ISSUE REPORT

F as in Fat:
HOW OBESITY THREATENS AMERICA’S FUTURE

2010

JUNE 2010 PREVENTING EPIDEMICS. PROTECTING PEOPLE.

ACKNOWLEDGEMENTS TRUST FOR AMERICA’S HEALTH IS A NON-PROFIT, NON-PARTISAN ORGANIZATION DEDICATED TO SAVING LIVES AND MAKING DISEASE PREVENTION A NATIONAL PRIORITY.
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. Helping Americans lead healthier lives and get the care they need—the Foundation expects to make a difference in our lifetime. For more information, visit www.rwjf.org.

TFAH BOARD OF DIRECTORS
Lowell Weicker, Jr. President Former three-term U.S. Senator and Governor of Connecticut Cynthia M. Harris, PhD, DABT Vice President Director and Associate Professor Institute of Public Health, Florida A & M University Robert T. Harris, MD Secretary Former Chief Medical Officer and Senior Vice President for Healthcare BlueCross BlueShield of North Carolina John W. Everets Treasurer Gail Christopher, DN Vice President for Health WK Kellogg Foundation David Fleming, MD Director of Public Health Seattle King County, Washington Arthur Garson, Jr., MD, MPH Executive Vice President and Provost and the Robert C. Taylor Professor of Health Science and Public Policy University of Virginia Alonzo Plough, MA, MPH, PhD Director, Emergency Preparedness and Response Program Los Angeles County Department of Public Health Jane Silver, MPH President Irene Diamond Fund Theodore Spencer Senior Advocate, Climate Center Natural Resources Defense Council

REPORT AUTHORS
Jeffrey Levi, PhD Executive Director Trust for America’s Health and Professor of Health Policy George Washington University School of Public Health and Health Services Serena Vinter, MHS Lead Author and Senior Research Associate Trust for America’s Health Rebecca St. Laurent, JD Health Policy Research Associate Trust for America’s Health Laura M. Segal, MA Director of Public Affairs Trust for America’s Health

CONTRIBUTORS
Daniella Gratale, MA Government Relations Manager Trust for America’s Health

PEER REVIEWERS
TFAH thanks the reviewers for their time, expertise and insights. The opinions expressed in this report do not necessarily represent the views of these individuals or their organizations. Marice Ashe, JD, MPH Director Public Health Law & Policy (with staff and consultants: Q. Dang, C. Fry, S. Graff, H. Laurison, I. McLaughlin, T. Mermin, S. Stevens, S. Zimmerman) Joyal Mulheron, MS Senior Director, Health Transformation Association of State and Territorial Health Officials

TABLE OF CONTENTS
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 SECTION 1: Obesity Rates and Related Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 A. Adult Obesity and Overweight Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 B. Adult Obesity Rates by Sex, Race and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 C. Childhood and Youth Obesity and Overweight Rates . . . . . . . . . . . . . . . . . . . . . . . . . .16 D. Physical Inactivity in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 E. Diabetes and Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 F. Obesity and Poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 G. Fruit and Vegetable Consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 H. Breast-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 SECTION 2: State Responsibilities and Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 A. State Obesity-Related Legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Building the Foundation for a Healthier California -- By Arnold Schwarzenegger . . .31 Raising a Healthier Generation by Transforming the School Environment -- By Joseph W. Thompson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Local School District Wellness Policies: A Missed Opportunity? -- By Jamie F. Chriqui . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Balancing “Calories In” with “Calories Out”: How Companies Can Help Customers and Employees Fight Obesity -- By Indra Nooyi . . . . . . . . . . . . . . . . .44 B. CDC Grants to States for Obesity Prevention and Control . . . . . . . . . . . . . . . . . . . . .51 C. State and Community Success Stories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 SECTION 3: Federal Policies and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 A. The Patient Protection and Affordable Care Act of 2010 . . . . . . . . . . . . . . . . . . . . . . .57 B. Prevention and Wellness Initiatives in the American Recovery and Reinvestment Act Of 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 C. Federal Obesity-Related Legislation up for Reauthorization in 2010 . . . . . . . . . . . . . .60 The Childhood Obesity Epidemic: Time to Fight Back -- By Sen. Tom Harkin . . . . . . .63 D. Other Federal Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Game-Changing Policy Advances -- By Kelly D. Brownell . . . . . . . . . . . . . . . . . . . . . . .71 E. CDC Grants to States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 F. Summary of Federal Agencies’ Involvement in Obesity Policy . . . . . . . . . . . . . . . . . . . .74 SECTION 4: Spotlight Issue -- Removing Barriers to Healthy Choices . . . . . . . . . . . . . . . . . . . .77 A. Obesity and Racial and Ethnic Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 B. Making Healthy Choices Easier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 Ensuring that Every American Has Access to Affordable, Nutritious Foods -- By Yael Lehmann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82 Creating Healthy Communities for Everyone: The Time is Now -- By Angela Glover Blackwell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 SECTION 5: Public Opinion Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 SECTION 6: Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 A. Enhancing Obesity Prevention and Control Efforts within the Reforming U.S. Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 Appendix A: Fast Facts about Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99 What Is Behind the Obesity Epidemic? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99 Obesity’s Impact on Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 Weight Bias and Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 Obesity and Physical Inactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104 Nutrition: The Other Side of the Energy Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 Economic Costs of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107 Appendix B: Methodology for Obesity and Other Rates Using BRFSS . . . . . . . . . . . . . . . . . . .108 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110

1

Introduction

I

n 2001, then-Surgeon General David Satcher issued a landmark statement that obesity had reached epidemic proportions in America.1 The country began to react, but slowly. As the F as in Fat report has documented over the previous six years, efforts to address the skyrocketing rise of obesity rates and obesity-related diseases have slowly been growing across the country, ranging from school districts trying to improve the nutritional quality of school lunches to communities building new sidewalks to make walking safer and more accessible to millions of Americans.
While it is clear that, in order to prevent obesity and reverse the epidemic, people need to make healthy choices, it is also clear that people do not make choices in a vacuum. The high rates of obesity in the United States are evidence that making healthy choices and managing one’s weight are difficult for many people because there are many barriers to healthy living in America. Healthy foods are often more expensive and scarce in many neighborhoods, while cheap processed foods are widely available. In addition, finding safe, accessible places to be physically active can be a challenge for many. While all Americans face barriers to healthy choices, these obstacles are often higher for people with lower incomes and less education, and for racial and ethnic minorities, who often have more limited access to affordable foods and safe, accessible places to be active. Where you live, learn, work and play all have a major impact on the choices you are able to make. Reversing the obesity epidemic will require individuals, families, schools, communities, businesses, government, and every other sector of American society to reduce the barriers to healthy eating and active living. Every American must have the chance to lead a healthy lifestyle. In the decade just begun, the nation has the opportunity to build on the growing momentum and set policy goals that will make healthy choices the easy choices in every neighborhood in the United States. One immediate next step should be to ensure that the disease-prevention measures in the new health reform law are implemented in smart, strategic ways to help prevent and reduce obesity. By effectively investing in proven community-based programs and policies and increasing access to preventive care, the law has the potential to greatly improve the health of millions of Americans. The recommendations in this report focus on a number of important considerations for implementation.

In the past two years, however, programs and policies to prevent obesity have increased exponentially in number, strength and breadth. A new poll shows that 80 percent of Americans now recognize that obesity is a significant and growing challenge for the country.2 Furthermore, 50 percent of Americans believe that childhood obesity is such an important issue that we need to invest more to prevent it immediately. Obesity-prevention programs have received an unprecedented level of support in the new health reform law, the Patient Protection and Affordable Care Act of 2010, and the American Recovery and Reinvestment Act of 2009 (ARRA). President Barack Obama created a White House Task Force on Childhood Obesity, which issued a groundbreaking new national obesity strategy in May 2010 that included the bold goal of reducing child obesity rates from 17 percent to 5 percent by 2030 and contained concrete measures and roles for every agency in the federal government. In addition, First Lady Michelle Obama launched the “Let’s Move” initiative to solve childhood obesity within a generation. And less than a decade after Dr. Satcher’s pronouncement, current Surgeon General Regina Benjamin declared that combating obesity is a top national health priority. She elaborated: “The real goal is not just a number on a scale, but optimal health for all Americans at every stage of life.”3 Despite these important advances, obesity remains one of the biggest public health challenges the country has ever faced, wide disparities remain among different racial and ethnic groups, and our response as a nation has yet to fully match the magnitude of the problem. Most Americans continue to believe that weight is an issue linked almost exclusively to personal responsibility, and this view is a serious obstacle in the fight against obesity.4 “Isn’t what people eat and how active they are up to them? Isn’t this just a matter of willpower or personal choice?”

3

Obesity in the States and the Nation
In this F as in Fat report, Trust for America’s Health (TFAH) finds that in the past year adult obesity rates increased in 28 states, while only the District of Columbia (D.C.) saw a decline. Nationally, two-thirds of adults and nearly onethird of children and teens are currently obese or overweight. Since 1980, the number of obese adults has doubled. Since 1970, the number of obese children ages 6-11 has quadrupled, and the number of obese adolescents ages 12-19 has tripled.5, 6 The alarming increases in obesity rates over the past several decades indicate that much has changed in American society that makes it harder for children and families to eat healthy foods and be physically active. Higher obesity rates are often linked to regional, economic and social factors. Obesity rates tend to be highest in areas where poverty rates are highest and incomes are lowest. Except for Michigan, the 10 states with the highest adult obesity rates are in the South, and nine of the 10 states with the highest childhood obesity rates are in the South. Nine of the 10 states with the highest rates of poverty are also in that region. Adult obesity rates among Blacks are at 30 percent and above in 43 states and D.C., compared with 19 states for Latinos and only one state for Whites, which reflects long-standing disparities in income, education and access to health care. Higher rates of obesity translate into higher rates of obesity-related diseases, such as diabetes and heart disease. As documented in this year’s report, 10 of the 11 states with the highest rates of diabetes are in the South, as are the 10 states with the highest rates of hypertension. Previous studies have shown Blacks and Latinos have higher rates of diabetes, hypertension and heart disease than other groups. For instance, 32 percent of Blacks have hypertension compared with 22.5 percent of Whites, and 10.8 percent of Blacks have diabetes compared with 10.6 percent of Latinos, 9.0 percent of American Indians and 6.2 percent of Whites.7 Recent studies have shown that the number of obese children and adolescents may have leveled off since 1999, except among the very heaviest boys ages 6–19, but the rates remain startlingly high.8 If we do not reverse the childhood obesity epidemic, today’s youth may be the first generation in American history to live shorter, less healthy lives than their parents.

Toll on the Nation’s Health and Pocketbook
I Obesity is related to more than 20 major chronic diseases. Currently, one in three adults has some form of heart disease, more than 80 million Americans have type 2 diabetes or are pre-diabetic, and obese children are more than twice as likely to die prematurely before the age of 55 compared with healthy-weight children.9, 10, 11, 12, 13, 14, 15, 16 I Obesity-related medical costs are nearly 10 percent of all annual medical spending.17 Rising health care costs and a workforce in poor health are driving down our ability to compete in the global economy.18 The obesity epidemic affects every state in the country, but those states and communities with the highest rates of obesity are paying a very steep price. Businesses are reluctant to locate in areas where the population, particularly the future workforce, is unhealthy. High health care costs and lower productivity are unattractive to employers and investors. By creating policies and programs to help communities lower health care costs and improve worker productivity, government can play an important role in making communities more attractive to businesses.

4

F AS IN FAT 2010

T

his is the seventh edition of F as in Fat. The 2010 report examines current obesity trends in America and promising policy approaches, particularly actions taken by the states and federal government. This report includes: 4. Removing Barriers to Healthy Choices. 5. Public Opinion Survey. 6. Conclusion and Recommendations.
I Yael Lehmann, Director of the Philadelphia Food Trust, addresses access to healthy, affordable foods on p. 82. I Angela Glover Blackwell, Director of PolicyLink and Co-director of the RWJF Center on Childhood Obesity, writes about creating healthy communities for all Americans on p. 84.

I. Obesity Rates and Related Trends. 2. State Responsibilities and Policies. 3. Federal Policies and Programs.
In addition, for the first time, the report features commentaries from guest authors on a variety of relevant subjects including reauthorization of the Child Nutrition Act; expanding communities’ access to affordable healthy foods; and steps food manufacturers are taking to improve the nutritional quality of their products and their own employees’ wellness. TFAH asked the following policy-makers and experts in the field of obesity to offer their perspectives on what needs to be done to address the obesity crisis in the United States. I Arnold Schwarzenegger, Governor of California, talks about his goal to make California a national model for healthy living on p. 31. I Joe Thompson, Co-director of the RWJF Center on Childhood Obesity, addresses the need to create a culture of health and wellness for our kids where they live, play and learn on p. 36. I Jamie Chriqui, Senior Research Scientist with the Bridging the Gap Program at the University of Illinois at Chicago, writes about the need for more robust local school wellness policies on p. 39. I Indra Nooyi, CEO of PepsiCo, addresses the role of companies in providing consumers and employees with the information and choices to make healthier decisions on p. 44. I Tom Harkin, Chair of the Senate Health, Education, Labor and Pensions Committee (DIA), writes about changing the default status of our society to one that favors health and the role federal child nutrition policies can play in this beginning on p. 63. I Kelly Brownell, Director of the Rudd Center for Food Policy & Obesity at Yale University, highlights some of the major breakthroughs in obesity prevention and control on p. 71.

5

F AS IN FAT 2010: MAJOR FINDINGS Adult Obesity Rates and Trends (2007-2009)
I Adult obesity rates rose in 28 states over the past year. Only D.C. experienced a decline in adult obesity rates. More than two-thirds of states (38) now have adult obesity rates above 25 percent. Eight states have rates above 30 percent – Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Oklahoma, Tennessee and West Virginia. In 1991, no state had an obesity rate above 20 percent. In 1980, the national average of obese adults was 15 percent. I Adult obesity rates rose for a second year in a row in 15 states, and rose for a third year in a row in 11 states. Mississippi had the highest rate of obese adults at 33.8 percent. Colorado had the lowest rate at 19.1 percent and is the only state with a rate below 20 percent. I Obesity and obesity-related diseases such as diabetes and hypertension continue to remain the highest in the South. Except for Michigan, the top 10 most obese states in the country are all in the South. In addition, 10 of the 11 states with the highest rates of diabetes are in the South, as are the 10 states with the highest rates of hypertension and physical inactivity. Northeastern and Western states continue to have the lowest obesity rates. I Adult diabetes rates increased in 19 states in the past year. In eight states, more than 10 percent of adults now have type 2 diabetes. I The number of adults who report that they do not engage in any physical activity rose in 12 states in the past year. Two states and D.C. saw a decline in adult physical inactivity levels. I Adult obesity rates for Blacks and Latinos are higher than those for Whites in nearly every state. Adult obesity rates for Blacks are greater than or equal to 30 percent in 43 states and D.C. In nine states, the rates exceed 40 percent. Adult obesity rates for Latinos are greater than or equal to 30 percent in 19 states. I There is a very strong correlation between adult obesity rates and socioeconomic status. Among individuals earning less than $15,000 per year, 35.3 percent were obese compared to 24.5 percent of adults earning $50,000 or more per year. I Among adults who did not graduate from high school, 33.6 percent were obese compared to only 22 percent of adults with a college degree.

Child and Adolescent Obesity Rates and Trends (2007)*
I More than one-third of children ages 10–17 are obese (16.4%) or overweight (18.2%). State-specific rates ranged from a low of 9.6 percent in Oregon to a high of 21.9 percent in Mississippi. I Eight states, plus D.C., have childhood obesity rates greater than 20 percent: Arkansas, Georgia, Illinois, Kentucky, Louisiana, Mississippi, Tennessee and Texas. I Nine of the 10 states with the highest rates of obese children are in the South, as are nine out of the 10 states with the highest rates of poverty. I Recent studies have shown that the number of obese children and adolescents may have leveled off since 1999, except among the very heaviest boys ages 6–19, but the rates remain startlingly high.19 I Nationwide, less than one-third of all children ages 6–17 engage in vigorous activity, defined as at least 20 minutes of physical activity that makes the child sweat and breathe hard. I The percentage of children engaging in daily, vigorous physical activity ranged from a low of 17.6 percent in Utah to a high of 38.5 percent in North Carolina. Obesity Rates among High School Students (2009) I Nationally, 12 percent of high school students are obese and 15.8 percent of high school students are overweight. I Obesity rates among high school students ranged from a high of 18.3 percent in Mississippi to a low of 6.4 percent in Utah. I Overweight rates among high school students ranged from a high of 18 percent in Louisiana to a low of 10.5 percent in Utah, with a median overweight rate of 14.6 percent. I Obesity rates among Black and Latino high school students were higher compared with White students (15.1 percent and 10.3 percent, respectively).

6

State Legislation Trends
I Twenty states and D.C. set nutritional standards for school lunches, breakfasts and snacks that are stricter than current United States Department of Agriculture (USDA) requirements. Five years ago, only four states had legislation requiring stricter standards. I Twenty-eight states and D.C. have nutritional standards for competitive foods sold in schools on à la carte lines, in vending machines, in school stores or through school bake sales. Five years ago, only six states had nutritional standards for competitive foods. I Every state has some form of physical education requirement for schools, but these requirements are often limited, not enforced or do not meet adequate quality standards. I Twenty states have passed requirements for body mass index (BMI) screenings of children and adolescents or have passed legislation requiring other forms of weight-related assessments in schools. Five years ago, only four states had passed screening requirements. I Twenty-three states and D.C. have laws that establish programs linking local farms to schools. Five years ago, only New York State had such a program. I Thirty-three states impose a sales tax on soda. I Five states have enacted statewide menu labeling legislation. I Twenty-four states have passed legislation that limit obesity liability by preventing individuals from suing restaurants, food manufacturers and marketing firms for contributing to unhealthy eating, weight gain and related health problems. I Thirteen states have passed Complete Streets legislation, which aims to ensure that all users -pedestrians, bicyclists, motorists and transit riders of all ages and abilities -- have safe access to a community’s streets.

Main Recommendations
I Support obesity- and disease-prevention programs through the new health reform law’s Prevention and Public Health Fund, which provides $15 billion in mandatory appropriations for public health and prevention programs over the next 10 years. I Adopt a “Health-in-All-Policies” approach -- which recognizes that many factors outside of health care have a huge impact on health and therefore every policy decision should take into consideration its impact on health -- through the National Prevention, Health Promotion and Public Health Council, which includes departmental secretaries across the federal government. I Expand the commitment to community-based prevention programs initiated under ARRA through new provisions in the health reform law, such as Community Transformation grants and the National Diabetes Prevention Program. I Align health care coverage and access provisions in the health reform law with obesity prevention and control to ensure that every American has access to the most effective practices for preventing, controlling and treating obesity and obesity-related conditions. Policies also should be put in place to encourage the development and incorporation of emerging and innovative practices. I Align federal policies and legislation with the goals of the National Prevention and Health Promotion Strategy. Opportunities to do this can be found through key pieces of federal legislation that are up for reauthorization in the next few years, including the Child Nutrition and WIC Reauthorization Act (CNR); the Elementary and Secondary Education Act (ESEA), also known as the No Child Left Behind Act; and the Surface Transportation Authorization Act. I Continue to invest in research and evaluation on nutrition, physical activity, obesity, and obesity-related health outcomes and associated interventions. *Note: TFAH first reported on the 2007 National Survey of Children’s Health results in F as in Fat 2009. Data collection for the next NSCH will begin in 2011 and will likely be available in 2013.

7

Obesity Rates and Related Trends

SECTION

M

ore than two-thirds (68%) of American adults are either overweight or obese.20 Adult obesity rates have grown from 15 percent in 198021 to 34 percent in 2008, based on a national survey.22 during 1999–2008, except among the very heaviest boys ages 6–19.26 While some scientists and public health officials speculate that the data reflect the effectiveness of recent public health campaigns to raise awareness about obesity and the importance of increased physical activity and healthy eating among children and adolescents, others note that the prevalence of high BMI in children remains high and has not declined.

1

Meanwhile, the rates of obesity among children ages 2–19 have more than tripled since 1980.23,24 According to the most recent National Health and Nutrition Examination Survey (NHANES), 16.9 percent of children ages 2–19 are obese and 31.7 percent are overweight or obese.25 Researchers at the Centers for Disease Control and Prevention (CDC) report there was no statistically significant change in the number of children and adolescents with high BMI-for-age

OBESITY TRENDS * AMONG U.S. ADULTS
BRFSS, 1991 and 2007-2009 Combined Data
(*BMI >30, or about 30 lbs overweight for 5’ 4” person) 1991
WA MT ND MN OR SD ID WY IA NE NV IL UT CO KS MO TN AR SC MS TX LA AL GA TX LA IN KY OH WV VA NC AZ NM PA NJ DE MD DC CT WI MI NY NH MA RI NV UT CO VT ME OR SD ID WY IA NE IL KS MO TN AR SC MS AL GA IN KY OH WV VA NC PA NJ DE MD DC CT WA

2007-2009 Combined Data
MT ND MN WI MI NY NH MA RI VT ME

CA OK AZ NM

CA OK

AK HI

FL

AK HI

FL

No Data