On stairs carved into an old narrow gauge railway just outside of Colorado Springs, hikers and runners push themselves up 2,000 vertical feet in just under a mile. Here on the Manitou Incline, it’s easy to see why Colorado is ranked America’s leanest state.

But only forty miles to the south is Pueblo, a former steel mill town of 100,000, with an obesity rate that reached 30% in 2013-2014, according to the Pueblo City-County Health Department. That’s around 9% more than the statewide average of 21.3%, but fairly close to the nationwide average, according to the US Centers for Disease Control.

The parking lots in this once-thriving manufacturing city are full of cars with blue disabled placards hanging from their rearview mirrors. Here in the city’s Wal-Marts and grocery stores, shoppers using mobility carts are a common sight, as are those breathing oxygen through tubes in their nose.

Pueblo is not alone. Although it is something of an anomaly in a state that prides itself on its health-conscious reputation, this city is also emblematic of a larger national trend in which obesity is becoming the new face of disability.

Pueblo is emblematic of a larger national trend in which obesity is becoming the new face of disability.

In December 2015, the number of Supplemental Security Income/disability recipients in Pueblo County was nearly 6,000, according to the Colorado Health Institute. Of those, 76% were between the ages of 18 and 64. SSI is a federal, need-based supplemental security program for the very poor or the disabled that bundles together other federal benefits like Medicaid and the SNAP food program (formerly known as food stamps). In Pueblo in 2014, nearly 34% of residents received Medicaid, according to the institute. In Colorado, the state average for Medicaid was 19.5%. The other federal program for the disabled, SSDI, requires that applicants have previously worked for at least ten years in a job that paid into the social security system. In 2014, 7,200 recipients in Pueblo were enrolled in SSDI, according to the Social Security Administration.

“Pueblo is not unique,” says Michael Fenster, a cardiologist on the faculty of the University of Montana’s College of Health Professions and Biomedical Sciences. “It’s a microcosm of what’s going on all over, and unfortunately, it’s not something that’s going to get better.

An aging population, high unemployment and poor transportation options make healthy eating an afterthought.

“Obesity itself originates as an inflammatory disease,” Fenster, who has also practiced in rural areas of Georgia and Florida, says. “In these lower socio-economic areas, what you see is people eating the cheap foods—the sodas, the bags of chips, the energy drinks. So you see a direct correlation in these areas between the type of food consumption and obesity, and then you see the development of what we’re learning now are inflammatory conditions, neurodegenerative conditions, strokes, heart attacks, joints, diabetes, and of course obesity.“

In January of 2016, Mathematica’s Center for Studying Disability Policy reported a growing correlation between obesity rates and those applying for SSI and SSDI in their policy brief, “The Prevalence of Obesity Among Recent Applicants to Federal Disability Programs.” But unraveling the reasons for this link are complex, according to economist Jody Schimmel Hyde, who authored the report.

In Pueblo, the high rates of obesity and disability stem from a variety of cultural and national trends. This is the home of the Slopper, a green-chile hamburger worth 1,100 calories that was celebrated on the Travel Channel’s Food Wars in 2010. Pueblo also has double drive-throughs at the many McDonalds and its Sonics bustle at all hours.

Meanwhile, an aging population, high unemployment and poor transportation options make grocery shopping difficult and healthy eating an afterthought.

“When you can’t afford your house anymore, you’re not going to care about your health.”

“It’s become a social norm to overeat,” says Rob Archuleta, who grew up in Pueblo and now runs a program in the city for recovering drug addicts called Addict2Athlete. For Archuleta, a recovering addict who was once obese, the connection between weight and addiction is clear. “We define addiction as a toxic compulsive behavior. And overeating can be toxic, behind alcohol and drugs. You couple that with not knowing what a serving size is anymore as a society, and in Pueblo it’s really bad.”

Pueblo’s economic history has also played a role. Thousands of residents lost their steel-mill jobs during the steel crash of 1982. The era marked a turning point in the health of the region, according to social workers and health-care providers here.

“When you can’t afford your house anymore, maybe you’re getting unemployment or on disability, you’re not going to necessarily care about your health,” says Austin Clark, 66, who was a longtime nurse at both of the city’s hospitals. “I think we’re still seeing that malaise. People in town just kind of gave up.”

Then, in 1999, federal law changed so that extreme obesity alone did not qualify as a disability says Hyde, of Mathematica’s Center for Studying Disability Policy. Instead, applicants were required to show that obesity interfered with their ability to work. The change meant that applicants were required to show obesity interfered with their ability to work, Hyde said. But this ended up increasing the number of people who satisfied the requirements.

“I think what they were doing is acknowledging that obesity alone may not be meeting that criteria,” Hyde explained. “But a lower level of obesity in conjunction with other things might be.”

Of course, obesity and weight loss continue to be both a public health crisis and a source of impassioned debate in the medical community, many of whom now believe obesity is a disease.

Obesity and weight loss continue to be both a public health crisis and a source of impassioned debate.

One of those doctors is Glenn Rich, a longtime endocrinologist and internist in Trumbull, Connecticut, who recently became board certified in the new field of obesity medicine.

“In 2013, obesity finally got diagnosed as a disease, rather than a life choice,” Rich says. “And the reason why they changed the diagnosis as a disease is because there’s so many biological factors that lead to it.”

In obese patients with a Body Mass Index (BMI) of 30-35, Rich explains, the body is geared to conserve energy, so it sees that new weight as the normal weight and wants to retain it. The key, according to Rich, is catching the problem early, before a person’s body decides a high BMI is the status quo.

Clearly, this is an epidemic that won’t be going away anytime soon. From a disability standpoint, however, cardiologist Michael Fenster believes that physicians must do more to disrupt the cycle at the beginning.

“We enable people to a degree by saying oh, you know, you’re disabled, you’re too fat, here, ride the scooter, park in the handicapped spot, and we give them pills,” he says. “Western medicine isn’t set up for prevention. We’re set up to triage and treat. People come in after a heart attack and I put a stent in. But we don’t talk to them about how to prevent the heart attack from happening. “

From a disability standpoint, physicians must do more to disrupt the cycle at the beginning.

Back in Pueblo, the city and county health departments have come up with creative solutions designed to increase access to healthy foods and easily accessible exercise options, like bike paths and walking trails in the city’s parks.

The Pueblo City-County Health Department has made fighting obesity an urgent priority, according to Sarah Joseph, the department’s public information officer. And they are taking their battle to the streets, as they continue to work with both corporate and neighborhood stores to offer healthy, reasonably priced food options prominently displayed in stores.

“We have been targeting obesity since the campaign for ‘A Healthier Pueblo’ began almost ten years ago,” says Shylo Dennison, a public health planner at the health department. “It requires us to really think outside the box and work together as a community.”

One of these outside the box solutions is a program at St. Mary Corwin Hospital in which physicians write healthy food “prescriptions” that patients can use to buy fresh fruits and vegetables at local farmer’s markets. But there is a lot more work yet to be done.

“We know how to take a problem, figure out why it’s a problem, and then come up with solutions,” adds Lindsay Reeves, the community engagement director for Pueblo Triple Aim, a non-profit whose mission is to coordinate other agencies to help improve the county’s health. “Just as we did with lowering the teen pregnancy rate here in Pueblo, we need to stop admiring the problem of obesity and do something about it.”