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.

20. Pharr, Texas
> Heart disease incidence: 7.5%
> Current lack of health insurance: 47.6%
> Smoking: 15.7%
> Obesity: 39.8%
> Adults who report poor physical health: 18.2%

Pharr, a city of about 80,000 people, has the largest share of the population without health insurance. Research shows a connection between less care of hypertension and diabetes, two conditions that increase the risk of heart disease. The city has the third highest share of adults who have been diagnosed with diabetes, at just over 17% of the population, compared to the national share of 9.3% of adults who have been diagnosed.

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19. Laredo, Texas
> Heart disease incidence: 7.5%
> Current lack of health insurance: 43.6%
> Smoking: 17.3%
> Obesity: 40.2%
> Adults who report poor physical health: 17.7%

Laredo is another example of a correlation between lack of health insurance — it has the third highest share of working-age adults without insurance among the 500 largest U.S. cities — and incidence of heart disease. Also, similarly to Pharr, close to 17% of adults in the city have been diagnosed with diabetes — the fifth highest rate among the 500 cities included in the database. Diabetics are two to four times more likely to die from heart disease because they often have high blood pressure and high LDL cholesterol (the bad kind).

18. Passaic, New Jersey
> Heart disease incidence: 7.5%
> Current lack of health insurance: 33.2%
> Smoking: 20.5%
> Obesity: 37%
> Adults who report poor physical health: 18.1%

Lack of exercise is a major cause of chronic disease. Over 42% of adults in Passaic report they don’t take time for physical activity, the second highest rate among the 500 largest U.S. cities after Camden, New Jersey. Among all American adults, the share is 25.5%. The American Heart Association recommends a minimum of 150 minutes per week of moderate exercise — about 21 minutes a day — or 75 minutes per week of vigorous exercise.

17. Springfield, Massachusetts
> Heart disease incidence: 7.5%
> Current lack of health insurance: 17.9%
> Smoking: 24%
> Obesity: 36.6%
> Adults who report poor physical health: 17.8%

A third of the adults in Springfield have been diagnosed with high cholesterol. The body needs some cholesterol to build cells and produce hormones, but too much causes a problem for the heart. An excess of the fat-like waxy substance builds up in the walls of the arteries, causing cardiovascular disease. Also, about 35% of adults in Springfield report no leisure-time physical activity, compared to the 25.5% of adults nationwide who do not exercise during their free time.

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16. Hammond, Indiana
> Heart disease incidence: 7.5%
> Current lack of health insurance: 23.8%
> Smoking: 23.1%
> Obesity: 36.9%
> Adults who report poor physical health: 16.2%

While the rate of heart disease among Americans decreased nationwide from 6.0% of adults to 5.6% of adults, in Hammond, however, the rate of heart disease increased slightly between 2014 and 2015. No single factor clearly stands out as the culprit in Hammond’s high incidence of heart disease. Rather, a combination of very high rates of several factors are collectively driving up the risk of the illness. The city has among the highest shares high blood pressure, high cholesterol, and a lack of health insurance.

15. Muncie, Indiana
> Heart disease incidence: 7.5%
> Current lack of health insurance: 17.3%
> Smoking: 26.7%
> Obesity: 37%
> Adults who report poor physical health: 15.8%

Muncie has one of the highest rates of heart disease incidence in the country, and it also is one in a minority of major cities where the rate of heart disease went up, albeit just slightly, even as the national share went down.

About 35% of the adults who have been screened for high cholesterol in the last five years have the condition — the 11th highest rate among the 500 cities in the database.

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14. Albany, Georgia
> Heart disease incidence: 7.5%
> Current lack of health insurance: 24.5%
> Smoking: 24.9%
> Obesity: 41.4%
> Adults who report poor physical health: 17.0%

More than 40% of adults in Albany are obese — the sixth highest share among the 500 largest U.S. cities. Obesity is perhaps the greatest factor contributing to heart disease, according to Arashvand. This is because it is linked to several factors known to contribute to coronary artery disease and stroke, such as metabolic syndrome, high blood pressure, impaired glucose tolerance, and high blood lipids (fat).

13. Springdale, Arkansas
> Heart disease incidence: 7.5%
> Current lack of health insurance: 21.5%
> Smoking: 23.8%
> Obesity: 32.7%
> Adults who report poor physical health: 16.2%

Springdale may be one of the nation’s heart disease capitals but it actually is making some progress in reducing incidence of the disease. The rate of coronary heart disease among adults decreased between 2014 and 2015 by 0.5 percentage points, slightly faster than the national decline of 0.4 percentage points over the same period.

12. Fort Smith, Arkansas
> Heart disease incidence: 7.6%
> Current lack of health insurance: 18.7%
> Smoking: 23.1%
> Obesity: 32.2%
> Adults who report poor physical health: 16.6%

The share of adults who reported ever having been diagnosed with angina or coronary heart disease went down by 0.4 percentage points between 2014 and 2016. All five major cities in Arkansas on the list have seen a decrease in the illness incidence while their populations increased.

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11. Birmingham, Alabama
> Heart disease incidence: 7.6%
> Current lack of health insurance: 19.8%
> Smoking: 24.6%
> Obesity: 42.7%
> Adults who report poor physical health: 16.4%

About a third of adults in Birmingham have arthritis. Similarly to heart disease, arthritis is an inflammation process. This is why people with arthritis are at a greater risk of developing heart disease, including irregular heartbeats, high blood pressure, heart failure and plaque in the arteries. More than half of premature deaths in people with rheumatoid arthritis result from cardiovascular disease.

10. Canton, Ohio
> Heart disease incidence: 7.7%
> Current lack of health insurance: 15.7%
> Smoking: 27.8%
> Obesity: 38.3%
> Adults who report poor physical health: 16.6%

Canton also has a high proportion of adults with arthritis — the sixth highest on the list — but it also has a large number of people smoking — over 10%, the fourth highest rate. Smoking is a major contributor to coronary heart disease because the chemicals in the smoke cause the blood to thicken and form clots, blocking circulation.

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9. Macon, Georgia
> Heart disease incidence: 7.9%
> Current lack of health insurance: 25.5%
> Smoking: 25.8%
> Obesity: 41.2%
> Adults who report poor physical health: 17.9%

Macon is in the top 20 for many health conditions that pose a high risk for developing heart disease. One that particularly stands out is stroke. Close to 6% of the adult population have had a stroke, the third highest rate among the 500 largest U.S. cities. Stroke is associated with coronary heart disease because both share common risk factors, such as high LDL (bad) cholesterol, high blood pressure, diabetes, and being overweight.

8. Cleveland, Ohio
> Heart disease incidence: 8.2%
> Current lack of health insurance: 19.9%
> Smoking: 28.3%
> Obesity: 40.1%
> Adults who report poor physical health: 17.9%

Cleveland has a high rate of adults who have had a stroke — 5.3%, the sixth highest share among major cities. Also, many city residents smoke too — 28.3%, the fourth highest share. High blood pressure is also very common in the city — almost 69% take medication for it, the ninth highest share among major cities.

7. Camden, New Jersey
> Heart disease incidence: 8.3%
> Current lack of health insurance: 30.3%
> Smoking: 26.8%
> Obesity: 40.9%
> Adults who report poor physical health: 19.4%

In Camden, 41.8% of adults have high blood pressure, the ninth highest share among major cities and well above the 29.4% of American adults who do. Almost 45% of adults in the New Jersey city don’t exercise in their spare time — the highest rate of lack of physical activity on the list. Also, Camden has the second highest rate of adults with diabetes. The city is also in the top 10 for obesity among adults.

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6. Gary, Indiana
> Heart disease incidence: 8.3%
> Current lack of health insurance: 23.3%
> Smoking: 26.9%
> Obesity: 45.2%
> Adults who report poor physical health: 18.3%

Of all 500 cities on the list, Gary has the highest rate of diabetes — 18.4%; the second highest stroke rate among adults — 5.9%; and the third highest rate of people with high blood pressure. Hypertension can lead to hardened arteries, stroke, or heart attack because the force with which the heart is pushing blood through arteries is too high.

5. Dayton, Ohio
> Heart disease incidence: 8.4%
> Current lack of health insurance: 17.1%
> Smoking: 27.5%
> Obesity: 39.7%
> Adults who report poor physical health: 17.7%

Cardiovascular disease accounts for 37% of all deaths in the state, compared with a quarter of deaths nationwide. The Ohio Department of Health supports several initiatives to reduce the risk, and they may have been a factor in the positive effect between 2014 and 2015. All nine cities in Ohio on the list had a decrease in the incidence of heart disease. Dayton’s share fell by 0.2 percentage points, which was not enough to keep the city from having one of the five highest shares among the nation’s major cities.

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4. Youngstown, Ohio
> Heart disease incidence: 8.5%
> Current lack of health insurance: 21.0%
> Smoking: 30.6%
> Obesity: 40.6%
> Adults who report poor physical health: 18.7%

Youngstown was No. 1 on the list of cities with the highest rates of heart disease in 2014. The slight improvement of 0.1% brought it down to fourth place a year later. A combination of several factors associated with heart disease help keep the city in the top five, including a high rate of chronic obstructive pulmonary disease, at 10.8% of adults — the second highest among the 500 largest U.S. cities. COPD is linked to a higher risk of heart conditions due to elevated pulse rates during both rest and exercise.

3. Reading, Pennsylvania
> Heart disease incidence: 8.6%
> Current lack of health insurance: 31.5%
> Smoking: 26.3%
> Obesity: 43.8%
> Adults who report poor physical health: 19.4%

Of the seven cities in Pennsylvania on the list, Reading is the only one where the rate of heart disease went up between 2014 and 2015, although by just 0.1 percentage point. The city’s problems with heart disease extent to wider health issues. Among Reading adults, 19.1% report at least 14 days of poor health per year, the highest share of all 500 cities in the database.

2. Detroit, Michigan
> Heart disease incidence: 8.6%
> Current lack of health insurance: 23.6%
> Smoking: 31.4%
> Obesity: 45.1%
> Adults who report poor physical health: 18.7%

Among the 500 largest U.S. cities, Detroit has the third highest adult diabetes rate, the second highest arthritis and obesity rates, and the highest rates of high blood pressure and smoking. Also, Detroit is No. 2 in people with asthma, which has been linked to a 57% higher risk of heart disease.

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1. Flint, Michigan
> Heart disease incidence: 8.7%
> Current lack of health insurance: 21.8%
> Smoking: 31.5%
> Obesity: 42.0%
> Adults who report poor physical health: 18.9%

The lead contamination crisis in Flint may help partially explain why the city has the highest share of heart disease incidence of any major city. Chronic exposure to lead and higher concentrations of lead in blood cause hypertension, ECG abnormalities, peripheral arterial disease, and cardiovascular disease. Flint has the highest rates of arthritis (34.9%), asthma (13.4%), chronic obstructive pulmonary disease (10.9%), and smoking (31.5%) — all of which significantly increase the risk of heart disease.

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