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Cardiovascular disease—principally heart disease and stroke—is the number one cause of death in the United States. In 2002, it was responsible for 38% of the 2.4 million deaths in the nation. But epidemiological studies show that cardiovascular disease (CVD) does not always strike randomly. More people die of CVD in Mississippi than any other state in the nation. In 2001, CVD accounted for 43% of the deaths in the Magnolia State, more than cancers, suicides, traffic injuries, and AIDS combined.

Mississippi holds the title of America’s unhealthiest state. According to Mississippi’s latest “State of the Heart Report,” 7 out of 8 Mississippi adults over the age of 45 have at least one major risk factor for cardiovascular disease (CVD). And America’s Health Rankings, the longest running annual assessment of health on a state-by-state basis, has placed Mississippi in the bottom 5 since 1990, when the rankings began. The rankings cite a high prevalence of obesity (33.3%), as well as a high rate of deaths from CVD (378.5 deaths per 100,000).

If the odds that a person in the United States will die from cardiovascular disease in a year are 1 in 337.1, why in Mississippi do those odds become 1 in 261.8? Is there a connection among states with the highest prevalence of CVD mortalities, which include Oklahoma (1 in 272), Alabama (1 in 274.6), Tennessee (1 in 286.4), and West Virginia (1 in 290.3)?

According to health policy experts, one connection may be poverty. “Many Mississippians, especially the 51% who live in rural counties, experience poverty levels that are hard to imagine for most Americans,” Professor Leonard Jack, Jr. of Jackson State University wrote in the journal Preventing Chronic Disease. People living in poverty often lack quality health care and education. They also do not have the luxury to eat a healthy diet, as the cheapest food is usually the most fattening. Combine this with the high rates of physical inactivity in these states and you have an obese population vulnerable to cardiovascular disease.

Race is also a factor in how many CVD mortalities a state records. In 1995, African American men and women from Mississippi had CVD mortality rates approximately 50% and 70% higher than their white counterparts, respectively. A Centers for Disease Control survey of behavioral risk factors between 2001 and 2004 found that black males and females exercised less, had higher blood pressure, were more obese, and were less likely to have health care than white Mississippians.

Poverty and racial disparities are present in states that record the least number of CVD mortalities, but obesity seems to be less prevalent. The odds a person will die from cardiovascular disease in a year are 1 in 473.7 in Minnesota, 1 in 447.6 in Alaska, 1 in 434 in Hawaii, 1 in 427.5 in Colorado, and 1 in 421.4 in Utah. According to the “F is for Fat Report” 2009, Colorado has the lowest statewide obesity while Mississippi has the highest. Minnesota, the state with the least cardiovascular disease mortality (35%), also has one of the lowest rates of childhood obesity. The key to staying alive may be staying slim.