Between 2005 and 2014, more than 45,000 people were struck and killed by cars while walking in the United States. In the two years since, walking has only grown more dangerous.

A new report from Smart Growth America, a D.C.-headquartered advocacy group that’s anti-sprawl, highlights the most dangerous metro areas in the country for pedestrians, and takes a look at who is most at risk for being struck and killed by a car. The study examines 104 metro regions to calculate a “pedestrian danger index” or PDI — a calculation of the total number of pedestrian deaths relative to the number of pedestrian commuters in the region.

Of the largest metros in the country, Houston ranked among the least safe, coming in at 15th overall, while New York City was among the safest cities for pedestrians, coming in at 95th. Chicago came in 80th, Washington, D.C., at 69th, Philadelphia at 68th, and Los Angeles landed at 51st.

Many of the 20 most dangerous are in the South, and eight of the top 10 are in Florida (which has long carried a rep for not being the friendliest state for people who walk or bike). In the top spot, the Cape Coral-Fort Meyers metro area, saw 2.55 annual pedestrian deaths per 100,000 pedestrian commuters.

The top 10 most dangerous metro regions for pedestrians were ranked as:

Cape Coral-Fort Myers, Fla. ​Palm Bay-Melbourne-Titusville, Fla. Orlando-Kissimmee-Sanford, Fla. Jacksonville, Fla. Deltona-Daytona Beach-Ormond Beach, Fla. Lakeland-Winter Haven, Fla. Tampa-St. Petersburg-Clearwater, Fla. Jackson, Miss. Memphis, Tenn-Miss.-Ark. North Port-Sarasota-Bradenton, Fla.

An interactive heat map shows the risk of pedestrian deaths in the Fort Myers region of Florida. Dark blue areas are low risk, while white areas indicate high-risk areas.

Out of the 51 metro areas that were also studied in 2014, 30 were found to be less dangerous in 2016. Of the 18 that grew more dangerous (three saw no change), the greatest increases were found in metros of Jacksonville, Florida, Riverside, California, Detroit, Memphis and Las Vegas.

The report also dug into the demographics of who was most at risk of being struck and killed by a car, and two key groups stood out: people of color and older adults.

While people of color account for only about 35 percent of the population, they make up more than 46 percent of pedestrian deaths. Native Americans are the most over-represented, making up 2.7 percent of pedestrian deaths and only 0.7 percent of the population. Hispanics make up 21.5 percent of pedestrian deaths, and African-Americans 19.3 percent. The authors attribute this racial disparity in part to the fact that people of color are less likely to own a car or to have access to public transportation, so they are more likely to have no choice other than to walk along roads without safe pedestrian infrastructure. (The amount of investment in making poor and majority-minority neighborhoods safer for walking is at least one other factor. Then there’s drivers’ racial bias.)

Older adults are also at greater risk, often due to greater difficulty seeing or hearing, and because much pedestrian infrastructure is not well designed to accommodate walkers or wheelchairs. Those over 65 years old are 50 percent more likely than younger individuals to be struck and killed by a car while walking.

There is also a strong correlation between median household income and rates of uninsured individuals and the dangerousness of walking in the region. As median household incomes and the rates of insured individuals fall, the PDI rises. This means that the people who can least afford to be injured often live in the most dangerous places.

Smart Growth America recommends taking a “complete streets” approach to pedestrian safety, looking at how and why people use streets and how streets aren’t serving the needs of the community. Wide, straight lanes, for example, encourage people to drive faster, making neighborhood streets less safe for those walking. Cars are three times more likely to cause death when hitting pedestrians while traveling at 30 mph than at 20 mph. And when some of the population does not have access to transit or a car, making a street pedestrian-free isn’t a realistic option.

Emiko Atherton, director of the National Complete Streets Coalition, points out that poor pedestrian infrastructure is a health issue, as well as an equity issue.

“America is facing an obesity epidemic, and the U.S. Surgeon General has encouraged people to walk more to help address it,” Atherton says. “But how can we ask people to walk more when so many streets are so dangerous for pedestrians? It’s outrageous.”

Design interventions have been shown to make a difference in boosting pedestrian safety, including slowing traffic, wide sidewalks, curb extensions, pedestrian countdown signals, midblock crosswalks (especially at transit stops), street trees, banning right turns on red and compact intersections.