The first Report Card (2011) identified a dozen priorities for decisive action to improve health in Massachusetts. The need to act was summed up in the title of our first report, The Boston Paradox, published in 2007. As we saw it, Massachusetts had "plenty of health care, but not enough health." The Commonwealth ranked high on many measures of health status and health care compared to the rest of the United States. But it was not immune to risks such as rising rates of overweight, obesity and diabetes that threatened to increase the burden of illness on many families, to drive up health-care costs that were already too high, and to sap the economic vitality of the state.

So how have we done? Clear signs have emerged that rates of growth in overweight and obesity in the Massachusetts population at large have stayed flat over the last two to three years. Similarly, overweight and obesity have leveled off among youth in several high-risk communities aided by the Commonwealth's Mass in Motion program. We have seen a widespread effort to promote a "culture of health."

A real culture of health requires investment of real dollars in priorities that shape our lifelong health. Here there have been encouraging signs as well.

In 2011 we documented a "mismatch": increased health care spending by the Commonwealth came at the expense of investment in crucial long-term determinants of health such as education and public health programs. Since then, the Commonwealth's spending on health care and other health-related priorities has come closer into balance.

But it is far too early to give ourselves good grades. First, it remains to be seen whether the unhealthy weight gain in Massachusetts has stopped for good. After all, America's obesity crisis has been more than 30 years in the making. In Massachusetts, rates of overweight, obesity and related conditions such as diabetes remain at historically high levels. Disparities in rates and resulting health risks among African-American and Latino residents remain stubbornly high. There is an especially urgent need for addressing what can be termed "ZIP-code disparities," or huge differences in health between affluent communities and low-income, high-risk urban neighborhoods throughout the state.

And while Massachusetts adults are among the nation's healthiest, the state's youth consistently fall in the middle of the pack for risks such as overweight and obesity, with especially troubling numbers for the youngest children. These facts do not bode well for our economic future.

It likewise remains to be seen whether the Commonwealth's tentative steps toward a better balance can be sustained in state expenditures on both health care and the determinants of health. The growth in health-care spending in Massachusetts has slowed in the last two to three years, but experts are divided on whether this trend will continue. Meanwhile, recent budget increases for public health and other health-related programs have not come close to making up for cuts in real inflation-adjusted spending suffered over the last 15 years.

And so as Governor Baker, the Legislature and community leaders reset the state's agenda, we offer one overarching goal and five specific recommendations for further action. The Commonwealth's overarching goal should be to make steady progress toward a culture of health. To make this a reality, Massachusetts officials need to fully embrace the "health in all policies" approach that many experts and health-care leaders see as essential if we are to improve health, avoid unnecessary spending, and sustain our economic vitality. Nearly every government action, from capital planning and construction to the design or reform of programs, represents an opportunity to contribute to better health for all residents.