The rate that America is growing more obese is picking up speed, according to a new study by Trust for America’s Health.

One measure of obesity is nearly 12 times as high as that found in another study 16 years. At least one in five people is obese in a whopping 47 states, researchers found. Back in 1991, just four states could say the same.

The implications for long-term care providers are ominous. Caregivers have increasingly had to struggle to care for extremely fat residents in recent years, often having to buy special equipment or remodel facilities to do so.

Lisa Hark, director of the Nutrition Education Program at the University of Pennsylvania School of Medicine, said obesity in the U.S. is “probably worse” than stated in the study, which relied on self-reporting. “When self-reporting, people tend to overestimate their height and underestimate their weight,” she said.

At 30% plus, Mississippi has the highest obesity rate, while Colorado (17.6%) has the lowest. A body mass index of 25 to 29.9 is considered overweight, while a BMI of 30 and above is obese.