For the third year in a row, America’s Health Rankings, an annual accounting of Americans’ health, has found that Hawaii is the healthiest state and Mississippi is the least healthy state in the US.

Since the rankings began in 1990, Mississippi — which has high rates of obesity and diabetes, low availability of primary care, and high incidence of infectious disease — has always ranked among the bottom three. Hawaii — which has low rates of obesity, smoking, cancer deaths, and preventable hospitalizations — has always been among the top six.

The rankings are funded by the United Health Foundation and are based on data from the Centres for Disease Control and Prevention, the American Medical Association, the Census Bureau, and other sources. They take into account 27 distinct measures including rates of smoking, obesity, drug deaths, education, violent crime, pollution, childhood poverty, infectious disease, and infant mortality.

Overall, the rankings showed progress in some areas and not in others. The 2014 analysis found increases from the previous year in obesity and physical inactivity and decreases in infant mortality and smoking rates.

In the past 25 years, there have been some notable changes. Since 1990, there have been major reductions in infant mortality (down 41%), death from heart disease (down 38%), and premature death (down 20%). In 1990, 29.5% of Americans smoked; in 2014, 19% smoke, though smoking remains “the leading cause of preventable death in the country,” a press release noted.

Unfortunately, in that same time period, rates of diabetes and obesity have more than doubled.

There has also been an 8% decline in cancer mortality since its peak in 1996. Cancer is the second leading cause of death in the US (heart disease is number one), and 2014 saw an estimated 1.6 million new diagnoses.

The full 2014 rankings are at right, but here’s a map showing how each state fared:

And here are the states that have changed the most in the rankings since 1990, for better or worse:

While rates of premature death, for example, plummeted in 32 states by 10% or more, states like Oklahoma — where the rates of premature death have increased by more than 10% since 1990 — were left behind.

“A key challenge,” the report notes, “is that health gains are not experienced equally across the United States.”

The full ranking, analysis, and state-by-state reports are available on the America’s Health Rankings site.

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