6. Pueblo, Colorado
> Premature death rate: 418.2 per 100,000
> Adult obesity rate: 27.1%
> Adult smoking rate: 17.1%
> Median household income: $44,677
The least healthy city in one of the healthiest states, Pueblo is the only metro in Colorado where residents report worse health outcomes than the United States as a whole. In Pueblo, 418 in every 100,000 residents die before age 75, the highest premature death rate of cities in the state and far more than the national rate of 336 per 100,000 Americans. Some 22.1% of adults report feeling in fair or poor health, also the largest share in Colorado and far greater than the national share of 16.0%.
Health outcomes and behaviors in Colorado tend to vary by income. While the typical household in Boulder, the healthiest city in the state, earns $74,615 a year, the median household income in Pueblo is just $44,677 a year, the lowest of any Colorado metro area. Some 20.3% of the Pueblo population lives in poverty, the largest share in Colorado and far greater than the 11.0% poverty rate statewide.
7. New Haven-Milford, Connecticut
> Premature death rate: 295.4 per 100,000
> Adult obesity rate: 27.0%
> Adult smoking rate: 13.6%
> Median household income: $66,176
Connecticut has some of the worst income inequality and the largest health disparities in the country. Residents in the state’s poorest and least healthy metro area, however, are still better off than the average American in a number of measures related to health and wellness. The typical household in the New Haven-Milford metro area earns $66,176 a year, the least of any city in Connecticut yet far above the national median household income of $57,617 a year.
People earning higher incomes have greater access to health care, can afford healthier food, may have more time to exercise, and have better health outcomes overall. In New Haven, 13.6% of adults smoke and 21.0% do not exercise, each the largest share of cities in the state, but still below the national shares. Some 295 in every 100,000 residents die before age 75, the highest premature death rate in Connecticut — yet far below the national rate of 336 deaths per 100,000 Americans.
8. Dover, Delaware
> Premature death rate: 399.0 per 100,000
> Adult obesity rate: 33.6%
> Adult smoking rate: 18.2%
> Median household income: $54,140
While Dover is the only metro area in Delaware and is the least healthy city in the state by default, city residents still report worse health outcomes and behaviors than the state as a whole. Some 30.3% of Dover adults do not exercise, compared to the state inactivity rate of 26.1%. Similarly, 33.6% of adults are obese, more than the state obesity rate of 30.6%. Every year, 399 in every 100,000 Dover residents die before age 75, far more than the state premature death rate of 344 per 100,000 Delaware residents.
While the relationship is complicated, income is one of the largest determinants of health. The typical Dover household earns $54,140 a year, far less than the $61,757 median household income for Delaware.
9. Homosassa Springs, Florida
> Premature death rate: 480.0 per 100,000
> Adult obesity rate: 27.1%
> Adult smoking rate: 18.4%
> Median household income: $39,206
In Homosassa Springs, 480 in every 100,000 residents die before age 75, the highest premature death rate in Florida and more than the statewide rate of 332 premature deaths per 100,000 residents. Poor health outcomes are likely the result of the city’s high incidence of unhealthy behavior. Smokers are more than 25 times as likely to get lung cancer than non-smokers, and are at a greater risk of dying prematurely. Additionally, adults who exercise seven hours a week are 40% less likely to die prematurely than those engaging in less than 30 minutes of exercise per week. Some 18.4% of Homosassa Springs adults smoke and 29.5% do not exercise, each the largest such share of cities in the state.
Income is a large determinant of health outcomes, and Homosassa Springs is one of the poorest metro areas in Florida. The typical household in the metro area earns $39,206 a year, the second lowest of any metro area in the Florida and approximately $18,000 less than the U.S. median household income.
10. Albany, Georgia
> Premature death rate: 490.0 per 100,000
> Adult obesity rate: 34.8%
> Adult smoking rate: 20.6%
> Median household income: $40,667
As measured by a number of health outcomes and health behaviors, Albany is the least healthy metro area in Georgia. Some 20.6% of adults in Albany smoke, the largest share of any city in the state. Smokers are more than 25 times as likely to get lung cancer than non-smokers, and are more likely to die prematurely overall. Additionally, 34.8% of adults are obese, the second largest share in the state, which increases the risk of cardiovascular disease and diabetes. Every year, 490 in every 100,000 Albany residents die before age 75, the second highest premature death rate in Georgia.
A number of environmental and socioeconomic factors may contribute to the negative health outcomes in Albany. The metro area is highly rural, and just 58.4% of metro area residents have access to a opportunities for physical activity — by far the smallest share of cities in the state. Exposure to violent crime can also contribute to poor health outcomes as it can induce mental stress, physical stress, and discourage outdoor recreational opportunities. In 2016, there were 735 violent crimes reported per 100,000 city residents, the most of any city in Georgia and the 19th highest violent crime rate in the United States.