FRANKFORT, Ky. (AP) — The 25 million people who live among the Appalachian mountains have struggled to keep up with health gains of the rest of the nation, falling behind in most major public health indicators, according to a study released Thursday .

The report shows the 13-state region lags the rest of the country in 33 out of 41 population health indicators, including seven of the leading 10 causes of death in the United States. Deaths by poisoning, which include drug overdoses, were 37 percent higher than the rest of the country — a testament to the opioid addiction crisis that has gripped the area for years.

Central Appalachia, which is mostly in the eastern portion Kentucky, was the worst of the worst. It led all other regions of Appalachia in deaths from heart disease, cancer, lung disease, injuries and diabetes. In the category of "years of potential life lost," a measure of premature deaths, central Appalachia lost more than 11,200 years from 2011 to 2013. No other Appalachian region was above 9,200.

"I think it's a wakeup call," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which issued the study along with the Appalachian Regional Commission and the Robert Wood Johnson Foundation. "We are dealing with real challenges in Appalachian Kentucky and the health of the entire state, both economically and physically."

A spokeswoman for Republican Gov. Matt Bevin of Kentucky said the report highlights why states "need flexibility to tailor programs like Medicaid to the unique needs of their populations."

Bevin has asked the federal government for permission to change the state's Medicaid program by charging premiums to some beneficiaries and requiring some to have jobs in order to keep their benefits. Bevin said such changes would encourage people to be healthy, while critics said it would make it harder for poor people to obtain health coverage.

The report showed the health of the regions' residents has improved over the years, but it has not kept up with gains elsewhere in the country. The result is a widening disparity that leaders worry is affecting the region's economic potential as it struggles to recover from the decline of the once dominant coal industry.

"I'm picturing county commission battles and, you know, town meetings and high school football games and the things that make up life in a small town in Appalachia," said Hilary Heishman, senior program officer with the Robert Wood Johnson Foundation and a native of West Virginia. "I read this and I feel, I can't say I feel it more than other people, but I feel a certain weight to it. It's not just numbers to me."

While the area has some of the worst health problems, it has the least amount of doctors and other medical staff when compared to what's available in the rest of the country. The region's suicide rate is 17 percent higher than the national population and depression among Medicare beneficiaries is 16.7 more frequent than any other part of the country. Despite that, Appalachia has 35 percent fewer mental health providers than everywhere else in the U.S.

The report was not all bad. It showed Appalachian residents did better than the rest of the country in areas of HIV and chlamydia prevalence, excessive drinking, student-teacher ratios and the percentage of the population under age 65 that is uninsured. Later this year, the advocacy groups plan to release a second report titled, "Bright Spots." That report will highlight 10 Appalachian counties that are bucking the regions' trends and what can be learned from them.

"I would say the report really gives us some work to do," said Earl Gohl, the federal co-chair of the Appalachian Regional Commission.