An enormous amount of time and money is spent keeping Americans healthy. Governments at all levels and individuals invest many resources on anything from medical expenses to the costs of insurance, health research, nutritional programs, and exercise facilities. Environmental factors also play a role. A great deal of how healthy Americans are depends on where they live.

24/7 Wall St. reviewed county-level health rankings from County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute joint program. The health of Americans varies tremendously not just between states, but within each state. In some areas in even the healthiest states, certain health outcomes are on par with that of developing nations.

The report ranked each state’s counties based on the incidence of premature death and self-reported levels of health — that is, how long and how well residents live. Premature death rates, measured as the number of years lost prior to age 75 per 100,000 people annually, range from 28,822 years in Sioux County, North Dakota, to 6,078 years in Windham County, Connecticut. These counties are each the least healthy in their respective states. By contrast, just 3,081 years are lost per 100,000 people annually in Valley County, Idaho, one of the healthiest areas in the nation.

Click here to see the least healthy county in every state.

The quality of life, measured by several self-reported levels of well-being, also varies considerably across the United States. Of all counties reviewed, Brooks County, Texas, residents report nearly the lowest quality of life, with 40% reporting fair or poor health. This is in stark contrast with Douglas, Colorado, where just 7% of adults report such low levels of health.

How long and how well people live are a consequence of health factors, which include behavioral indicators such as exercise habits, smoking rates, obesity, and alcohol consumption; and socioeconomic indicators such as violent crime rates, unemployment, teen birth rates, the ratio of residents to physicians, and child poverty rates. In an interview with 24/7 Wall St., Bridget Catlin, co-director of the County Health Rankings & Roadmaps program at the University of Wisconsin, explained that these are factors that community leaders and county residents can improve.

No single factor can explain poor health outcomes in an area, and the circumstances leading to such adverse health outcomes are often extremely complicated. A few indicators stand out, however. Low incomes and poverty, for example, are very common in these less healthy areas. Of the 50 counties on this list, only Windham County, Connecticut, has a child poverty rate lower than the national share of 20%.

“When you are struggling trying to make ends meet it’s difficult to focus on being sure that you have healthy food on the table,” Catlin said.

Premature death rates are lowest in suburban and urban areas, and in large cities in particular, preventable deaths have declined in recent years. Premature death rates in rural areas, by contrast, have gone up over the past several years.

Like people, health care services are also few and far between in rural places. In 36 states, the ratio of primary care physicians to residents in the least healthy county is worse than the national level, for example.

Catlin noted that poor access to health care is only one reason for the worse health outcomes in rural areas. These counties also tend to have fewer job opportunities, and with smaller tax bases, the funding for health and many other institutions and services is often lower. Of the 50 states, the unemployment rate in the least healthy county exceeds the national rate in all but seven counties. In all but one case, the jobless rate is higher than the state’s.

Poor access to services is not limited to rural areas, nor is it a consequence of distance alone. The lack of health insurance also restricts access to medical care and is far more common in the least healthy counties. Nationwide, 17% of Americans under 65 years old do not have health insurance. The percentage is higher in over half of these areas.

In a number of states, the least healthy county also overlaps at least one Indian reservation, where poor economic conditions, unhealthy behaviors, and the resulting negative health outcomes are far more common than elsewhere. According to A Program of Partnership With Native Americans, a national charity, economic and living conditions on most reservations are very poor compared to other U.S. areas. Numerous problems are facing these communities. The pressures to adopt a Western lifestyle over traditional ways of life, for example, have led to particularly detrimental health consequences.

To identify the least healthy county in every state, 24/7 Wall St. reviewed county-level data from County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute joint program. Rankings are based on overall health outcomes — a weighted composite of length of life, quality of life, and maternal health — and overall health factors. The health factors component is itself a weighted composite of healthy behaviors, clinical care, social and economic factors, and physical environment measures. Data was compiled from over 20 different sources, and is of the most recent year available. A total of 3,140 counties were considered.

These are the least healthy counties in each state.

1. Alabama
> Least healthy county: Wilcox
> Pct. without health insurance: 16.9%
> Pct. limited access to healthy food: 27.6%
> Obesity rate: 44.4%
> 2015 unemployment rate: 17.4%

Compared to the typical American, Alabama residents are not especially healthy. In Wilcox, the state’s least healthy county, residents report even worse outcomes than the state as a whole. An estimated 17,193 years are lost per 100,000 Wilcox residents annually due to preventable deaths, well above the comparable state figure of 9,545 years, which itself is far higher than the national estimate. Obese individuals are at a considerably greater risk of worse health outcomes than other people. This may be one major factor in Wilcox’s poor health outcomes, where 44% of adults are obese, versus the state obesity rate of 34%, and the national figure of 27%.

2. Alaska
> Least healthy county: Kusilvak
> Pct. without health insurance: 28.6%
> Pct. limited access to healthy food: 44.1%
> Obesity rate: 34.4%
> 2015 unemployment rate: 23.7%

Like a number of other unhealthy areas, particularly in Alaska, Kusilvak is rural. Access to quality food, health care, and other services is frequently more challenging in sparsely populated areas. This is also the case in Kusilvak, where 44% of individuals do not have access to affordable, healthy food. Similarly, 29% of residents in the area do not have health insurance, a considerably higher uninsured rate than across the state and the nation.

3. Arizona
> Least healthy county: Apache
> Pct. without health insurance: 23.6%
> Pct. limited access to healthy food: 43.8%
> Obesity rate: 32.8%
> 2015 unemployment rate: 16.0%

Habits and health outcomes vary considerably throughout Arizona. In Apache, the least healthy county in the state, an estimated 14,300 years of life are lost per 100,000 people each year due to preventable death, more than in any other county in the state. By comparison, 6,800 years of life are lost per 100,000 across Arizona as a whole. Considering that several health indicators in Apache are far worse than they are statewide, the county’s poor health outcomes may not come as a surprise. More than a quarter of county residents report a smoking habit and a third of all adults in the county are obese, each a considerably larger share than the comparable statewide figure. Apache is one of several predominantly American Indian communities that are among the least healthy in the country. American Indians are significantly more likely than the average American to suffer from extreme poverty and other conditions that can lead to poor health.

4. Arkansas
> Least healthy county: Phillips
> Pct. without health insurance: 17.6%
> Pct. limited access to healthy food: 24.1%
> Obesity rate: 41.5%
> 2015 unemployment rate: 9.6%

Most of the least healthy counties in Arkansas, including Phillips County, are located near the state’s eastern border with Mississippi. Phillips residents, on the whole, are significantly less likely to have access to healthy food than the average American, and only 60% of adults exercise, compared to 77% of U.S. adults who do. Diet and exercise are crucial to preventing obesity, which is a leading indicator of many of the most common life-threatening illnesses. The adult obesity rate in Arkansas of 33% is quite high compared to the national rate of 27%. In Phillips County, an even higher 42% of adults are obese, one of the highest rates of any county in the United States.

5. California
> Least healthy county: Kern
> Pct. without health insurance: 20.4%
> Pct. limited access to healthy food: 5.4%
> Obesity rate: 28.5%
> 2015 unemployment rate: 10.4%

Education and financial security are often major determinants of health. In Kern, California’s least healthy county, fewer than half of all adults have completed at least some college, well below the state and national rates. Also, one-third of children live in poverty in Kern, versus the nationwide child poverty rate of 22%. These poor socioeconomic factors have contributed to poor health outcomes. More than one in every five adults living in Kern assess their own health as poor or fair. By contrast, 14% of adults nationwide report feeling in similarly poor health.

6. Colorado
> Least healthy county: Costilla
> Pct. without health insurance: 29.9%
> Pct. limited access to healthy food: 55.3%
> Obesity rate: 21.4%
> 2015 unemployment rate: 9.1%

Higher educational attainment is closely tied to better health outcomes. In Costilla, Colorado’s least healthy county, 28% of adults have at least some postsecondary education compared to 70% of adults statewide. County residents are also far more likely to die before age 75 than adults across Colorado. Costilla residents are also less likely to exercise than adults across the state, and only 20% of residents have access to locations for physical activity — compared to 91% of adults statewide.

7. Connecticut
> Least healthy county: Windham
> Pct. without health insurance: 11.3%
> Pct. limited access to healthy food: 6.2%
> Obesity rate: 28.9%
> 2015 unemployment rate: 7.3%

Connecticut residents tend to be affluent and relatively healthy compared to those in other states. So, while Windham County is the state’s least healthy area, many residents still fare better than people across the nation. Windham’s median household income of $57,547 is lower than the state figure of $70,007 but still significantly higher than the national median of $53,700. Incidence of premature death, for example, is more common in Windham than across the state, but it is still less common than it is nationwide.

8. Delaware
> Least healthy county: Kent
> Pct. without health insurance: 10.4%
> Pct. limited access to healthy food: 4.8%
> Obesity rate: 33.2%
> 2015 unemployment rate: 6.4%

Of Delaware’s three counties, Kent is the least healthy, with several behavioral measures and health outcomes trailing statewide figures. The county is home to a larger share of obese adults and a smaller share of adults who exercise regularly than the state a whole. Kent County’s adults may be exercising less because only 69.5% of residents have access to areas for physical activity, compared to the 84.9% of people across the state who do.

9. Florida
> Least healthy county: Gadsden
> Pct. without health insurance: 22.6%
> Pct. limited access to healthy food: 5.8%
> Obesity rate: 38.1%
> 2015 unemployment rate: 8.0%

Gadsden’s population is the least healthy in Florida. While good personal health is closely correlated with healthy habits, several factors outside of an individual’s control also play a major role. Only 59% of county residents have adequate access to areas for exercise, while 92% of all Floridians have adequate access. Activity can be crucial to both physical and mental well-being, and Gadsden residents are less likely to exercise, more likely to be obese, and more likely to have frequent mentally unhealthy days than most Floridians.

10. Georgia
> Least healthy county: Taliaferro
> Pct. without health insurance: 24.9%
> Pct. limited access to healthy food: 43.9%
> Obesity rate: 34.1%
> 2015 unemployment rate: 11.0%

Rural populations appear to face greater obstacles to maintaining good health. Taliaferro County, which has a 100% rural population, is the least healthy county in Georgia. Poor health not only reduces the life expectancy of a population, but it can also significantly diminish the quality of life for the average person. This is clearly the case in Taliaferro, where nearly 30% of county residents report being in fair or poor health, more than double the national proportion. Residents also report an average of close to five days of poor mental health each month, compared to a U.S. average of 3.5 days.

11. Hawaii
> Least healthy county: Hawaii
> Pct. without health insurance: 10.7%
> Pct. limited access to healthy food: 10.8%
> Obesity rate: 23.5%
> 2015 unemployment rate: 5.5%

Hawaii is among the national leaders in numerous measures of health and well-being. Residents of Hawaii County, the state’s least healthy area, are by no means the least healthy Americans. Still, area residents are slightly more likely than adults nationwide to report a low quality of life, and premature death is more common in the county than across the nation. Obesity, on the other hand, is far less common in the area. Of adults in the county, 23.5% are obese, well below the national rate, but still higher than the state’s 22.1% rate.

12. Idaho
> Least healthy county: Owyhee
> Pct. without health insurance: 31.1%
> Pct. limited access to healthy food: 7.2%
> Obesity rate: 32.1%
> 2015 unemployment rate: 3.3%

One of the consequences of unhealthy habits is a lower life expectancy, and this is clear in Idaho’s least healthy county, Owyhee. Nationally, 6,600 years of life are lost on per 100,000 residents due to premature death, but in Owyhee nearly 8,100 years of life are lost annually. Rural populations are much more likely to struggle with health problems. People living outside of cities and suburban neighborhoods tend to lack access to healthy diet and exercise options as well as medical care. This is both because incomes tend to be lower, and resources tend to be spread farther apart in these areas. Idaho is a relatively rural state, with nearly 30% of the population living outside of cities or suburban neighborhoods. In Owyhee, 77% of the population lives in a rural area.

13. Illinois
> Least healthy county: Pulaski
> Pct. without health insurance: 14.1%
> Pct. limited access to healthy food: 23.8%
> Obesity rate: 32.1%
> 2015 unemployment rate: 10.4%

Entirely rural, Pulaski is the least healthy county in Illinois. Rural areas have a smaller tax base and, consequently, fewer resources for public investment in health. In Pulaski, only 34% of the county’s population has adequate access to places for physical activity such as parks or recreational facilities, compared to 89% of state residents with access to such locations. People living in rural areas are also more likely than others to report certain unhealthy behaviors. In Pulaski, 19% of adults report a smoking habit, considerably more than the 15% of adults statewide who identify as smokers.

14. Indiana
> Least healthy county: Scott
> Pct. without health insurance: 15.6%
> Pct. limited access to healthy food: 2.0%
> Obesity rate: 28.9%
> 2015 unemployment rate: 6.7%

An area’s economic vitality can dramatically impact the collective health of its residents. In Scott County, Indiana’s least healthy county, residents face high unemployment and poverty rates. At 6.7%, the county’s unemployment rate is higher than the 6.0% statewide jobless rate. Additionally, 27% of children in Scott County live in poverty, a considerably larger share than Indiana’s 21% child poverty rate. As unemployment and poverty can limit an individual’s ability to make healthy choices, such as maintaining a healthy diet and regularly visiting the doctor, health outcomes in Scott are poor. County residents report a higher average number of physically and mentally unhealthy days a month than Indiana residents as a whole. Also, a larger share of the county’s population reports less than optimal health than the corresponding share of adults across the state.

15. Iowa
> Least healthy county: Wapello
> Pct. without health insurance: 12.3%
> Pct. limited access to healthy food: 11.2%
> Obesity rate: 32.9%
> 2015 unemployment rate: 5.7%

Poverty can directly hinder a population’s ability to access healthier foods and exercise and afford medical care. In Iowa, which is one of the healthiest states, just 15.5% of children live in poverty. However, in Wapello, the state’s least healthy county, 22% of children live in poverty. On the whole, though, Wapello compares relatively favorably to many unhealthy counties. For example, county residents report approximately the same number of days in fair or poor health each month.

16. Kansas
> Least healthy county: Wyandotte
> Pct. without health insurance: 21.5%
> Pct. limited access to healthy food: 13.6%
> Obesity rate: 37.8%
> 2015 unemployment rate: 6.9%

Nearly 38% of adults in Wyandotte County are obese, the second highest share of any county in Kansas and considerably higher than the 30% statewide obesity rate. Being overweight can significantly impact quality of life, and Wyandotte residents report worse health outcomes than state residents overall. On average, adults in the county report 3.6 mentally unhealthy days and 3.9 physically unhealthy days a month, each at least half a day more than is typical among state residents. Additionally, more than one in five adults in Wyandotte County say they are in fair or poor health compared to only 13.6% of Kansas adults.

17. Kentucky
> Least healthy county: Harlan
> Pct. without health insurance: 19.4%
> Pct. limited access to healthy food: 9.9%
> Obesity rate: 36.6%
> 2015 unemployment rate: 13.9%

Like many of the least healthy counties in America, Harlan is one of the poorest. A typical household in Harlan County makes just $26,351 annually, less than half the $53,700 median household income nationwide. Harlan County’s 13.9% unemployment rate is one of the highest in the country, and the 42.6% of children who live in poverty is one of the worst child poverty rates nationwide. Financial distress has likely increased the difficulty of maintaining healthy habits and ultimately contributes to the county’s poor health outcomes. Just 59.9% of county adults regularly exercise, the lowest share in Kentucky. Similarly, 36.6% of adults are obese, significantly more than the 32.3% state rate, itself higher than the 27.0% national obesity rate.

18. Louisiana
> Least healthy county: Madison
> Pct. without health insurance: 22.7%
> Pct. limited access to healthy food: 2.5%
> Obesity rate: 43.0%
> 2015 unemployment rate: 11.3%

Measuring both quality of life and life expectancy, Louisiana is one of the least healthy states in the country. Not surprisingly, the state’s least healthy county — Madison — has some of the lowest quality of life and highest mortality figures in the country. On a national level, 6,600 years of life are lost due to premature death per 100,000 residents. In Madison, 12,073 years of life are lost. In the United States, 14% of adults report being in poor or fair health, while 35% of adults in Madison say the same, tied for 11th worst among the nation’s more than 3,000 counties.

19. Maine
> Least healthy county: Washington
> Pct. without health insurance: 18.5%
> Pct. limited access to healthy food: 5.4%
> Obesity rate: 30.9%
> 2015 unemployment rate: 8.4%

Residents of Washington County report feeling in poor physical health an average 4.4 days each month, a full day more than is typical across Maine. Low exercise rates are likely contributing to such poor health outcomes. Only 71.7% of county residents exercise regularly, the smallest such share of any county in the Maine. Limited access to places for physical activity may be partially behind the low exercise rate. Less than 39% of county residents live in an area with adequate access to a park or recreational facility. By contrast, more than two-thirds of Maine residents have access to places for physical activity.

20. Maryland
> Least healthy county: Baltimore City
> Pct. without health insurance: 12.8%
> Pct. limited access to healthy food: 1.2%
> Obesity rate: 34.3%
> 2015 unemployment rate: 8.7%

Nearly 20% Baltimore City residents report being in fair or poor health, a considerably higher share than the corresponding state rate of 13%. While in many states the least healthy county is rural and relatively safe, Maryland is an exception. Baltimore City, Maryland’s least healthy county, is entirely urban — and relatively dangerous. There are 1,449 violent crimes reported per 100,000 each year in the area, the third highest rate of any U.S. county. Baltimore’s economy is also not especially strong, which can contribute to lower incomes and hinder public programs and services supporting health. Baltimore’s unemployment rate of 8.7% exceeds the state and national rates.

21. Massachusetts
> Least healthy county: Hampden
> Pct. without health insurance: 5.0%
> Pct. limited access to healthy food: 5.3%
> Obesity rate: 28.5%
> 2015 unemployment rate: 7.8%

Massachusetts is by many measures one of the healthiest states in the country. State residents exhibit very healthy behavior, as they are less likely to smoke, die from drinking and driving, transmit sexually transmitted diseases, or avoid exercise than Americans nationwide. The county of Hampden, however, compares unfavorably to national statistics in each of these behavioral factors. Perhaps for this reason, Hampden residents spend a full day on average more than the typical american feeling physically unwell each month.

22. Michigan
> Least healthy county: Wayne
> Pct. without health insurance: 15.8%
> Pct. limited access to healthy food: 4.0%
> Obesity rate: 33.5%
> 2015 unemployment rate: 10.0%

Some economic indicators, such as unemployment and poverty rates, are closely associated with health outcomes. Nearly 40% of Wayne county residents live in Detroit, one of the most economically depressed cities in the country. Indeed, 10% of the county workforce is in need of a job, and more than 35% of children in Wayne live in poverty. Such poor economic conditions can reduce access to proper nutrition, to health care, and ultimately yield some of the worst health outcomes in the state. More than 10% of children born in Wayne have a low birthweight, the largest share in Michigan. Even more distressing, one of every 100 children in the county dies before turning one year old, the highest infant mortality rate in Michigan.

23. Minnesota
> Least healthy county: Mahnomen
> Pct. without health insurance: 14.2%
> Pct. limited access to healthy food: 19.5%
> Obesity rate: 28.6%
> 2015 unemployment rate: 5.6%

While Minnesota is one of the more healthy states in the country, Mahnomen County bucks the trend. Approximately 22% of county adults report fair or poor health, double the 11% of Minnesota adults reporting similar poor health. Also, 11,029 years of life are lost to premature death per 100,000 residents each year, more than twice the statewide figure of 5,071 lost years per 100,000 Minnesotans. The White Earth Reservation includes all of Mahnomen County as well as portions of other counties, and American Indians comprise 41.7% of the county’s population. Reservations have unique legal status and are often considered risky places to invest. They tend to offer far fewer jobs, and the pressures to conform to Western norms have their own consequences. Due to these and numerous other factors, American Indians are far more likely than the average American to face serious health issues.

24. Mississippi
> Least healthy county: Holmes
> Pct. without health insurance: 20.6%
> Pct. limited access to healthy food: 19.9%
> Obesity rate: 46.6%
> 2015 unemployment rate: 15.8%

Holmes is the least healthy county in a particularly unhealthy state. Over 10,000 years are lost annually due to premature death in Mississippi, more than in any other state in the country. In Holmes, premature death is even more common with over 13,600 years lost annually to preventable deaths. Unhealthy habits play a major role in such negative outcomes. More than a quarter of county residents report a smoking habit, the largest share of any county in the state. Economic conditions also play a factor. Well over half of all children in Holmes live in poverty, and one in every five county residents is low income and does not live close to a grocery store. These proportions are considerably higher than the respective state and national rates.

25. Missouri
> Least healthy county: Pemiscot
> Pct. without health insurance: 13.8%
> Pct. limited access to healthy food: 4.4%
> Obesity rate: 33.8%
> 2015 unemployment rate: 9.0%

People in poverty are more likely to be malnourished, suffer from poor mental health, and die prematurely. In Pemiscot, more than 40% of children live below the poverty line, compared to a statewide child poverty rate of 21%. The inability to regularly afford food is a major obstacle to proper nutrition, and 23.1% of Pemiscot residents struggle to afford food each year, the second highest share in the state. Additionally, more than 14% of county residents report frequent medical distress, one of the highest rates of any county in the state and the country as a whole. Overall, 16,183 years of life are lost to premature death per 100,000 residents in Pemiscot each year, nearly the highest incidence of premature death in the nation.

26. Montana
> Least healthy county: Glacier
> Pct. without health insurance: 29.8%
> Pct. limited access to healthy food: 10.3%
> Obesity rate: 34.2%
> 2015 unemployment rate: 10.7%

Of Glacier County residents, 62.6% identify as American Indian, most of whom are members of the Blackfeet Nation, the largest American Indian tribe in Montana. As is the case in many parts of the country, American Indians are far more likely to be in poor health than the average American. Every year, 15,095 years of life are lost per 100,000 residents due to premature death, more than double the statewide premature death rate. Unhealthy habits among area residents may partially explain the high incidence of premature death. Almost 31% of Glacier County adults smoke, the highest share in Montana and well above the national rate. Also, the 69.7% of adults who exercise regularly is a smaller share than the 78.0% activity rate Montana adults report overall.

27. Nebraska
> Least healthy county: Thurston
> Pct. without health insurance: 17.7%
> Pct. limited access to healthy food: 6.8%
> Obesity rate: 40.8%
> 2015 unemployment rate: 6.7%

Of adults in Thurston County, 22.9% say they are in fair or poor health, a higher share reporting less than optimal health of any county in Nebraska. Statewide, a much smaller 12.3% of adults report similarly poor health. The prevalence of poor health is not especially surprising considering that more than 40% of adults in the county are obese, the largest share in the state.

Low incomes and financial distress can make staying health very challenging. In Thurston, the median household income is only $41,344 a year, much lower than the $52,803 the typical Nebraska household earns annually.

28. Nevada
> Least healthy county: Mineral
> Pct. without health insurance: 19.9%
> Pct. limited access to healthy food: 15.7%
> Obesity rate: 26.4%
> 2015 unemployment rate: 11.1%

The Hawthorne Army Depot in Mineral County is the largest ammunition storehouse in the world. While the facility brings major industry to the region, 11.1% of the county’s workforce are currently unemployed. More than 32% of Mineral County children live in poverty, a higher share than the 22% national child poverty rate. Unfavorable economic conditions may have lead to poor health outcomes in the region. For every 100,000 county residents, 666 die before the age of 75, more than twice the national rate of 330 premature deaths for every 100,000 Americans each year. Also, one in five Mineral County adults report being in fair to poor health, the second highest such share in Nevada.

29. New Hampshire
> Least healthy county: Coos
> Pct. without health insurance: 16.1%
> Pct. limited access to healthy food: 3.7%
> Obesity rate: 30.1%
> 2015 unemployment rate: 5.8%

A relatively healthy state, New Hampshire’s least healthy county reports health measures that roughly resemble the health of the national population. For example, 14% of Coos County adults report being in fair or poor health, and the typical resident reports 3.5 physically unhealthy days a month, each figure in line with the corresponding national figure.

While mostly as healthy as the national population, Coos County residents are far less healthy than the statewide population. Obesity, smoking, and premature death are all more common in Coos County then they are across the state.

30. New Jersey
> Least healthy county: Cumberland
> Pct. without health insurance: 18.0%
> Pct. limited access to healthy food: 9.2%
> Obesity rate: 33.6%
> 2015 unemployment rate: 9.9%

Economic conditions can have a profound effect on the health of a population. In Cumberland, the least healthy county in New Jersey, the unemployment rate of 9.9% is considerably higher than the 6.6% unemployment rate across the state. High unemployment has likely contributed to a higher than average 18% uninsured rate in the county, as well as a higher than average number of days each month residents report feeling either physically or mentally unhealthy.

Bad habits are also likely taking their toll on Cumberland County residents. Nearly 20% of area residents identify as smokers, the largest share of any county in New Jersey.

31. New Mexico
> Least healthy county: McKinley
> Pct. without health insurance: 29.7%
> Pct. limited access to healthy food: 33.4%
> Obesity rate: 33.3%
> 2015 unemployment rate: 9.8%

Native Americans settled in McKinley centuries ago and today make up 76.8% of the county’s population. McKinley is home to several American Indian tribes, including significant shares of the Navajo, Zuni, and Pueblo peoples. While the area benefits from natural resources and a tourism industry centered on its Indian history, much of the county’s population struggles with unfavorable economic conditions. A typical county home earns $29,497 a year, one of the lowest median incomes in the United States. The 42.9% child poverty is similarly bad. The extreme poverty may increase the difficulty of maintaining a healthy lifestyle and ultimately lead to poor health outcomes. Every year, 12,943 years of potential life are lost to premature death per 100,000 county residents, nearly double the corresponding national figure.

32. New York
> Least healthy county: Bronx
> Pct. without health insurance: 15.6%
> Pct. limited access to healthy food: 4.8%
> Obesity rate: 28.9%
> 2015 unemployment rate: 9.8%

For all the six years of County Health Rankings & Roadmaps reporting, the Bronx has been the least healthy county in New York. However, local leaders and community members have made great strides in improving health the area. The Bronx won the 2015 RWJF Culture of Health Prize, an award given to just eight U.S. counties by the Robert Wood Johnson Foundation for improving health.

Still, the borough is host to the worst health behaviors and outcomes in New York. The area’s 18.9% smoking rate is the highest in the state, and the 28.9% obesity rate is higher than the corresponding 24.2% obesity rate for the state as a whole. About 29% of residents in the Bronx report being in fair or poor health, the largest share of any New York county.

33. North Carolina
> Least healthy county: Robeson
> Pct. without health insurance: 24.7%
> Pct. limited access to healthy food: 6.0%
> Obesity rate: 39.1%
> 2015 unemployment rate: 9.2%

Nearly 47% of children in Robeson County live below the poverty line, the largest share of any county in North Carolina. Impoverished families are less likely to receive preventative medical treatment and care, and this is especially true in North Carolina, one of over a dozen states that have not expanded medicaid under the Affordable Care Act. Robeson County residents are at a further disadvantage, as less than half of all county residents have adequate access to places for exercise, such parks or recreation centers. Statewide, more than three-quarters of the population has adequate access to such facilities. Economic and environmental conditions have likely contributed to the state leading 29.4% share of residents who report less than optimal health.

34. North Dakota
> Least healthy county: Sioux
> Pct. without health insurance: 18.3%
> Pct. limited access to healthy food: 26.2%
> Obesity rate: 39.1%
> 2015 unemployment rate: 4.8%

American Indian populations are far more likely than the typical American to live in poverty and in other conditions that may hinder good health. In Sioux County, the least healthy county in North Dakota and the nation, more than one in four residents is American Indian. Economic conditions and adverse health outcomes are almost always much worse on reservations than neighboring regions, leading to a greater incidence of preventable death. On a national level, 6,600 years of life are lost for every 100,000 Americans due to premature death annually. In Sioux County, 28,281 years are lost for every 100,000 residents, also the worst of any county in the United States.

35. Ohio
> Least healthy county: Pike
> Pct. without health insurance: 13.7%
> Pct. limited access to healthy food: 10.9%
> Obesity rate: 31.2%
> 2015 unemployment rate: 9.0%

Due to a variety of factors, rural areas tend to report worse health outcomes than more urban areas, and Pike, the least healthy county in Ohio, is nearly 75% rural. A state-leading infant and child mortality rate in the county has contributed to a total of 12,381 years of life lost for every 100,000 residents annually due to premature death. In contrast, the premature death rate across the state is 7,534 years of life lost annually per 100,000 residents.

Pike County residents are also more likely than the typical Ohio resident to perceive their own health as poor. More than 20% of people in Pike report being in less than optimal health, a considerably larger share than the 16% of Ohio residents reporting similarly poor health.

36. Oklahoma
> Least healthy county: Adair
> Pct. without health insurance: 26.6%
> Pct. limited access to healthy food: 3.7%
> Obesity rate: 38.2%
> 2015 unemployment rate: 7.6%

In Adair County, unhealthy habits are relatively common. Over 29% of residents smoke and over 38% are obese, each some of the higher rates nationwide. Less healthy people tend to live shorter lives and their quality of life is also often much lower than that of healthy people. In Adair County, 11,324 years of life are lost per 100,000 residents due to premature death, one of the highest rates of premature death in the country. Also, while Americans report feeling mentally unhealthy approximately 3.5 days each month, county residents report feeling in poor health nearly two full days more — one of the highest figures of any county in the United States.

37. Oregon
> Least healthy county: Jefferson
> Pct. without health insurance: 24.3%
> Pct. limited access to healthy food: 10.8%
> Obesity rate: 31.1%
> 2015 unemployment rate: 9.0%

Nearly one-quarter of Jefferson County residents under age 65 do not have health insurance, the largest share of any county in Oregon and well above the national proportion. Uninsured residents are far less likely to receive adequate medical treatment and preventative care than residents with insurance, and in Jefferson, the effects are apparent. Jefferson County residents report more physically and mentally unhealthy days than the typical Oregon resident and are more likely to die before age 75 than people across the state and the nation.

38. Pennsylvania
> Least healthy county: Philadelphia
> Pct. without health insurance: 16.5%
> Pct. limited access to healthy food: 0.2%
> Obesity rate: 29.2%
> 2015 unemployment rate: 8.0%

In most states, the least healthy county is heavily rural and has limited access to healthy and affordable food. Philadelphia County, however, is entirely urban and has the smallest share of residents with limited access to food of any Pennsylvania county. Nevertheless, Philadelphia is the least healthy county in the state. It is home to the highest rates of fatal drug overdose, teen pregnancy, and chlamydia in Pennsylvania. Additionally, 11.0% of babies are born with low birth weight — the largest share in the state. More than 1 in every 100 live births result in death before the age of one, an infant mortality rate more in line with the extremely poor isolated nation of Grenada than with the United States.

39. Rhode Island
> Least healthy county: Providence
> Pct. without health insurance: 16.2%
> Pct. limited access to healthy food: 4.6%
> Obesity rate: 27.6%
> 2015 unemployment rate: 8.2%

Providence County, the least healthy of Rhode Island’s five counties, is only slightly less healthy than the state as whole. Of adults in Providence, 16.4% say they are in fair or poor health, a larger share than the 13.9% of state residents reporting such a poor state of health. Large urban areas tend to be healthier than suburban and rural areas, with larger tax bases and less distant health and other services. In Providence County unhealthy habits have likely contributed to the negative health outcomes. For example, despite having greater access than most people in the state to areas for exercise, such as parks or recreational centers, Providence residents are less likely to exercise than most Rhode Islanders. Only 73.8% of county residents exercise regularly compared to 75.9% of Rhode Island residents. The county also has a higher share of smokers than the state as a whole.

40. South Carolina
> Least healthy county: Marlboro
> Pct. without health insurance: 19.4%
> Pct. limited access to healthy food: 6.8%
> Obesity rate: 37.4%
> 2015 unemployment rate: 10.6%

Marlboro County is the least healthy county in South Carolina. County residents are more likely to smoke, be physically inactive, have poor access to healthy food, and transmit STDs than Americans overall. Poor diet and lack of exercise can lead to obesity, which is strongly correlated with many of the leading causes of preventable death, including diabetes, heart disease, and high blood pressure. More than 37% of Marlboro’s population is obese compared to 27% of the nation’s adults.

41. South Dakota
> Least healthy county: Todd
> Pct. without health insurance: 15.4%
> Pct. limited access to healthy food: 13.1%
> Obesity rate: 37.5%
> 2015 unemployment rate: 8.7%

The vast majority of Todd County’s residents identify as American Indian. The county is home to the Rosebud Indian Reservation and has some of the worst health outcomes in the nation. More than 38% of county adults have a smoking habit, the fourth highest share of any county in the United States. With 22,159 years of life lost before age 75 for every 100,000 people in the county, premature death is more common in Todd than in all but only three other U.S. counties.

Economic conditions also play a role in residents’ poor health. Low incomes can dramatically limit an individual’s options in food and medical care, and incomes in Todd County are among the lowest in the country. The typical household in Todd makes $27,481 a year, far less than the statewide median household income of $51,059 and the national $53,700 median income.

42. Tennessee
> Least healthy county: Lauderdale
> Pct. without health insurance: 15.4%
> Pct. limited access to healthy food: 5.3%
> Obesity rate: 38.2%
> 2015 unemployment rate: 9.9%

Lauderdale is the least healthy county in a fairly unhealthy state. The county’s 28.9% smoking rate is the highest in Tennessee, and the 38.2% adult obesity rate is higher than the 32.2% state obesity rate. On average, Lauderdale residents report feeling in poor physical health for 5.6 days in poor mental health for 5.1 days every month, each some of the highest figures in the country. Lauderdale County’s infant mortality rate — a reflection of poor health and health care — is the seventh highest in the United States. For every 1,000 live births, 16 infants die before the age of one, an infant mortality rate roughly double that of the state’s and closer to that of developing Latin American countries.

43. Texas
> Least healthy county: Brooks
> Pct. without health insurance: 24.9%
> Pct. limited access to healthy food: 10.5%
> Obesity rate: 29.1%
> 2015 unemployment rate: 7.6%

Brooks County is not only the least healthy county in Texas, but one of the least healthy in the United States. It is one of just two counties in the nation in which more than 40% of residents report being in fair to poor health, a much larger larger share than the 14% of Americans who report similar health. Also, 21.2% of adults in Brooks have diabetes, the fourth largest share of any U.S. county. Like many of the least healthy counties, Brooks is relatively poor. The typical household makes just $27,875 a year, almost half of what the typical American household makes. Brooks is located near the U.S.-Mexico border and is almost entirely Hispanic. It is one of many border towns struggling with poverty and poor health outcomes.

44. Utah
> Least healthy county: San Juan
> Pct. without health insurance: 21.1%
> Pct. limited access to healthy food: 27.5%
> Obesity rate: 25.6%
> 2015 unemployment rate: 7.5%

San Juan County illustrates the impact poor economic conditions can have on the collective health of a population. Income and health insurance are often dependent on employment. Consequently, unemployment can limit the number of healthy options an individual has. The 7.5% unemployment rate in Utah’s least healthy county is nearly double the 3.8% statewide unemployment rate. Also, more than 21% of county residents under 65 do not have health insurance, a considerably larger share than the 15.3% of state residents without insurance. Similarly, nearly 20% of county residents struggle to afford food compared to a statewide food insecurity rate of 14.6%.

45. Vermont
> Least healthy county: Orleans
> Pct. without health insurance: 11.1%
> Pct. limited access to healthy food: 5.5%
> Obesity rate: 29.9%
> 2015 unemployment rate: 6.4%

Rural areas tend to be poorer, and residents often have lower access to services. While people are not especially unhealthy in Vermont, rural living in Orleans may have contributed to the residents’ relatively poor health. While just under 20% of Americans live in rural areas, 61% of Vermonters do, and in Orleans, 85% of residents live outside of cities and suburban neighborhoods. Orleans residents also earn lower incomes, which may also make staying healthy more difficult. The typical household in Orleans earns $42,089 a year, well below the median household income across the state, which at $54,153 is higher than the national figure. On the other hand, Orleans is one of the safest U.S. counties, with a violent crime rate of just 135 incidence per 100,000 people.

46. Virginia
> Least healthy county: Petersburg City
> Pct. without health insurance: 16.5%
> Pct. limited access to healthy food: 12.7%
> Obesity rate: 38.3%
> 2015 unemployment rate: 10.6%

Virginia has one of the lowest violent crime rates, at 200 incidents per 100,000 state residents. In Petersburg City, the state’s least healthy county, 560 violent crimes are reported per 100,000 people annually, higher than the state and national rates. Not only does violence often reflect poor economic conditions in an area, but also individuals who feel unsafe in their community are at greater risk of adverse health outcomes. The area’s unemployment rate of 10.6% is double the state’s jobless rate and well above the national jobless rate of 6.2%. Of adults living in Petersburg, more than one-quarter report being in poor or fair health, a far higher share than adults of the state or nationwide.

47. Washington
> Least healthy county: Ferry
> Pct. without health insurance: 23.6%
> Pct. limited access to healthy food: 22.8%
> Obesity rate: 27.4%
> 2015 unemployment rate: 11.7%

Financial distress is closely tied to adverse health outcomes. In Ferry, Washington’s least healthy county, 11.7% of workers are unemployed — nearly double both the state and national rates. With no cities or suburban areas, Ferry is 100% rural. Residents of rural areas tend to have lower incomes and are more likely to live in poverty. The availability of health services is also lower in these areas. In Ferry, there is only one primary care physician for every 1,900 people, well below the state and national proportions. Similarly, 23.6% of area residents do not have health insurance versus the statewide percentage of 15.9%.

48. West Virginia
> Least healthy county: McDowell
> Pct. without health insurance: 20.2%
> Pct. limited access to healthy food: 2.4%
> Obesity rate: 40.1%
> 2015 unemployment rate: 12.9%

More than one-third of adults in West Virginia are obese, the third highest rate of all states. In McDowell, the state’s least healthy area, the obesity rate is even higher, at two in every five adults. Also, more than 30% of area adults smoke, well above the statewide smoking rate of 23.9%, which is the highest of all states. Overweight individuals and tobacco users are at greater risk of disease and poor health outcomes, and the two factors may explain the considerably high incidence of premature death in McDowell. An estimated 20,157 years of life are lost per 100,000 people in the area annually due to preventable deaths, more than double the state estimate, which itself is nearly the highest compared with other states. Widespread poverty is likely at the root of the area’s poor health outcomes. Of children in McDowell, 46.2% live in poverty, the highest share of any county in the the state.

49. Wisconsin
> Least healthy county: Menominee
> Pct. without health insurance: 17.0%
> Pct. limited access to healthy food: 18.4%
> Obesity rate: 41.0%
> 2015 unemployment rate: 13.1%

Rural areas, which frequently have fewer services to offer and smaller tax bases to support public institutions, are home to the least healthy people in a number of states. Menominee is no different. The 100% rural county is the least healthy in Wisconsin. More than 18% of area residents do not have access to affordable, quality food, several times higher than the statewide percentage of 4.8%. The Menominee economy is also struggling. Of area workers, 13.1% are unemployed and 44.2% of children in the county live in poverty, each considerably higher than the corresponding state and national rates. Weak socioeconomic factors such as these contribute to poor health outcomes. The incidence of premature death in Menominee is higher than in the vast majority of U.S. counties, and 28.2% of adults report a low quality of life, double the state and national shares.

50. Wyoming
> Least healthy county: Fremont
> Pct. without health insurance: 21.0%
> Pct. limited access to healthy food: 4.8%
> Obesity rate: 26.0%
> 2015 unemployment rate: 5.2%

Wyoming’s least healthy county is Fremont, which is home to part of the Wind River Indian Reservation. More than one in every five county residents identifies as American Indian, far higher than the statewide and national proportions. Residents of reservations frequently struggle far more than others with poverty and poor access to services. Since poor, minority, young women are the most likely to have unwanted pregnancies, the prevalence of teen births in an area often reflects poor social and economic conditions. In Fremont, the teen birth rate is 66 for every 1,000 teen women, considerably higher than the state and national rates. Compared to residents across the state, people in Fremont are more likely to struggle to afford food as well.

For the state’s least healthy county, Fremont residents have relatively healthy habits. The smoking and excessive alcohol use rates are in line with or lower than the state and national shares.

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