Which US States Pose the Greatest Threats to Military Readiness and Public Health? Public Health Policy Implications for a Cross-sectional Investigation of Cardiorespiratory Fitness, Body Mass Index, and Injuries Among US Army Recruits

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Many states in the southern region of the United States are recognized for higher rates of obesity, physical inactivity, and chronic disease. These states are therefore recognized for their disproportionate public health burden. The purpose of this study was to investigate state-level distributions of cardiorespiratory fitness, body mass index (BMI), and injuries among US Army recruits in order to determine whether or not certain states may also pose disproportionate threats to military readiness and national security.


Sex-specific state-level values for injuries and fitness among 165 584 Army recruits were determined. Next, the relationship between median cardiorespiratory fitness and injury incidence at the state level was examined using Spearman correlations. Finally, multivariable Poisson regression models stratified by sex examined state-level associations between fitness and injury incidence, while controlling for BMI, and other covariates.

Main Outcome Measures:

Cardiorespiratory fitness and training-related injury incidence.


A cluster of 10 states from the south and southeastern regions (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas) produced male or female recruits who were significantly less fit and/or more likely to become injured than recruits from other US states. Compared with the “most fit states,” the incidence of injuries increased by 22% (95% CI, 17-28; P < .001) and 28% (95% CI, 19-36; P < .001) in male and female recruits from the “least fit states,” respectively.


The impact of policies, systems, and environments on physical activity behavior, and subsequently fitness and health, has been clearly established. Advocacy efforts aimed at active living policies, systems, and environmental changes to improve population health often fail. However, advocating for active living policies to improve national security may prove more promising, particularly with legislators. Results from this study demonstrate how certain states, previously identified for their disproportionate public health burden, are also disproportionately burdensome for military readiness and national security.

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