Issue Category: Obesity/Chronic Disease
Trust for America’s Health Releases Issue Brief on Preventive Services
Washington, D.C., March 30, 2017 –Impact of the 2017 Health Reform Proposals on Clinical Preventive Services, released today by Trust for America’s Health (TFAH), reviews the current status of public and private insurance coverage of preventive services, and what would be at stake if they were eliminated or reduced, either through legislation or administrative actions.
The Affordable Care Act (ACA) expanded coverage of a range of effective, targeted preventive services to make them accessible to millions of Americans.
- As of 2015, around 137 million private insured Americans received guaranteed preventive services without cost sharing. Small and individual insurances plans are required to cover 10 Essential Health Benefits, such as blood pressure screenings and well care visits, and non-grandfathered individual, small and large plans are required to cover evidence-based services with top effectiveness ratings, recommended vaccines and preventive maternal and child health coverage (Section 2713 Preventive Services).
- The 14 million Americans covered via Medicaid expansion qualify for no-cost coverage of Essential Health Benefits, other top rated preventive services and tobacco cessation services. States determine coverage of preventive services for enrollees in traditional Medicaid plans.
“For too long, America has propped up a sick care system. Instead of prioritizing keeping people healthy in the first place, we’ve waited until they get sick—often with chronic, debilitating and expensive conditions—and then paid the price,” said John Auerbach, president and CEO, TFAH. “Research tells us time and again two truths: Americans with coverage of preventive services are more likely to access these services and investing in preventive services improves health and reduces costs, yielding massive returns on investment.”
According to the brief, a range of proposals could potentially lead to millions of Americans losing access to preventive services – either through reductions or changes in requirements or as part of losing health insurance coverage. Studies have shown that expanding coverage for preventive services contributes to an uptick in routine exams; screenings for blood pressure, cholesterol and diabetes; use of flu shots; and annual dental exams. Examples of some outcomes of preventive services include:
- Among the Medicaid population in Massachusetts, an evidence-based, Medicaid tobacco-cessation benefit was associated with a reduction in smoking rates and an estimated $3.12 in medical savings from averted cardiovascular hospitalizations alone for each dollar spent.
- The Diabetes Prevention Program reduced risk for developing type-2 diabetes by 58 percent. Even after 10 years, people who completed the program were one-third less likely to develop type 2 diabetes.
- Comprehensive prenatal maternal care helps reduce premature birth and infant mortality rates.
- Vaccines prevented an estimated 322 million illnesses, 21 million hospitalizations and 732,000 deaths among children born in the U.S. between 1994 and 2013 – and yield a net savings of $295 billion in direct costs and $1.38 trillion in societal costs.
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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.
TFAH Statement: Strongly Opposed to the House Obamacare Replacement Bill
Washington, D.C., March 7, 2017 – The below is a statement from John Auerbach, president and CEO, of Trust for America’s Health (TFAH).
“We are strongly opposed to the House Obamacare Replacement bill, which would repeal significant portions of the Affordable Care Act (ACA), including the Prevention and Public Health Fund.
Under this plan, millions of people could lose health insurance—a devastating blow to the health of many of our nation’s most vulnerable individuals and families. Without affordable insurance coverage we will see increased levels of preventable illnesses, injuries and deaths.
In addition, eliminating the Prevention Fund would erase 12 percent of the Centers for Disease Control and Prevention’s (CDC) budget. Of that investment, $625 million directly supports state and local public health efforts to fight preventable diseases such as diabetes, heart disease and cancer.
Losing this funding would wreak havoc on our efforts to reduce chronic disease rates, immunize our children, stop the prescription drug and opioid epidemic and prepare the public health system to prevent infectious disease outbreaks.
We know how to prevent many chronic and infectious illnesses—which make up a significant portion of the $3 trillion the nation spends yearly on healthcare. If we lose access to health care coverage and to the Prevention Fund, our children, families and communities will suffer and ultimately costs will rise.
The bottom line? This Bill would make untold numbers of the American people less healthy.”
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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.
TFAH Statement on the Draft House Republican Obamacare Replacement Bill: Our Nation’s Health Will Suffer
Washington, D.C., February 24, 2017 – The below is a statement from John Auerbach, president and CEO, of Trust for America’s Health (TFAH).
“The draft House Republican Obamacare replacement bill—which would eliminate the Prevention and Public Health Fund—would threaten the health of American children, families and communities.
Thanks to the Prevention Fund, hundreds of thousands of Americans benefit from increased access to vaccines and other preventive health services. Quite simply, more people are getting and remaining healthy because of the Prevention Fund.
Yet, the proposed replacement bill would eliminate this important Fund and 12 percent of the U.S. Centers for Disease Control and Prevention’s (CDC) budget along with it.
And, without the Prevention Fund, states will lose substantial sums of money—totaling as much as $3 billion over the next 5 years—which fight growing epidemics and emerging diseases.
Every year, we spend $3 trillion on healthcare, yet millions suffer from chronic diseases and death rates among Blacks and other people of color remain too high. At the same time, death rates among white middle-aged Americans increased for the first time in decades, mainly due to preventable conditions.
Time and again research shows that the vast majority of these conditions—heart disease, diabetes and others—can be prevented by investing in addressing the root causes. Yet, the country has repeatedly failed to do so.
The nation cannot afford to trade away our single best investment in preventing disease, preparing for and responding to infectious disease outbreaks, reducing rates of chronic illness, and saving lives and money.
If this draft becomes law, our nation’s health will suffer—and it will be exponentially harder to fight growing epidemics, like the rise in prescription drug and heroin overdoses.”
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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.
Survey Finds 73 Percent Support Investments to Improve Health; Obesity, Future Health of Children Top Concerns
Washington, D.C., January 19, 2017 —A new national survey of registered voters has found that nearly three-quarters (73 percent) of Americans support increasing investments to improve the health of communities. Support spans across party lines (57 percent of Republicans, 87 percent of Democrats and 70 percent of Independents) and regionally across the country (75 percent in the Northeast, 71 percent in the Central U.S., 72 percent in the South, and 75 percent in the West). Women are the strongest proponents of supporting health improvement efforts (62 percent of Republican women, 87 percent of Democratic women and 80 percent of Independent women).
The survey, released today by the Robert Wood Johnson Foundation and the Trust for America’s Health, was conducted by Greenberg Quinlan Rosner Research, in consultation with Bellweather Research, on September 8-9, 2016 of a nationwide sample of 1302 registered voters across the country.
A majority (51 percent) believe that today’s children will be less healthy than previous generations when they reach adulthood. The groups who hold this belief most strongly include: Republicans (55 percent); rural residents (60 percent); Southerners (57 percent); Independent women (62 percent); and Black women (68 percent). Most registered voters with children under age 18, however, believe their own children are very healthy (92 percent give an 8-10 rating on a 10-point scale); this is the case for parents of all ideologies, incomes, education levels, and ethnicities.
Additionally, 64 percent believe that the number of health issues facing the country has grown in recent years. Obesity is the top health concern (41 percent), cancer ranked second (33 percent), followed by heart disease and stroke (14 percent) and diabetes and substance misuse (both at 11 percent).
Americans also rate their own health better than the health of the community where they live (66 percent rate their own health as 8-10 (very good) on a 10 point scale, but only 36 percent rank their community’s health as very good). There are differences based on income, age, education and area of the country on how people rank their health. For instance:
- 73 percent of college-educated Whites rank their health as very good compared to 57 percent of Whites without college degrees; and
- 72 percent of individuals with a household income above $50,000 per year rank their health as very good compared to 59 percent of those with incomes below $50,000.
A majority of American registered voters also strongly support (rating 8-10 out of a 10 point scale) a range of priorities and strategies for improving health, including:
- 74 percent of people highly support providing enough time — during the school day and afterschool – for kids’ physical education, physical activity or community sports;
- 74 percent also highly support creating partnerships among farmers, food suppliers and community health groups to bring fresh produce trucks or mobile markets to communities that lack access to grocery stores;
- 65 percent highly support providing kids with more information on making healthy food choices and being physically active;
- 63 percent highly support investing more in preventing obesity and chronic diseases like heart disease, diabetes and stroke;
- 62 percent highly support increasing early childhood health programs, including home visit programs, mobile health screenings and treatment for diseases like asthma;
- 61 percent highly support investing more in preventing the spread of infectious diseases like the Zika virus, bird flu and hepatitis;
- 60 percent highly support treating substance use, including addiction to prescription painkillers and heroin, like a disease, not a crime;
- 60 percent highly support planning for building more parks, walking and biking trails and other recreation areas for people to be physically active in all communities;
- 60 percent highly support increasing access to safe and affordable housing and routinely testing for things that create health problems in homes, like lead in water and paint, carbon monoxide, and harmful chemicals in the air;
- 59 percent highly support increasing incentives that encourage business owners to open grocery stores in communities that lack access to healthy food options; and
- 58 percent highly support building local partnerships across businesses, health systems, schools and community organizations to address specific health problems in communities.
Methodology: On behalf of the Robert Wood Johnson Foundation and the Trust for America’s Health, Greenberg Quinlan Rosner Research, in consultation with Bellwether Research, conducted a survey among 1,320 registered voters nationwide (1,019 weighted). The survey was conducted between September 8th and 19th, 2016. Voters were randomly selected from a list of registered voters and reached on a landline or cell phone depending on the number they designated on their voter registration. Interviews were conducted by live telephone interviewers; 50 percent were reached on a cell phone. Included in the sample were three oversamples: 100 Black voters, 100 Hispanic voters, and 100 White non-college voters. Upon completion of the survey, the results were weighted to bring the three oversamples into line with the racial and ethnic composition of registered voters nationwide. The data was weighted to reflect the total population of registered voters, taking into account regional and demographic characteristics according to known census estimates and voter file projections. The data are subject to a margin of error of +/- 3.1 percentage points. Full survey and topline results are available upon request.
For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter atwww.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.
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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.
Majority of States Score 6 or Lower Out of 10 Indicators in Report on Health Emergency Preparedness
Washington, D.C., December 20, 2016 – In Ready or Not? Protecting the Public from Diseases, Disasters and Bioterrorism, 26 states and Washington, D.C. scored a six or lower on 10 key indicators of public health preparedness.
The report, issued by the Trust for America’s Health (TFAH), found that the nation is often caught off guard when a new threat arises, such a Zika or the Ebola outbreak or bioterrorist threat, which then requires diverting attention and resources away from other priorities.
In the report, Alaska and Idaho scored lowest at 3 out of 10, and Massachusetts scored the highest at 10 out of 10, with North Carolina and Washington State scoring 9’s.
“Health emergencies can quickly disrupt, derail and divert resources from other ongoing priorities and efforts from across the government,” said Rich Hamburg, interim president and CEO, TFAH. “Many areas of progress that were made after 9/11 and the anthrax attacks to improve health security have been undercut. We aren’t adequately maintaining a strong and steady defense, leaving us unnecessarily vulnerable when new threats arise.”
Ready or Not? examines the nation’s ability to respond to public health emergencies, tracks progress and vulnerabilities, and includes a review of state and federal public health preparedness policies. Some key findings include:
- 26 states increased or maintained funding for public health from Fiscal Year (FY) 2014-2015 to FY 2015-2016.
- Just 10 states vaccinated at least half of their population (ages 6 months and older) against the seasonal flu during the 2015-2016 flu season (from July 2015 to May 2016).
- 45 states and Washington, D.C. increased the speed of DNA fingerprinting using pulsed-field gel electrophoresis (PFGE) testing for all reported cases of Shiga toxin-producing E. coli O157, a measure of a state’s ability to detect foodborne outbreaks.
- 10 states have a formal access program or a program in progress for getting private sector healthcare staff and supplies into restricted areas during a disaster.
- 30 states and Washington, D.C. met or exceeded the overall national average score (6.7) of the National Health Security Preparedness Index™ (as of 2016).
- 32 states and Washington, D.C. received a grade of C or above in States at Risk: America’s Preparedness Report Card, a national assessment of state-level preparedness for climate change-related threats – which have an impact on human health.
In addition, the report examined trends in public health preparedness over the last 15 years, finding successes and ongoing concerns.
- One-third of funds for health security and half of funds for healthcare system preparedness have been cut: Health emergency preparedness funding for states has been cut from $940 million in fiscal year (FY) 2002 to $660 million in FY 2016; and healthcare system preparedness funding for states has been cut by more than half since FY 2005 – down to $255 million.
- Some major areas of accomplishment: Improved emergency operations, communication and coordination; support for the Strategic National Stockpile and the ability to distribute medicines and vaccines during crises; major upgrades in public health labs and foodborne illness detection capabilities; and improvements in legal and liability protections during emergencies.
- Some major ongoing gaps: Lack of a coordinated, interoperable, near real-time biosurveillance system; insufficient support for research and development of new medicines, vaccines and medical equipment to keep pace with modern threats; gaps in the ability of the healthcare system to care for a mass influx of patients during a major outbreak or attack; and cuts to the public health workforce across states.
The Ready or Not? report provides a series of recommendations that address many of the major gaps in emergency health preparedness, including:
- Requiring strong, consistent baseline public health Foundational Capabilities in regions, states and communities—so that everyone is protected.
- Ensuring stable, sufficient health emergency preparedness funding to maintain a standing set of foundational capabilities alongside a complementary Public Health Emergency Fund which would provide immediate surge funding during an emergency.
- Improving federal leadership before, during and after disasters – including at the White House level.
- Recruiting and training a next generation public health workforce with expert scientific abilities to harness and use technological advances along with critical thinking and management skills to serve as the Chief Health Strategist for a community.
- Reconsidering health system preparedness for new threats and mass outbreaks by developing stronger coalitions and partnerships among providers, hospitals, insurance providers, pharmaceutical and health equipment businesses, emergency management, and public health agencies.
- Prioritizing efforts to address one of the most serious threats to human health by expanding efforts to stop Superbugs and antibiotic resistance.
- Improving rates of vaccinations for children and adults – which are one of the most effective public health tools against many infectious diseases.
Ready or Not? was released annually from 2003-2012, and more recently, TFAH has released Outbreaks: Protecting Americans from Infectious Diseases, from 2013-2015. The report was supported by a grant from the Robert Wood Johnson Foundation (RWJF).
Score Summary:
A full list of all of the indicators and scores and the full report are available on TFAH’s website. For the state-by-state scoring, states received one point for achieving an indicator or zero points if they did not achieve the indicator. Zero is the lowest possible overall score, 10 is the highest. The data for the indicators are from publicly available sources or were provided from public officials.
10 out of 10: Massachusetts
9 out of 10: North Carolina and Washington
8 out of 10: California, Connecticut, Iowa, New Jersey, Tennessee and Virginia
7 out of 10: Colorado, Delaware, Florida, Indiana, Maryland, Michigan, New Hampshire, New Mexico, New York, North Dakota, Oregon, Rhode Island, South Carolina, Utah and Wisconsin
6 out of 10: Arizona, Arkansas, District of Columbia, Georgia, Hawaii, Illinois, Kansas, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Montana, Nebraska, Ohio, Pennsylvania, Texas and Vermont
5 out of 10: Alabama, Missouri, Oklahoma, South Dakota and West Virginia
4 out of 10: Nevada and Wyoming
3 out of 10: Alaska and Idaho
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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.
Trust for America’s Health: Deeply Disappointed Congress Utilized the Prevention Fund as a 21st Century Cures Offset
Washington, D.C., December 7, 2016 – The below is a statement from Rich Hamburg, interim president and CEO, of Trust for America’s Health (TFAH) on the 21st Century Cures legislative package.
“TFAH is deeply disappointed Congress will utilize the Prevention and Public Health Fund as an offset for the legislative package known as 21st Century Cures. Cutting the Prevention Fund will limit the nation’s ability to improve health and quality of life and prevent disease.
While TFAH supports aspects of this legislative package, including the much-needed funds to address the opioid epidemic, we remain opposed to using the Prevention Fund to offset the cost of this legislation.
The Prevention Fund is inextricably tied to the nation’s future ability to reign in healthcare costs. This is the nation’s first and only substantial investment in moving from our current “sick care” system to a true preventive health system. The Prevention Fund should be dedicated to its intended purpose: helping all Americans stay healthy.
Despite the exponentially growing burden of largely preventable diseases, federal disease prevention and public health programs remain critically underfunded. Public health spending is still below pre-recession levels, having remained relatively flat for years. Today, more than 12 percent of the CDC budget is supplied through Prevention Fund investments, including the 317 immunization program, epidemiology and laboratory capacity grants and the entire Preventive Health and Health Services Block Grant program—all critical to preparing for and responding to public health emergencies.
The United States spends $3 trillion annually on healthcare without much to show for it: Millions of Americans suffer from chronic diseases, which are responsible for seven out of 10 deaths and $1.3 trillion in treatment costs and lost productivity every year.
And, two-thirds of Americans are overweight or obese and nearly 20 percent of Americans smoke. Obesity costs the country $147 billion and tobacco use leads to another $130 billion in healthcare spending each year.
Time and again research shows that the vast majority of these chronic diseases can be prevented by investing in addressing the root causes. Yet, the country has repeatedly failed to do so.
The nation cannot afford to trade away our single best investment in preventing disease, preparing for and responding to infectious disease outbreaks, reducing rates of chronic illness, and saving lives and money.”
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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.
Obesity Rates Among Young Children from Low-Income Families Declined in 31 States
Robert Wood Johnson Foundation and Trust for America’s Health Highlight Signs of Progress Among WIC Participants, but Emphasize Obesity Rates Remain Too High
Washington, D.C., November 17, 2016 – Obesity rates showed a statistically significant decrease in 31 states and three territories and increased significantly in four states among 2- to 4-year-olds enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) from 2010 to 2014, according to a study published today in Morbidity and Mortality Weekly Report (MMWR) by the Centers for Disease Control and Prevention (CDC) and U.S. Department of Agriculture (USDA).
Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) released a new data visualization showing how state-by-state obesity rates have changed among 2- to 4-year-old WIC participants since 2000 and a series of maps highlighting states’ efforts to help promote nutrition and physical activity in early child care settings.
“These data are encouraging because kids from lower-income families are especially vulnerable and often face higher risk for obesity,” said Donald F. Schwarz, MD, MPH, MBA, vice president, RWJF. “We must continue to track and analyze child obesity and the programs that aim to reduce rates, especially among our nation’s youngest kids. This is critical for informing efforts to address disparities and ensuring that all children—no matter who they are or where they live—have a healthy start from their very first days.”
Utah had the lowest rate of 2- to 4-year-old WIC participants who were obese at 8.2 percent, while Virginia had the highest rate at 20.0 percent, according to today’s findings.
Additional data on obesity rates among young children:
WIC
- 18 states have obesity rates at or above 15 percent among 2- to 4-year-old WIC participants (in 2014). In 2010, 26 states had a rate at or above 15 percent.
- While obesity rates among this population have declined in recent years, they remain high – with a national average of 14.5 percent. The national average was 8.4 percent in 1992.
NHANES
- These new data for young children from low-income families reflect the significant inequity in obesity and health related to income—the national obesity rate among 2- to 5-year-olds across all economic levels is 8.9 percent (from the National Health and Nutrition Examination Survey, 2014).
“It is heartening to see evidence of progress after decades of work,” said Rich Hamburg, interim president and CEO, TFAH. “However, this doesn’t mean we’ve accomplished our goal. We need to keep the momentum going to ensure young children and families have the support they need — through programs like WIC — that help improve access to healthy, affordable food, quality healthcare, home visiting programs and health and nutrition education programs.”
Last month, CDC released a new Early Care and Education State Indicator Report, tracking state policies that aim to prevent obesity in child care settings. Some key findings include:
- 38 states and Washington, D.C. have Quality Rating and Improvement Systems (QRIS) for child care programs, and, of those, 29 have included obesity prevention in their state standards;
- 41 states and Washington, D.C. offer online professional development training for early childhood education (ECE) providers that cover obesity prevention topics;
- 42 states and Washington, D.C. include ECE settings in their comprehensive plans for addressing chronic disease or nutrition and physical activity; and
- 28 states and Washington, D.C. encouraged enhanced nutrition standards in their Child and Adult Care Food Programs (CACFP) as of 2015.
In September 2016, RWJF and TFAH released State of Obesity 2016: Better Policies for a Healthier America, which included a detailed policy analysis of WIC and other related childhood nutrition and obesity prevention initiatives, noting that:
- WIC provides benefits — direct food assistance as well as counseling and education support — to approximately 8 million low-income individuals, including around 2 million pregnant and post-partum women, 2 million infants and 4 million children under age 5;
- For every dollar spent on pregnant women enrolled in the WIC program, up to $4.21 is saved in Medicaid spending;
- Around 15 million U.S. children live in “food-insecure” households, where they have limited access to adequate food and nutrition due to cost, proximity and/or other resources; and
- Food insecurity among families is particularly concentrated in different areas around the country — in 321 counties, the average food insecurity rate is 23 percent, while in the other 2,821 counties, the average rate is 15 percent. Fifty percent of the high food-insecurity counties are in rural areas, 26 percent are metropolitan and 90 percent are in the South.
The State of Obesity report includes recommended strategies and policies to help ensure all young children have the opportunity to maintain a healthy weight. Some key areas of emphasis include:
- Ensuring access to quality healthcare and family home visiting programs for at-risk families, which includes supporting early screening for health, nutrition and social service needs and connecting families directly to programs and resources;
- Nutrition assistance and education programs and healthy food financing initiatives to make healthy choices affordable and available for all families in all neighborhoods;
- Active living initiatives in communities that support places that are convenient and safe to be physically active;
- Supporting healthy nutrition and physical activity in all child care settings, including limiting screen time, eliminating sugar-sweetened beverages and implementing the updated standards from the Child and Adult Care Food Program and Child Care and Development Block Grant; and
- Prioritizing early childhood education opportunities under the Every Student Succeeds Act (ESSA).
Data released today are from the WIC Participant and Program Characteristics Study (WIC PC) as reported in an analysis of the Morbidity and Mortality Weekly Review. WIC PC summarizes the demographic information of WIC participants and is based on measured height and weight data. Women, infants and children in families with incomes at or below 185 percent of the federal poverty level (FPL) who are at nutritional risk are eligible for the WIC program (FPL is $24,250 for a family of four); some participants become income eligible for WIC through participation in other programs based on income or other economic variables programs. Further analysis of the WIC program and changes in participation levels could provide additional evidence on the factors that helped contribute to the decline in obesity rates.
Follow the conversation at #StateofObesity.
Trust for America‘s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.
For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.
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2014 STATE-BY-STATE OBESITY RATES OF WIC PARTICIPANTS AGES 2-4
Based on an analysis of new state-by-state data from the WIC Participant and Program Characteristics Study (WIC PC), obesity rates for children ages 2-4 by state from highest to lowest were:
1. Virginia (20.0); 2. Alaska (19.1); 3. Delaware (17.2); 4. South Dakota (17.1); 5. Nebraska (16.9); 6. (tie) California (16.6) and Massachusetts (16.6); 8. Maryland (16.5); 9. West Virginia (16.4); 10. (tie) Alabama (16.3) and Rhode Island (16.3); 12. (tie) Connecticut (15.3) and 12. New Jersey (15.3); 14. Illinois (15.2); 15. (tie) Maine (15.1) and 15. New Hampshire (15.1); 17. (tie) North Carolina (15.0) and Oregon (15.0); 19. (tie) Tennessee (14.9) and Texas (14.9); 21. (tie) Iowa (14.7) and 21. Wisconsin (14.7); 23. Mississippi (14.5); 24. (tie) Arkansas (14.4) and North Dakota (14.4); 26. (tie) Indiana (14.3) and New York (14.3); 28. Vermont (14.1); 29. Oklahoma (13.8); 30. Washington (13.6); 31. Michigan (13.4); 32. (tie) Arizona (13.3) and Kentucky (13.3); 34. Louisiana (13.2); 35. Ohio (13.1); 36. (tie) District of Columbia (13.0) and Georgia (13.0) and Missouri (13.0); 39. Pennsylvania (12.9); 40. Kansas (12.8); 41. Florida (12.7); 42. (tie) Montana (12.5) and New Mexico (12.5); 44. Minnesota (12.3); 45. (tie) Nevada (12.0) and South Carolina (12.0); 47. Idaho (11.6); 48. Hawaii (10.3); 49. Wyoming (9.9); 50. Colorado (8.5); 51. Utah (8.2).
Note: 1 = Highest rate, 51 = lowest rate.