A staggering 26 million Americans are walking on a tightrope, precariously close to falling victim to the leading cause of death in the United States – atherosclerotic cardiovascular disease (ASCVD).1
In fact, every 33 seconds, one person dies in the United States from cardiovascular disease that results from atherosclerosis or plaque formation within arterial walls. In 2021 alone, ASCVD claimed an estimated 695,000 lives in the United States, equivalent to 1 in every 5 mortalities.2 Though total CVD mortality has declined steadily in the past two decades, based on the most current study of trends in CVD-related deaths supported by the National Institutes of Health, half of American adults remain affected by some type of heart disease.
While the statistics above offer a comprehensive overview of cardiovascular disease in the United States, it is critical to acknowledge the complexity of heart health across different regions, unveiling significant variations. These regional disparities further suggest we consider the context of how the communities we live in either promote or impede our heart health. The question, therefore, arises: Does the state we live in may play a role in our heart health?
A recently released study from the University of Alabama at Birmingham, featured in the Mayo Clinic Proceedings, suggests significant geographical disparities were highlighted across the United States in the prevalence of atherosclerotic cardiovascular risk factors, which include hypertension, high cholesterol levels, obesity, smoking, inadequate exercises, diabetes, and unhealthy eating habits.3
In our quest to better elucidate these findings and their potential impact on you, we have adopted a state-by-state approach and calculated heart-health danger scores for each state based on nine risk factors for atherosclerotic cardiovascular disease: fruits and vegetable consumption, physical inactivity, obesity, high blood pressure, coronary heart disease, smoking, heavy alcohol consumption, heart disease, and high cholesterol.
In the end, we will present you with the most and least heart-healthy states as well as a comprehensive analysis of heart health across the nation. No matter where you live, we hope you will gain insightful revelations regarding the state of heart health in the United States, thereby fostering a comprehensive knowledge of how local contexts can shape your cardiovascular health outcomes and how you can protect your heart.
First, the Secret of Cardiovascular Health: Meet Seven Guardians for Your Heart
To comprehend what it takes to attain optimal Cardiovascular Health (CVH), imagine it as hosting the seven dwarfs under two different roofs in the grand household that is our body.
The first roof, namely, health behaviors, shelter three dwarfs: diet quality, Physical Activity (PA), and smoking habits. Under the second roof, that is, health factors, we have four dwarfs: blood cholesterol, Body Mass Index(BMI), Blood Pressure (BP), and blood glucose.
Optimal Cardiovascular Health:
The Grand Household of Seven Dwarfs - Illustrated by Zhiyao Zhang
Hence, despite an individual being free from clinically evident atherosclerotic cardiovascular disease (ASCVD), maintaining seven dwarfs’ optimal state is equally important when it comes to ensuring that our body, this grand house, functions at its best.
Fortunately, unlike unchangeable risk factors like family history, gender, and ethnicity, the seven dwarfs, or the health risk factors, can be managed to help you with atherosclerotic cardiovascular disease prevention. This means you can significantly lower the risk of atherosclerotic cardiovascular disease by maintaining a healthy diet pattern, abstaining from smoking, staying active, and constantly keeping your cholesterol, BMI, BP, and blood glucose levels in check without medication treatment.
With this understanding of the health risk factors associated with ASCVD and what it means to have optimal Cardiovascular Health, we now focus on examining the heart health landscape across each state and observe how various risk factors contribute to cardiovascular health disparities nationwide.
Heart-health Danger Score Across the Nation: An Interactive Map of the United States
The interactive map below presents an in-depth analysis of heart health across the United States, derived from the Centers for Disease Control and Prevention (CDC) for 2021. This map employs a visually intuitive color-coding system, where brighter hues correspond to states exhibiting healthy cardiovascular profiles. As you move your mouse over a specific state, you will see the state's Heart-health Danger Score in addition to the detailed percentages and ranks for nine critical health risk factors associated with ASCVD, gaining valuable insights into the multifaceted dynamics affecting heart health disparities across the United States.
The nine health risk factors include:
2.Fruit and Vegetable Consumption (indicator: Percent of adults who report consuming fruit less than one time daily)
3.Percentage of Adults with Coronary Heart Disease
4.Prevalence of High Cholesterol Among Adults
5.Percentages of High Blood Pressure Among Adults
6.Smoking Rates Among Adults
7.Physical Activity (indicator: Adults with no physical leisure-time activity)
8.Prevalence of Heavy Alcohol Consumption (indicator: adult men having more than 14 drinks per week and adult women having more than 7 drinks per week)
9.Prevalence of Heart Disease
A Call to Action: The Five Least Heart-Healthy States in the U.S.
5. Arkansas - The Smoke in Heartland
Arkansas heart-health danger score: 65.11 out of 100
Arkansas ranks sixth in the prevalence of heart diseases among adults nationwide, which is believed to be attributed to a higher prevalence in Arkansas of major, modifiable risk factors.
One problem with Arkansas is that adults have a high smoking prevalence: 21.5% of Arkansas adults report smoking, the second highest rate across the United States.4
Given the established link between smoking and ASCVD, the high smoking rates among adults are an urgent issue that deserves more attention in Arkansas. Smoking, as a major risk factor of ASCVD, can have a permanent health impact on your body, such as reducing blood flow from the heart, damaging your blood vessels, and lowering the amount of oxygen that reaches your body’s tissues. Further emphasizing these health concerns is the 2014 Surgeon General’s Report on smoking and death, which shows that smoking leads to approximately 1 in every 4 ASCVD-related deaths, and cigarette smokers are 2 to 4 times more likely to develop heart diseases than non-smokers.
Moreover, the probability of a person having atherosclerotic cardiovascular disease increases in proportion to the number of cigarettes they smoke daily, and the risk continues to grow when one smokes for years consistently.5 Even if an individual consumes cigarettes that do not have high levels of nicotine and are marketed as “less harmful,” the risk associated with ASCVD will still persist.
The correlation between smoking prevalence and the increasing risk of ASCVD validates the necessity of addressing the smoking issue in Arkansas. Hence, putting more effort into lowering smoking prevalence may be one pivotal step to alleviating the burden of atherosclerotic cardiovascular disease in Arkansas and significantly enhancing the state’s cardiovascular health profile.
However, it is critical to note that the health concerns in Arkansas are more than smoking solely. Arkansas is also4
· 4th highest percentage of adults lacking consumption of vegetables and fruits (46.4%).
· 6th highest obesity rate in the nation (38.7%).
· 4th highest rate of high blood pressure (40.7%).
4. Louisiana - Cajun Heartbeat in a Veggie Desert
Louisiana’s heart-health danger score: 66.88 out of 100
Louisiana ranks fourth on the nation’s ranking of states with the poorest cardiovascular health, with a heat-health danger score of 66.88 out of 100.
Despite being the fifth in adult smoking rates, fifth in the prevalence of high blood pressure, and seventh in adult obesity rates, Louisiana confronts another major challenge: low fruit and vegetable consumption among adults. An astonishing 48.6% of adults in the state report a low intake of vegetables and fruit, trailing Oklahoma, the first-placed state, by only 0.1%.4
Compounding the issue, Louisiana is replete with food deserts, meaning regions with limited access to various healthy and affordable food. Across Louisiana, an estimated 10% of the population is low-income and lives more than 10 miles from the closest and largest grocery stores to secure nutritious food regularly.
Encouraging a fruit and vegetable-rich diet is essential, as such dietary patterns, which contain high concentrations of dietary fiber, Vitamin C, and electrolytes, are associated with a reduced likelihood of developing severe chronic diseases, including atherosclerotic cardiovascular disease. A meta-analysis of a prospective cohort study involving 1,498,909 participants, with a median follow-up of 10.5 years, has found a significant inverse association between fruit and vegetable consumption and the risk of CVD. The study also shows that participants with 800 g per day of fruit and vegetable intake had the lowest risk of CVD.6
Therefore, proactive steps promoting access to fresh and nutritious food options in Louisiana, particularly in conjunction with food desert areas, may reduce the burden of cardiovascular disease and enhance the overall well-being of Louisiana residents.
3. Tennessee - Harmonious Melodies, Discordant Heart Health
Tennessee's heart-health danger score: 67.33 out of 100
Tennessee is ranked third-worst in the United States for cardiovascular health.
In 2021, Tennessee had the fourth-highest prevalence of heart disease across the United States.
Tennessee’s daunting statistics also include4
· 5th highest percentage of adults lacking vegetable and fruit consumption (46.1%).
· 6th highest in rates of high cholesterol (38%).
· 7th highest smoking rate among adults (19.9%).
· 9th highest in the prevalence of high blood pressure (37.7%).
2. Mississippi - The Crossroads of Cardiovascular Health and High Blood Pressure
Mississippi’s heart-health danger score: 69.37 out of 100
Mississippi ranked second overall for heart-unhealthy states.
In Mississippi, 12.4% of adults experienced heart disease, the second highest rate across the United States. The state also ranked worst for several ASCVD-related risk factors, including:
· 3rd place in low fruit and vegetable intake (46.9%).
· 5th highest in adult obesity rates (39.1%).
· 5th highest prevalence of high cholesterol among adults (38.3%).
· 6th in adult smoking rates (19.9%).
However, despite the sobering statistics, one stands out as particularly alarming: high blood pressure.
In 2021, approximately 1 million adult Mississippians experienced high blood pressure, closer to one-third of the total population of 2,949,965.4 High blood pressure, characterized by a level of 140/90 or higher, can leave you endangered by an increased risk of heart attacks due to potential blockage of blood flow. It is critical to know that high blood pressure, as one major cause of ASCVD, can be controlled. You can do so through simple steps such as staying active, having a healthy weight, keeping a nutritious diet, and taking medication as directed by your doctors.
1. West Virginia - A Somber Picture in the Mountain
West Virginia’s heart-health danger score: 80 out of 100
Topping the list with a shocking cardiovascular health profile, West Virginia veers away from the benchmarks of heart health. The impressive burden of ASCVD in West Virginia undoubtedly leaves the Mountain State, along with its population of 1.8 million, in the darkness of seeking ideal Cardiovascular Health. When assessing state-by-state data as well as the heart-health danger score in-depth, troubling statistics further conclude that West Virginia is at the epicenter of this nationwide health challenge as adults are at heightened risk than any other state in the country.
As of recent records from CDC, West Virginia holds the following ranks within the nation4:
· 1st highest in the prevalence of cardiovascular diseases, even after considering the state’s older adults.
· 1st highest rates of obesity (40.6%) and high cholesterol among adults (41%).
· 1st place in percentages of adults with no physical leisure-time activity (23.6%).
· Notably, 23.6% of all adults report being cigarette smokers, a figure higher than 12.1 percent nationally.
The increased risk of health conditions such as high blood pressure, high blood cholesterol, coronary heart disease, and obesity, both individually and jointly, are associated with a high prevalence of cardiovascular diseases in the adult population of West Virginia. As such, interventions to promote healthier lifestyle habits and improve access to quality healthcare will optimize the prevention and management of atherosclerotic cardiovascular diseases in the state.
From Coast to Mountains: The Five States Leading the Charge in Heart Health in the U.S.
5. Illinois - The Heart of the Midwest
Illinois’ heart-health danger score: 46.02 out of 100
Illinois ranks as the fifth heart-healthiest state, including sixth for low prevalence of heavy alcohol drinking among adults.
Illinois is the best in the country for the following ASCVD-related risk factors4:
· 6th lowest prevalence of heavy alcohol consumption among adults (5%).
· 9th lowest rate of adult smoking (12.3%).
· 8th lowest prevalence of high cholesterol among adults (32.3%).
4. California - Surfing to a Healthy Heart
California’s heart-health danger score: 45.87 out of 100
With a total health score of 45.87 out of 100, the Golden State ranks the fourth heart-healthiest state in the United States. California residents had a statistically lower prevalence of heart disease at 5.4%, making the state the third lowest heart disease rate nationwide. Most likely due to the improvements in major risk factors as follows4:
· 4th in lowest rates of adult obesity (27.6%).
· 8th in lowest prevalence of a lack of physical activities during leisure time among adults (21.13%).
· 6th in lowest percentages of adults with coronary diseases (5.35%).
· 8th in most percentages of adults with fruit and vegetable consumption (36.2%).
3. Utah - A Healthy Heart in the Desert
Utah’s heart-health danger score: 44.18 out of 100
Utah is the third heart healthiest state, ranking second in the least prevalence of heart diseases among adults.
Utah’s highlights include4
· 1st in lowest adult smoking rates (7.2%).
· 1st in the lowest percentages of heavy alcohol consumption among adults (3.9%).
· 2nd in the lowest prevalence of high blood pressure (26.7%).
· 3rd in lowest rates of high cholesterol (31.6%).
Being the state with the youngest population is not the sole and dominating factor for Utah’s astounding health profile; rather, the state’s effort in battling atherosclerotic cardiovascular disease may also contribute to the partial success.
The Utah Department of Health’s Bureau of Health Promotion created a BeWise program. The program offers free cardiovascular risk screening to individuals aged 40-64 who fall into low-income, underinsured, or uninsured.7 The programs also include services designated to help women attain their health goals by providing various health topics such as diet, exercise, and support choices.
Despite these, Utah still needs to pay more attention to promoting physical activities, as Utah ranked 1st in the percentage of adults with no physical leisure time activity (35.74%). Regular physical activity is critical in maintaining heart health as the benefits of physical activity include reduced risk of high blood pressure and weight gain. In addition, staying active can lower the risk of developing coronary heart disease.
2. Connecticut - A Heaven for Heart Health
Connecticut’s heart-health danger score: 43.41 out of 100
Connecticut is the second heart-healthiest state in the United States, ranking second best in low percentage of adults with coronary heart diseases and fifth highest vegetable and fruit consumption.
The state has the sixth lowest rate in two categories: adult smoking rates (11.3%) and prevalence of physical inactivity (20.75%). In addition, Connecticut residents have the fifth most rates of fruits and vegetables. The low rates in the above risk factors reflect that a considerable portion of the population is making healthy food choices and lifestyles, further supporting overall cardiovascular wellness in Connecticut.
1. Colorado - The Peak of Cardiovascular Health
Colorado’s heart-health danger Score: 40 out of 100
Colorado secures the pinnacle position in the country for heart health, boasting a commendable health score of 40 out of 100. Closer scrutiny of risk factors associated with atherosclerotic cardiovascular diseases in Colorado, the prevalence of high blood pressure among adults is at 26%, and high cholesterol impacts 31.6% of adults, the lowest among all fifty states, demonstrating balanced diets and active engagement in leisure time physical activities. What’s more, a meager 25.1% of its adults battle obesity, once again the lowest prevalence in the United States.
Indeed, this feat is not merely a happenstance but the product of Colorado’s proactive efforts to combat atherosclerotic cardiovascular disease. A deeper examination reflects a combination of quality healthcare and community involvement at the heart of Colorado’s success.
Access to Quality Healthcare
Colorado, along with eleven other states, receives funding from the Centers for Disease Control and Prevention (CDC) for its specialized obesity initiative, the program underpins the state’s committed stance against obesity, a significant risk factor for cardiovascular disease.
In a similar vein, Colorado Heart Healthy Solutions (CHHS) serves as a beacon of cardiovascular wellness. As a community-based program, CHHS provides community navigation and ongoing follow-up services. The overarching objective of the program is to enhance overall cardiovascular health across Colorado by motivating healthy behaviors and enabling access to primary care via assistance from community health workers (CHWs). In addition to the zero-cost ongoing support from CHWs, the close collaboration between CHHS and local clinics or agencies creates a resource network in which health professionals and medical providers offer medical and healthy living resources. According to the CPC Community Health, CHHS has accounted for serving an estimated 45,213 underserved participants in the state since 2008 and has received a notable improvement in the biometric health markers of program participants.8
Nevertheless, given that cardiovascular disease is still a leading cause of death in Colorado, government officials need to collaborate more to tackle the top risk factors, including heavy alcohol consumption and physical inactivity.
Additional Notes on Methodology:
The assessment of the cardiovascular health of the 50 states in the United States is based on nine meticulously selected health indicators associated with ASCVD. The data for these health-risk factors were collected from the U.S. Centers for Disease Control and Prevention (CDC), ensuring a reliable foundation for our evaluation.
The chosen risk factors include Percent of Fruit and Vegetable Consumption (indicator: Percent of adults who report consuming fruit less than one time daily), Percentage of Adults with Coronary Heart Disease, Prevalence of High Cholesterol Among Adults, Percentage of High Blood Pressure Among Adults, Smoking Rates Among Adults, Physical Activity (indicator: Adults with no physical leisure-time activity), Prevalence of Heavy Alcohol Consumption (indicator: adult men having more than 14 drinks per week and adult women having more than 7 drinks per week), and Prevalence of Heart Disease.
However, it is critical to note that due to the unavailability of 2021 data for two health risk factors, namely “Prevalence of Heavy Alcohol Consumption” and “Smoking Rates Among Adults” in Florida, we have adopted 2020 data for these specific indicators. While this approach enables us to include Florida in evaluating its Cardiovascular Health, it may affect the precision of the final Heart-health Danger Score for the state and the ranking.
Adjusting the health scores to 40 - 80 enables a more realistic representation, fostering more apparent comparisons between each state.
Weights Assignment to Health Risk Factors in Cardiovascular Health Assessment:
Number | Health Risk Factor | Weights |
1 | Adult Obesity Prevalence | -0.7 |
2 | Fruit and Vegetable - Behavior | -0.75 |
3 | Percentage of Adults with Coronary Heart Disease | -1.25 |
4 | Prevalence of High Cholesterol Among Adults | -1.1 |
5 | Percentages of High Blood Pressure Among Adults | -1 |
6 | Smoking Rates Among Adults | -1 |
7 | Adults with No Physical Leisure-time Activity | -0.9 |
8 | Prevalence of Heavy Alcohol Consumption | -1 |
9 | Prevalence of Heart Disease | -1.25 |
References
1. Vasan, R. S., Enserro, D. M., Xanthakis, V., Beiser, A. S. & Seshadri, S. Temporal Trends in the Remaining Lifetime Risk of Cardiovascular Disease Among Middle-Aged Adults Across 6 Decades: The Framingham Study. Circulation 145, 1324–1338 (2022).
2. Heart Disease Facts | cdc.gov. Centers for Disease Control and Prevention https://www.cdc.gov/heartdisease/facts.htm (2023).
3. Parcha, V. et al. Geographic Variation in Cardiovascular Health Among American Adults. Mayo Clin. Proc. 96, 1770–1781 (2021).
4. BRFSS Prevalence & Trends Data: Explore by Topic | DPH | CDC. https://nccd.cdc.gov/BRFSSPrevalence/rdPage.aspx?rdReport=DPH_BRFSS.ExploreByTopic&irbLocationType=StatesAndMMSA&islClass=CLASS17&islTopic=TOPIC55&islYear=2021&rdRnd=39669.
5. Alberg, A. J., Shopland, D. R. & Cummings, K. M. The 2014 Surgeon General’s Report: Commemorating the 50th Anniversary of the 1964 Report of the Advisory Committee to the US Surgeon General and Updating the Evidence on the Health Consequences of Cigarette Smoking. Am. J. Epidemiol. 179, 403–412 (2014).
6. Madsen, H., Sen, A. & Aune, D. Fruit and vegetable consumption and the risk of hypertension: a systematic review and meta-analysis of prospective studies. Eur. J. Nutr. (2023) doi:10.1007/s00394-023-03145-5.
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