San Juan County once again topped the list of healthy counties in the state in a national wide-ranging annual survey assessing the health of county residents. King County slipped a notch, with air pollution, housing costs and crime pulling it down.

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Hampered by too much ozone pollution and too many fast-food restaurants, King County slipped a notch in a wide-ranging annual county-by-county assessment of residents’ health.

The 2012 County Health Rankings, produced by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation, assesses the health of residents in every county in the nation, using health measures ranging from rates of premature deaths, obesity and adult smoking to rates of violent crime, children in poverty and days of air pollution.

King County’s violent-crime rate, compared with other Washington counties, was higher than average but lower than in Pierce and Kitsap counties.

King was among the worst counties for “high cost of housing,” measuring households that spend at least 30 percent of total income on housing.

Counties that were the same or even worse in the housing-cost measure included Clark, Kittitas (the worst), Pierce, San Juan, Skagit, Snohomish and Whatcom.

The report found Ferry County the least healthy county, and for the third year in a row, San Juan County was the healthiest.

Despite having slipped, King County, in sixth place this year, was still in the top tier.

It did relatively well in a measure ranking the percentage of adults who said they had needed to see a doctor in the last 12 months but did not because of the cost. In King County, 11 percent of adults said they had that problem, compared with 20 percent in Wahkiakum County, the highest rate in the state.

King County also did significantly better than average in its residents’ premature-death rate, defined by the researchers as years of “potential life” lost before age 75, expressed as an age-adjusted premature-death rate per 100,000 people.

Health officials in King County, however, caution that overall county rankings can disguise vast differences among those of different races, incomes and education.

Such factors as small-business lending, land-use design and lack of access to fresh food make a difference in community health, according to Dr. David Fleming, director of Public Health — Seattle & King County.

A physical environment that encourages walking or biking and provides parks can help battle obesity, diabetes, heart disease and high stress, Fleming has noted.

Substandard housing, on the other hand, can lead to higher rates of asthma and other respiratory problems, and a high density of alcohol and tobacco retail outlets plays a part in statistics on liver disease, motor-vehicle deaths and lung and heart disease.

Even taking counties as a whole, however, different measures showed strengths and weaknesses. In San Juan County, at the top of the list, residents smoke less, fewer are obese and, in general, they are more physically active. The county has little violent crime and more access to recreational facilities.

But residents there also are slightly less likely to have health insurance, and drink to excess more than the average in Washington.

In Ferry County, which came in last again this year, unemployment is particularly high. Ferry residents smoked more, were less active and, compared with the state average, prematurely lost almost twice the number of years of life.

In general, rural counties rank lower in the surveys both in this state and nationally, often because of higher rates of unemployment and lack of insurance.

Snohomish County, which ranked ninth, had lower-than-average rates of children in poverty, teen births, violent crime and sexually transmitted infections. But it had more fast-food restaurants and lagged in the number of primary-care doctors for the size of its population.

Washington overall was as good or better than the national benchmark — defined as the top 10 percent of counties nationally — in several measures, including a low number of preventable hospital stays, a low rate of deaths from motor-vehicle crashes, and in percentage of residents with some college education.

But the state fell down, compared to the best counties nationally, with higher jobless rates, more excessive drinking, more poor children and a higher percentage of adults who smoked, among other measures.

The project, in its third year of ranking counties, is encouraging communities that are working to become healthier places to apply for “Roadmaps to Health” prizes of up to $25,000. In addition, the project is sponsoring a Health Action Center to provide guidance to advance pro-health policies.

Carol M. Ostrom: 206-464-2249 or