WASHINGTON–Montgomery County is Maryland’s healthiest county for the second year in a row, according to the 2015 County Health and Roadmaps Rankings report.

The Robert Wood Johnson Foundation published its annual report that ranks counties across the United States based on a variety of health factors for the sixth time Wednesday. While findings in each county differed, the report showed a nationwide decrease in premature death.

In Maryland, Montgomery County ranked highest in the health rankings with Howard County second. Baltimore City came in last of the 24 jurisdictions, just behind Caroline County.

The report’s authors considered a variety of health outcomes and factors to rank counties, including premature death rates, rates of sexually transmitted disease and teen pregnancy, graduation rates, air pollution, availability of healthy food and exercise opportunities and the number of preventable hospital stays.

Montgomery County and Howard County have competed for the top spot since the report’s inception, with Montgomery surpassing Howard last year. Both counties are not only among the wealthiest in Maryland, but are also in the top 10 wealthiest counties in the nation.

In this year’s report Howard County beat Montgomery in categories that measured factors such as income, insurance rates and quality of life. Montgomery County snagged number one thanks to lower rates of premature death and adult obesity as well as better access to exercise opportunities.

“The county has a fairly well-informed public,” Uma Ahluwalia, Director of the Department of Health and Human Services in Montgomery County, said. “We have hospitals, physicians and residents who are pretty forward thinking in terms of diet and exercise. We do a lot to invest in resources and activities for them.”

Ahluwalia credited the county’s strict anti-smoking laws, mandatory restaurant menu labeling for calories and robust exercise programs as reasons the county’s overall health is thriving.

Baltimore City ranked last due to poor health behaviors like obesity, smoking and a high rate of sexually transmitted diseases. High school dropout rates and high rates of teen pregnancy also contributed.

“It is true that our health rankings are not good in Baltimore City,” Dr. Leana Wen, Baltimore City Health Commissioner said. “One in four people live below the poverty line and 36 percent of our children live in poverty. It’s [no] wonder that our health metrics are not good.”

Rural counties, like Caroline and Somerset on the Eastern Shore, were also low on the list, mainly because of high obesity and smoking rates, but also because these counties have many uninsured citizens.

Wen said officials in Baltimore are looking to improve the city’s ranking by addressing health in all policy changes like housing, education and food security. She added that she is optimistic about the health of Baltimore residents in the future.

This is the effect the directors of the Health Rankings and Roadmap report say they hope to have.

“In the six years since the County Health Rankings began, we’ve seen them serve as a rallying point for change. Communities are using the rankings to inform their priorities as they work to build a culture of health,” Bridget Catlin, co-director of the County Health Rankings, said in a press release.