MAPLETON, N.D. — Jacky Kummer’s struggle with her weight began when she became a mother. At first, she was able to lose the extra pounds. But over time it became more and more difficult.

She found it especially challenging to shed weight after the birth of her fourth child, when she was in her 30s.

“Then it was kind of yo-yo up and down,” she said. Her weight crept up gradually. “It’s little by little by little.”

At the suggestion of her primary care doctor, Kummer, who is retired and lives in Mapleton, has been working with a physician assistant for several years to lose weight. Her diet restricts carbohydrates, replacing them with proteins, but is not severe.

“I really don’t know I’m dieting,” she said. “It’s just upping your proteins and watching your carbs. That’s the basis for it.”

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Her attitude about food has changed — she no longer views it as the “enemy” — and her food habits have changed for the better. Still, she doesn’t claim to have won the battle yet.

“It’s a way of life,” Kummer said. “It’s ongoing. It’s a hard battle.”

Kummer has plenty of company. North Dakota is among nine states with an adult obesity rate greater than 35% — and one of three states that recently reached that mark for the first time.

North Dakota, with a rate of 35.1%, ranks eighth in the nation. Minnesota, with an adult obesity rate of 30.1%, is tied for 30th.

The U.S. is losing its battle with the bulge, as obesity rates have soared nationwide over the past three decades, a point made in the recent report, “The State of Obesity: Better Policies for a Healthier America,” issued this month by the Trust for America’s Health.

Consider that as recently as 1985, no state had an adult obesity rate higher than 15%. In 1991, no state topped 20%, and in 2000, no state was greater than 25%.

Women are more likely than men to be obese — once defined as 20% over ideal weight, but more precisely determined by calculating body mass index.

Being obese places people at higher risk for many chronic diseases, including high blood pressure, diabetes, heart disease, stroke, arthritis, depression, sleep apnea, liver disease and kidney disease. Obesity also increases the risk for several types of cancer as well as pregnancy complications.

Those chronic diseases, in turn, add significantly to the nation’s health cost burden.

Studies show those with obesity had “substantially higher medical costs than healthy-weight individuals,” and a 2016 study found that obesity increased annual medical expenses in the U.S. by $149 billion.

In North Dakota, 71% of adults are overweight or obese, 9.6% of adults have diabetes and 29.5% have high blood pressure. In Minnesota, 65.8% of adults are overweight or obese, 8.9% have diabetes and 26.6% have high blood pressure.

Those who live in rural areas are significantly more prone to become obese. Obesity rates were 16% higher in rural areas than urban areas, according to a 2016 survey compiled by the Centers for Disease Control and Prevention.

The Trust for America’s Health report and others have pointed to the American diet as a major culprit in the obesity epidemic. Americans have easy access to calorie-dense foods and, perversely, healthy foods such as fresh fruits and vegetables are more expensive and time-consuming to prepare than junk food, according to critics.

“The food environment certainly plays a big role,” said Tiffany Swenson, the Sanford physician assistant who is working to help Kummer with weight reduction.

In order to succeed, patients have to commit themselves to a sustainable lifestyle change that includes diet and physical activity, Swenson said.

“We certainly see success with patients,” she said. “It’s definitely patient by patient. We really focus on a moderate diet, not necessarily an exclusionary diet.”

But Swenson is aware of the continued increase in obesity rates, despite a growing recognition of the role it plays in chronic disease.

“It doesn’t seem like anything has slowed down,” she said. “I certainly hope it slows and plateaus and declines. Unfortunately, I don’t see any change in the near future.”

Besides easy access to so many cheap, unhealthy foods, today’s work environment also poses a formidable obstacle, Swenson said. In earlier eras, many jobs involved physical activity, whereas many jobs today are deskbound, with activity limited to picking up a phone or clicking a computer mouse.

“We sit for hours and hours a day, not doing any real movement,” Swenson said.

Reducing the stubborn problem of obesity will take a range of steps, the Trust for America’s Health report argued, including providing healthier food assistance programs, ensuring all children have access to healthy school meals, imposing local beverage taxes for sugary drinks, ending unhealthy food marketing to children and enforcing healthy food marketing.

Kummer, who is recuperating from knee replacement surgery but remains active and is committed to her diet, believes she is a good example of what a struggle it can be to lose weight, which she said is the typical dieter’s experience.

“I used to hate the scale, and now it’s just a friend to guide me,” Kummer said. She’s resigned to a long battle, with Swenson in her corner.

“It’s not like it’s just going to stop,” Kummer said. “We have a long journey together. What I lost feels like me now. This feels really good.”