009/activity.aspx. These physical activities range from walking through exercise programs, so the range includes activities that are available to almost every individual.

Centers for Disease Control and Prevention presents guidelines for physical activities for adults, children and older adults at http://www.cdc.gov/physicalactivity/everyone/guidelines/index.html.

Diet: According to the Dietary Guidelines for Americans published by the CDC, a healthy eating plan : Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products Includes lean meats, poultry, fish, beans, eggs, and nuts Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars Stays within your daily calorie needs.

Data collected for this measure focus on the consumption of vegetables and fruits at the recommended five portions per day. These data are collected through the Behavioral Risk Factor Surveillance System by Centers for Disease Control and Prevention. A table of the percentage of adults who consume five or more servings of vegetables and fruit a day is at www.americashealthrankings.org/measure/2009/diet.aspx.

Nutritional information is abundant and overwhelming, but two sound starting points for information are the Centers for Disease Control and Prevention (http://www.cdc.gov/healthyweight/index.html) resources about healthy weight and the National Heart, Lung and Blood Institute DASH nutrition plan (http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/introduction.html). The DASH eating plan was originally developed as an eating plan to reduce high blood pressure, i.e. hypertension. (DASH stands for Dietary Approaches to Stop Hypertension.) However, the plan also represents a healthy approach to eating for those who do not have a problem with hypertension.

Teen Birth Rate: Prevention of teen and unplanned pregnancy is an important part of a healthy community. The CDC notes, "In 2006, there were 435,436 births to mothers aged 15-19 years in the United States, a birth rate of 41.9 per 1,000 women in this age group. The majority, nearly two thirds among mothers under age 18 and more than half among mothers aged 18-19 years, of teen births are unintended-they occurred sooner than desired or were not wanted at any time. U.S. teen pregnancy, birth, and abortion rates are considerably higher than most other developed countries."

Data collected for this measure focus on the rate of birth to mothers age 15 through 19. These data are collected by Centers for Disease Control and Prevention. The birth rate for teens is at www.americashealthrankings.org/measure/2009/teenbirth.aspx.

A valuable resource for further information about teen and unplanned pregnancy is available from The National Campaign to Prevent Teen and Unplanned Pregnancy (http://www.thenationalcampaign.org/default.aspx).

Chronic Disease: Six diseases are included in this category: cardiac heart disease, diabetes, high cholesterol, heart attack, stroke and hypertension (high blood pressure). These diseases are long term illnesses that many individuals can manage through lifestyle changes and healthcare interventions. However, they do place a burden on many of the affected individuals by constraining options and activities available to them and can mean expensive and on-going expenditures for health care. All measures are self reported by respondents to the Behavioral Risk Factor Surveillance System to the following questions.

Resources for heart and vascular diseases are at National Heart, Lung and Blood Institute (http://www.nhlbi.nih.gov/health/public/heart/index.htm) as well as at the Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention (http://www.cdc.gov/DHDSP/index.htm). Diabetes information is available at National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (http://www.cdc.gov/diabetes/ and http://www.cdc.gov/nccdphp/publications/aag/ddt.htm) and the American Diabetes Association (http://www.diabetes.org/).

Supplemental Economic Measures

Median Household Income: Median household income is the amount which divides the income distribution into two equal groups, half with income above that amount, and half with income below that amount. The household`s income reflects the ability for that household to afford aspects of a healthy lifestyle, including preventive medicine and curative care not provided to the individual through government, business, trade groups or other sources. Data for household income is from the U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplements and presented at www.americashealthrankings.org/measure/2009/MedianIncome.aspx.

Personal Income: An individual`s income reflects the ability for that individual to afford aspects of a healthy lifestyle, preventive medicine and curative care not provided to the individual through government, business, trade groups or other sources. Personal income has also been shown to be negatively correlated to morbidity and mortality, that is higher incomes relates to lower illness and death.

Data for personal income is from the Regional Economic Information System, Bureau of Economic Analysis, U.S. Department of Commerce and presented at www.americashealthrankings.org/measure/2009/income.aspx. Per capita personal income is total personal income divided by total mid-year population.

Unemployment Rate: For many individuals, their employer is the source for their healthcare insurance. For most, employment is the source of income for sustaining a healthy life and for accessing healthcare. The Bureau of Labor Statistics, U.S. Department of Labor releases unemployment figures monthly and annually. The official definition of the unemployment rate is "total unemployed, as a percent of the civilian labor force" and is the figure most widely published by the media.

Data for the most recent annual unemployment rate is at www.americashealthrankings.org/measure/2009/annualunemployment.aspx.

Data for the August 2009 unemployment rate is at www.americashealthrankings.org/measure/2009/augustunemployment.aspx.

Underemployment Rate: Many suggest that the official unemployment rate does not reflect the full impact of employment on the market. The Bureau of Labor Statistics uses an expanded definition to allow for individuals that are no longer seeking employment, those employed only part time when they desire full time work and workers that are only marginally attached, that is persons who currently are "neither working nor looking for work but indicate that they want and are available for a job and have looked for work sometime in the recent past."

Data for the most recent annual underemployment rate is at www.americashealthrankings.org/measure/2009/underemployment.aspx.

Income Disparity (Gini): The Gini coefficient is a common measure of income inequality. It varies between 0, which reflects complete equality of income and 1, which indicates complete inequality (one person has all the income or consumption, all others have none). Historically, the U.S. index has varied from .386 in 1968 to .470 in 2006.

There is debate among the public health and economic communities as to the effect of income disparity on health of a population. However, that need not be resolved to acknowledge that income disparity does play a factor in how a community will develop plans and take actions to change health. As such, income disparity provides a valuable description of the environment in which health improvement programs must be implemented.

The source for the data is U.S. Census Bureau, Current Population Survey, 1978 to 2008 Annual Social and Economic Supplements and it is presented at www.americashealthrankings.org/measure/2009/gini.aspx.

Historically, the U.S. index has varied from .386 in 1968 to .470 in 2006 (http://www.census.gov/hhes/www/income/histinc/h04.html). Most developed European nations and Canada have Gini indices between .24 and .36. (The Gini Index, which is the Gini coefficient times 100, is reported for other countries by the Central Intelligence Agency at https://www.cia.gov/library/publications/the-world-factbook/fields/2172.html and in Human Development Reports, United Nations Development Program at http://hdrstats.undp.org/en/indicators/147.html.)

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Division of Heart Disease and StrokePrevention, Centers for Disease Control and Prevention, http://www.cdc.gov/dhdsp/library/fs_cholesterol.htm, accessed Sept 3, 2009. Division of Oral Health, Centers for Disease Control and Prevention, http://www.cdc.gov/OralHealth/topics/adult.htm, accessed Sept 3, 2009. Centers for Disease Control and Prevention, http://www.cdc.gov/physicalactivity/everyone/health/index.html accessed Sept 3, 2009.

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"Poverty or income inequality as predictorof mortality: longitudinal cohort study" by Fiscella, Frank and Franks,Peter; BMJ 1997;314:1724 (14 June), http://www.bmj.com/cgi/content/full/314/7096/1724

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Centers for Disease Control and Prevention, http://www.cdc.gov/healthyweight/healthy_eating/index.html accessed Sept 3, 2009. Centers for Disease Control and Prevention, http://www.cdc.gov/reproductivehealth/AdolescentReproHealth/AboutTP.htm , accessed Sept 3, 2009.