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December 10, 2014 10:52 AM EST

In some ways, Americans today are healthier than they were in 1990, when the United Health Foundation first published America’s Health Rankings, an annual state-by-state assessment of our nation’s health. Cardiovascular and cancer deaths are down, and the smoking rate has decreased 36%. Plus, life expectancy is at an all-time high—78.7 years. “But although we’re living longer, we’re also living sicker, with preventable illness at an alarming level,” says Reed Tuckson, MD, external senior medical advisor to United Health Foundation. The number-one reason: Obesity. “Since 1990, the obesity rate went from 11.6% to 29.4%, a 153% increase,” Dr. Tuckson says. In the last year alone, it rose 7%. Physical inactivity is also at a new high: 23.5% of Americans do not exercise at all.

Read on for the states that are doing it right—and the 10 that have a lot more work to do to improve their health.

The 10 Most Healthy States

10. Nebraska

2013 Rank: 11
Change: +1

Nebraska is among the healthiest states in America in 2014, coming in at number 10 (a slight increase over last year). Nebraska has a low rate of drug deaths, high rate of high school graduation, and high immunization coverage among children.

Challenges:
High prevalence of binge drinking
High incidence of Salmonella
Large disparity in health status by education level

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9. North Dakota

2013 Rank: 9
Change: None

North Dakota is the ninth most-healthy state in the U.S. this year, thanks to its low rate of drug deaths, high immunization coverage among teens, and low prevalence of low birth weight. North Dakota also came in ninth in 2013.

Challenges:
High prevalence of binge drinking
High prevalence of obesity
High occupational fatalities rate

8. Colorado

2013 Rank: 8
Change: None

Colorado is known for its outdoor activities—hiking, skiing, biking—so it should come as no surprise that the state has the lowest rates for obesity and diabetes in the United States. It ranks eighth for the second year in a row.

Challenges:
High prevalence of binge drinking
High prevalence of low birth weight
Large disparity in health status by education level

7. New Hampshire

2013 Rank: 5
Change: -2

New Hampshire comes in at number seven, and is just one of several New England states to rank in the top 10 for 2014. New Hampshire residents are more active than most Americans, enjoy a low rate of infectious disease, and have a low infant mortality rate. There is also high immunization coverage among teens.

Challenges:
High prevalence of binge drinking
High rate of drug deaths
Low per capita public health funding

6. Minnesota

2013 Rank: 3
Change: -3

Minnesota is known for its bitterly cold winters, but that doesn’t stop residents of this snowy state from keeping active, which also helps the state have one of the lowest obesity and diabetes rates in the nation. Minnesota also has a low rate of drug deaths.

Challenges:
High prevalence of binge drinking
High incidence of pertussis
Low per capita health funding

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5. Utah

2013 Rank: 6
Change: +1

Fewer people smoke in Utah than in any other state. Utah also has the second-lowest diabetes rate, the fourth-lowest obesity rate, a low percentage of children in poverty, and a low rate of preventable hospitalizations.

Challenges:
High rate of drug deaths
Low immunization coverage among teens
Limited availability of primary care physicians

4. Connecticut

2013 Rank: 7
Change: +3

Connecticut, the 4th-healthiest state in the U.S. this year, has a low prevalence of smoking, high immunization coverage among children, and a low occupational fatalities rate.

Challenges:
High prevalence of binge drinking
High rate of preventable hospitalizations
Large disparity in health status by education level

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3. Massachusetts

2013 Rank: 4
Change: +1

Massachusetts is the third-healthiest state in the nation in 2014. In the past two years, drug deaths have decreased by 9% and the rate of physical inactivity has decreased 11%. Massachusetts also has more residents with health insurance than any other state.

Challenges:
High prevalence of binge drinking
High rate of preventable hospitalizations
Large disparity in health status by education level

2. Vermont

2013 Rank: 2
Change: None

The runner-up—and the healthiest state in the continental U.S.—is Vermont. Vermont has the highest high school graduation rate in the country, a low percentage of children in poverty, and a low violent crime rate. In the last year, binge drinking has decreased 11% (though it’s still a challenge), and in the last two years, smoking has declined by 13%.

Challenges:
High prevalence of binge drinking
Low immunization coverage among children
Large disparity in health status by education level

1. Hawaii

2013 Rank: 1
Change: None

For the second year in a row, Hawaii earns the honor of healthiest state in America. Relatively few people in the Aloha State are obese, the cancer rate is low, and the state has the lowest rate of preventable hospitalizations in the country. Smoking has decreased by 21% in the last two years, and binge drinking has declined by 15%.

Challenges:
High prevalence of binge drinking
High incidence of infectious disease
Low immunization coverage among children

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The 10 Least Healthy States

41. Indiana

2013 Rank: 41
Change: None

With 31.8% of adults obese, 28.3% of adults never exercising, and a huge air pollution problem, Indiana comes in at number 41.

Strengths:
Low incidence of infectious disease
Low percentage of children in poverty
High immunization coverage among teens

42. South Carolina

2013 Rank: 43
Change: +1

Coming in at 42, South Carolina is struggling to keep its children healthy: it has a low rate of high school graduation, high prevalence of low birth weight, and ranks in the bottom half of the states for the immunization of children. It also has high rates of obesity, diabetes, and physical inactivity.

Strengths:
Low prevalence of binge drinking
Low incidence of pertussis
Low rate of preventable hospitalizations

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The 10 Least Healthy States

43. Alabama

2013 Rank: 47
Change: +4

Ranking 43rd overall, Alabama has the highest diabetes rate in the nation, at 13.8% of adults—a 17% increase over the last two years. The state also has a high prevalence of low birth weight and a limited availability of dentists.

Strengths:
Low prevalence of binge drinking
High immunization coverage among children
Small disparity in health status by education level

44. West Virginia

2013 Rank: 46
Change: +2

With 27.3% of the adult population lighting up, West Virginia has the highest prevalence of smoking in America. It also has more drug deaths than any other state, as well as the second-highest obesity rate.

Strengths:
Low prevalence of binge drinking
Low incidence of infectious disease
High per capita health funding

45. Tennessee

2013 Rank: 42
Change: -3

Tennessee ranks 50th for violent crime, 49th for physical inactivity, 47th for obesity, and 45th overall.

Strengths:
Low prevalence of binge drinking
Low incidence of pertussis
Ready availability of primary care physicians

46. Oklahoma

2013 Rank: 44
Change: -2

Ranking 46th, the Sooner State has a high prevalence of physical inactivity, low immunization coverage among children, and a limited availability of primary care physicians. Since 1990, violent crime has increased 12%, while the nationwide rate dropped 37% during the same time period.

Strengths:
Low prevalence of binge drinking
Low incidence of pertussis
Low prevalence of low birth weight

47. Kentucky

2013 Rank: 45
Change: -2

While lots of people in Kentucky smoke, very few of them exercise, a combination that lands the Bluegrass State at number 47. Kentucky also suffers from a high percentage of children in poverty and a high rate of preventable hospitalizations.

Strengths:
Low prevalence of binge drinking
Low violent crime rate
High immunization coverage among children

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48. Louisiana

2013 Rank: 48
Change: None

Louisiana ranks 48th in 2014 thanks to its high incidence of infectious disease, high prevalence of low birth weight, and high rate of preventable hospitalizations.

Strengths:
Low incidence of pertussis
High immunization coverage among teens
Small disparity in health status by education level

49. Arkansas

2013 Rank: 49
Change: None

Coming in second to last—same as in 2013—Arkansas has a high incidence of infectious disease, a limited availability of dentists, and low immunization coverage among children. Additionally, obesity has increased 12% over the last two years.

Strengths:
Low prevalence of binge drinking
High per capita public health funding
Small disparity in health status by education level

50. Mississippi

2013 Rank: 50
Change: None

For the third year in a row, the least-healthy state in the U.S. is Mississippi. Mississippi ranks last on six measures: physical inactivity, rate of infectious disease, low birthweight, infant mortality, cardiovascular deaths, and premature deaths.

Strengths:
Low prevalence of binge drinking
High immunization coverage among children
Small disparity in health status by education level

This article originally appeared on Health.com

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