Every year cardiovascular disease kills about 18 million people worldwide — this is about a third of all deaths on the planet. In the United States, heart disease is still the top killer, leading to 610,000 deaths a year, or one in every four fatalities.

“It’s a chronic problem and, unfortunately, we see more and more younger patients developing heart disease,” said Mojgan Arashvand, D.O., founder of the Texas Center for Preventive Cardiology. The risk rises with age, she added, “but I see women in their 40s who come in with heart disease.”

Obesity is a major factor in heart disease rates, Arashvand said, and particularly stomach fat. “It’s a different kind of fat and very hormone-sensitive, specifically insulin, which can increase inflammatory markers, increasing the risk of heart disease.” Belly fat has become more common among young men, she added.

About 40% of adults in the country are obese. “Eating too much is the real problem,” Arashvand added. “People are not meant to eat five or six times a day.” Nobody really knows where this idea came from; it does not improve your metabolism, she added. Other risk factors for heart disease include unhealthy diet, family history, lack of exercise, smoking, diabetes, high cholesterol, and hypertension.

To identify the heart disease capitals in the United States, 24/7 Wall St. reviewed data from the Centers for Disease Control and Prevention for the largest 500 cities in the country. The 20 cities listed are those where at least 7.5% of people over 18 years of age report having been told by a health professional that they had angina or coronary heart disease in 2015. Additional data came come from the CDC’s Behavioral Risk Factor Surveillance System data, and the Census Bureau’s 2017 American Community Survey.

Click here to read about America’s heart disease capitals.