Obesity has been associated with some of the nation’s biggest killers — cancer, heart disease and diabetes. All have been closely linked to obesity. According to the National Cancer Institute, in some cases, obesity can cut a person’s lifespan more than smoking. The obesity epidemic afflicts every part of the country to some degree. At least one in five adults are obese in every state. In five states, at least one in three adults are obese.

24/7 Wall St. reviewed the percentage of adults who are obese in every state. Nine of the 10 states with the highest obesity rates are located in the South. Mississippi leads the nation with an obesity rate of 35.3%, in contrast with Colorado’s obesity rate of 20.1%.

Obesity is a complex health issue. While a balanced diet and exercise can help a person lose weight, many other factors influence obesity. Factors such as poverty, and low educational attainment rates are linked to higher obesity rates. In addition, genetic predisposition and community influences can impede efforts to combat obesity.

Click here to see the states with the highest obesity.

The Physical Activity Guidelines from the U.S. Department of Health and Human Services recommends 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity a week for adults. Many Americans, however, fall short of this recommendation. In Mississippi, the state with the highest obesity rate, one in three adults do not exercise, the highest rate in the nation.

Obesity increases the risk of many negative health outcomes that can lower quality of life. Obesity is a risk factor in a range of preventable illnesses, including diabetes, heart disease, and stroke. Also, obese individuals are far more likely to report mental illnesses such as clinical depression and anxiety. In the 10 states with the highest obesity rates, at least one in 10 adults are diagnosed with diabetes. Colorado, the state with the lowest obesity rate, also has the lowest rate of diabetes at 6.8%.

High obesity rates are also linked to higher levels of preventable hospitalizations in an area. Nine of the 10 states with the highest obesity rates have higher rates of preventable hospitalizations than the national average.

The increase in illness and hospitalizations drives up health care costs both for individuals and for health systems. Health care costs are highest in states with the highest rates of obesity. Louisiana, which has the second highest obesity rate, also has the highest annual health care costs in the nation. By contrast, Colorado has the lowest obesity rate and lowest health care costs of all states.

Ultimately, a lifetime of obesity can lead to a premature death. According to a National Institutes of Health study, participants with a BMI of 40-44.9 — an extreme level of obesity — lost 6.5 years of life. At BMI levels of 55-59.9, the years of life lost more than doubled to 13.7.

To identify the states with the highest obesity rates, 24/7 Wall St. reviewed the percentage of adults in each state with a body mass index (BMI) of 30.0 or higher — people with BMI values over this threshold are considered obese. Data came from County Health Rankings and Roadmaps, a Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute joint program. The percentage of adults who have been diagnosed with diabetes, the number of deaths before age 75 per 100,000 people in a given year (the premature death rate), as well as annual health care costs also came from County Health Rankings and Roadmaps. Annual health care costs are based on the amount of price-adjusted medicare reimbursements per enrollee, a widely used approximation of per capita health care costs in a population. All data is as of the most recent period available.

These are the states with the highest obesity rates.