Frankfort, Kentucky – A new study shows the 25 million people who live among the Appalachian mountains, including parts of western and central Pennsylvania, have struggled to keep up with the health gains of the rest of the country, falling behind in most major public health categories.

The report released Thursday shows the 13-state region lags behind the rest of the country in 33 out of 41 public health indicators, including seven of the leading 10 causes of death in the U.S., such as obesity and cancer.

Deaths by poisoning, which includes overdoses, were 37 percent higher in Appalachia than in other parts of the country.

The report wasn’t all bad. Some bright spots included the fact that Appalachia has a lower percentage of HIV and chlamydia. There is less excessive drinking. Student-teacher ratios are higher, and there is a lower percentage of the population under 65 that is uninsured.

The Appalachian region consists of all of West Virginia, plus portions of Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia.

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