A new study has ranked Hawaii No. 49, near the bottom, of a list of the most obese states in the United States.

The study, by Consumer Protect, found Hawaii to be the 49th most obese state in America, with 23.8% of its adult population struggling with obesity. The District of Columbia was No. 50 and Colorado, No. 51, with only 23% and 22.6% of obese adults, respectively.

West Virginia had the highest percentage of obese adults, at 38.1%.

Obesity is a rapidly growing epidemic, according to the study, which uses the most recent data from the Centers for Disease Control and Prevention. The national average shows 30.1% of adults are obese as of 2017, two times more than in 1990 at 15%.

According to the CDC, a person is considered obese when their Body Mass Index (BMI), which is a formula based on height and weight, is over 30. A person who is five-foot, nine inches tall and weighs 203 pounds, for instance, qualifies as obese.

“It’s not only bad news for our waistline, but also our wallet,” said Consumer Protect. “The cost of treating obesity — linked to early death, heart disease and diabetes — is up to $210 billion annually.”

The causes of obesity in Hawaii include lack of exercise, with 23.5% of adult residents that do zero physical leisure activity. Hawaii ranks No. 42 in lack of exercise. In addition, 37% of adults in the Aloha state eat less than one fruit per day.