Heart disease kills more Southerners than any other disease, according to a Centers for Disease Control and Prevention report.

The reasons are complex and not completely understood, but experts believe it is most likely a mix of risk factors, race, poverty and healthcare access in the South.

George Howard, a public health doctor and professor of biostatistics at the University of Alabama at Birmingham, said he’d bet that the reasons center on a higher population of blacks; more high blood pressure and diabetes, especially in rural areas; and a larger population of people with lower socio-economic status.

Race plays a role because there are “striking” health disparities between blacks and whites, including a higher likelihood of high blood pressure, heart attacks and strokes among blacks, Howard said.

The statistics line up against the region in many ways:

— More than half of all blacks in the U.S., including those of mixed race, live in the South, according to the 2010 U.S. Census. Only 10 percent of all blacks live in the West.

— Half of black men and 46 percent of black women had high blood pressure, compared to a third of white men and less than a third of white women, according to federal data. Black men and women had nearly twice the rate of diabetes as whites: 15.4 percent vs. 8.6 percent.

— Lower socio-economic status also has profound implications for high blood pressure, diabetes and other heart disease risk factors. People who are socially disadvantaged have been found to have higher risks for each.

–In the South, there are fewer medical professionals and less access to healthcare, according to Howard.

“Even if they get to the doctor, they may not have the total package of physicians that can take care of the problems they have. There’s not enough of us to go around,” said cardiologist Myrna Alexander-Nickens, M.D. associate professor of medicine at the University of Mississippi Medical Center in Jackson.

In addition, Alexander-Nickens said she’s seen her patients in the South get heavier, with more cases of diabetes and high blood pressure beginning at younger ages.

Children with risk factors lead to unhealthier adults, she said.

Culturally, Southerners are slow about changing their lifestyles, she added.  “We in the South tend to rebel against some of the changes, from our legislators on down.”

Based on the actual number of deaths in 2014, a recent CDC report showed cancer had edged out heart disease as the leading cause of death in 22 mostly non-southern states.

“I’m not at all surprised that cancer is rising into first place,” Howard said. “I think it reflects the success of research, the success of public health awareness, [and] the success of population efforts to control heart disease and stroke.”

Christina Clarke-Dur, Ph.D., research scientist at the Cancer Prevention Institute of California said, “Wow, those people working on heart disease are doing something right.”

The numbers used by the CDC didn’t account for age, the number of people living with a disease, or the death rate, which better reflect the risk of death.

After adjusting the data for age, Clarke-Dur said advances in treating cancer and heart disease should reduce the number of deaths from both diseases.

“Looking at only death understates some of the problems, as there are treatable heart diseases and death can be delayed,” said epidemiologist Russell Luepker, M.D. professor of epidemiology and community health at the University of Minnesota in Minneapolis.

“I certainly hope that cancer passes heart disease in every one of these states,” said Luepker, also an AHA volunteer. “I’d like to be No. 10 in deaths, because that is our mission.”


According to Robert Anderson, Ph.D., chief of the CDC’s mortality statistics branch, cancer and heart disease deaths are running neck-in-neck, even in southern states.

For example, South Carolina only had 34 more heart disease deaths than cancer deaths; Texas had 2,500 more. Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi and Tennessee fell somewhere in-between. The gap between heart disease and cancer deaths was generally lower in western states than in eastern states, Anderson said.

Despite reductions in heart disease deaths overall, a Journal of the American Medical Association study showed that in 2000-2011, the heart disease death rate dropped nearly 4 percent, but by 2011-2014, rates dropped by less than one percentage point.

In an editorial to the study, Donald Lloyd-Jones, M.D., chair of preventive medicine at Northwestern University Feinberg School of Medicine in Chicago suggested that higher obesity rates may be putting the brakes on progress.

“About 25 years into the obesity epidemic, there appears to have been a sudden slowing in the progress of declining CVD mortality rates, with now almost stagnant changes in age-adjusted CVD mortality and actual increases in crude mortality rates and total CVD deaths over the last few years as a result of population growth,” he wrote.

Southern states topped the charts of the number of people living with obesity at more than 31 percent, according to the CDC. Alabama, Louisiana, Mississippi and West Virginia each had 35 percent.
Although obesity is not a direct risk factor for heart disease or stroke, “it’s a risk factor for the risk factor,” said Howard. “It’s sort of like a time bomb that could bite us down the road.”

Another risk factor affecting southern states is smoking and tobacco use. Alabama, Kentucky, Mississippi, South Carolina and Texas got straight Fs from the American Lung Association in their efforts to reduce smoking. Georgia, Louisiana and Tennessee also achieved low marks.

A combination of 60 health risks and socioeconomic factors led three southern states – Arkansas, Mississippi and Louisiana – to rank last in the 2015 American’s Health Rankings of U.S. states, published by the United Health Foundation.

Ana Fuentevilla, M.D., chief medical officer, United Health Care Community and State and spokesperson for the organization’s 2016 Health of Women and Children Report, said low health rankings overlap “quite a bit” with high heart disease deaths in southern states.

There are long-standing health habits and healthcare issues in many southern states where many are poor and lack access to healthcare, Luepker said. “The problems that lead to higher rates in the South are ones that aren’t going to change quickly, certainly not in my lifetime or my children’s lifetime.”