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Background: This study aimed to assess the incidence of and risk factors for mountain bike injuries among users of a local mountain bike trail system., Methods: An email survey was sent to 1,800 member households, and 410 (23%) responded. Exact Poisson test was used to calculate rate ratios, and a generalized linear model was used for multivariate analysis., Results: The injury incidence rate was 3.6 injuries per 1,000 person-hours of riding, with beginners at a significantly higher risk compared to advanced riders (rate ratio = 2.6, 95% CI, 1.4-4.4). However, only 0.4% of beginners required medical attention, compared to 3% of advanced riders., Conclusions: More injuries occur among beginning riders, but the injuries are more severe with experienced riders, suggesting higher risk-taking or less attention to safety measures., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Introduction: Tobacco dependence treatment is usually offered in primary care settings. Yet, if many patients who smoke do no not access primary care, cessation interventions may be missing those who most need them. This study describes Wisconsin adults' health care utilization by smoking status., Methods: Data were analyzed from 1726 individuals participating in a population-based, cross-sectional, in-person health survey of Wisconsin residents (2014-2016). Demographic characteristics were compared across smoking status using Wald chi-square tests weighted for the complex survey design. Odds ratios were calculated using multivariate logistic regression models., Results: Of 1726 respondents, 15.3% reported current smoking, 25.4% former smoking, and 59.4% never smoking. Those currently smoking were more likely than former- or never-smoking respondents to report emergency departments as their "usual place to go when sick" (12% vs 3%) or report they had "no place to go when sick" (16% vs 7%). People who currently smoke also reported more emergency department visits during the past year (mean = 1.4 visits) than did others (mean = 0.4, P < 0.01). Among those currently smoking, 18% reported that they "needed health care but didn't get it" over the past year, compared to 6% of others ( P <  0.01). Those currently smoking also were more likely to report a "delay in getting care" (16% vs 9%, P = 0.02) and were less likely to have had a "general health checkup" within the past year (58% vs 70%, P <  0.02). These relationships persisted in logistic regression models controlling for variables related to smoking status and health care utilization, including health insurance., Conclusions: These findings suggest that more than a quarter of Wisconsin adults who smoke do not receive primary care every year and that they delay care or seek care in emergency departments more frequently than do those who never smoked or who quit smoking. As a result, such individuals may be missing out on evidence-based tobacco cessation treatment., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Introduction: Alcohol use increases the risk for some cancers and can cause complications during treatment. The prevalence of alcohol use during chemotherapy has not been well documented in current literature. This pilot study aimed to examine self-reported alcohol use during chemotherapy among cancer survivors as a basis for future research and interventions., Methods: We surveyed Wisconsin cancer survivors (N=69) who participated in the ongoing population-based research study, Survey of the Health of Wisconsin (SHOW), on alcohol use during chemotherapy., Results: Of the cancer survivors who reported receiving chemotherapy, 30.4% (N=21) reported consuming alcohol while receiving chemotherapy, and 38.1% (N=8) of those who drank reported complications. Alcohol use during chemotherapy was higher among older adults (age 65+, rate ratio [RR], 1.9; 95% CI, 0.7-4.9), men (RR, 2.7; 95% CI, 1.3-5.4), former and current smokers (former: RR, 1.6; 95% CI, 0.7-3.8, current: RR, 2.5; 95% CI, 1.1-5.8), and those with non-alcohol-related cancers (RR, 2.0; 95% CI, 0.9-4.2.)., Conclusion: Alcohol use during chemotherapy is common and may increase the risk of complications. More research is needed to better understand this problem and to design effective interventions., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Background: Wisconsin's health ranking dropped from 7th healthiest in 1990 to 23rd in 2018. The purpose of this paper is to identify the contributory factors to this decline., Methods: Trends in Wisconsin's health rank for 1990 to 2018 were compared overall and for only identical measures used in both years., Results: Of the identical measures used in both years (n=10), the median rank declined from 8.5 (range 6-21) in 1990 to 19 (range 9-43) in 2018, with the greatest declines for infectious diseases, infant mortality, and smoking. The ranks were lower in 2018 for the similar measures used and for measures used only in 2018 compared to measures used only in 1990., Discussion: Wisconsin's drop in health ranking is real and calls for action to address the root causes., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Background: Smoking during pregnancy remains a significant public health concern with widespread social, economic, and health effects., Objective: To describe the epidemiology of maternal smoking in Wisconsin over time and by county, age, race/ethnicity, education, and other characteristics., Methods: Cigarette smoking during pregnancy in 2011-2016 was evaluated using Wisconsin Interactive Statistics on Health data., Results: Maternal smoking rates declined from 14.4% in 2011 to 11.4% in 2016. Rates are highest among women aged 20-24 and those with less education. American Indians had the highest rates of smoking during pregnancy at all education levels., Conclusion: Despite continued declines in the rates of smoking during pregnancy in Wisconsin, disparities exist for American Indians, young, and less-educated women. Physicians should continue to encourage cessation throughout pregnancy and support evidence-based community programs and policies., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Importance: Although the trends in obesity in Wisconsin overall are well described, less is known about characteristics and health consequences of different degrees of obesity. The Survey of the Health of Wisconsin is a novel population-based health examination survey that provides reliable and valid objective measurements of body mass index., Objective: Data from the Survey of the Health of Wisconsin is used to characterize the prevalence and consequences of different levels of obesity and track trends over time., Methods: A total of 3,384 participants age 21-74 years and living in Wisconsin at the time of data collection were surveyed in 2008-2013. Participants completed computer-assisted interviews and physical exams. Predictors and comorbidities of different levels of obesity were measured as prevalence, odds ratios, and population-attributable prevalence., Results: Of Wisconsin adults, 1.2% (CI, 0.7-1.7) are underweight, 26.1% (CI, 23.8-28.4) are normal weight, 33.4% (CI, 31.0-35.7) are overweight, and 39.4% (CI, 35.0-43.7) are obese—with 20.1 % (CI, 18.4-21.9), 10.3% (CI, 9.0-11.7), and 8.9% (CI, 7.6-10.2) in Class I, Class II, and Class III obesity categories, respectively. Obesity rates are higher in people who are older, poor, less educated, minorities, or who live in a community with high economic hardship. There is a dose response relationship between level of obesity and prevalence of all 9 comorbidities that were examined., Conclusions and Relevance: Measured rates of obesity in Wisconsin adults are higher than previously reported for the state, and obesity accounts for a significant proportion of chronic diseases.

Importance: Obesity before and during pregnancy increases risk among mothers for poor health outcomes, such as diabetes, high blood pressure, and cardiovascular disease., Objective: To describe trends in pre-pregnancy obesity rates among women in Wisconsin., Methods: Cross-sectional data from Wisconsin birth certificates were analyzed. Prevalence of pre-pregnancy obesity (defined as body mass index ≥ 30) among Wisconsin women who gave birth from 2011 through 2014 was compared across demographic and geographic dimensions., Results: Overall, 27.8% of Wisconsin women who gave birth during 2011-2014 were obese. Obesity rates were highest among 40- to 44-year-old women (31.8%), women with a high school/ GED diploma (32.8 %), American Indian/Alaska Native women (43.9%), and women with 5 or more pregnancies (35.4%). Obesity rates varied by county of residence (highest in Forest County, 45.2%) and city of residence (highest in the city of Racine, 34.8%)., Conclusions: There are significant socioeconomic, racial, and geographic disparities in pre-pregnancy obesity among women who give birth in Wisconsin.

Importance: A comprehensive obesity surveillance system monitors obesity rates along with causes and related health policies, which are valuable for tracking and identifying problems needing intervention., Methods: A statewide obesity dashboard was created using the County Health Rankings model. Indicators were obtained through publicly available secondary data sources and used to rank Wisconsin amongst other states on obesity rates, health factors, and policies., Results: Wisconsin consistently ranks in the middle of states for a majority of indicators and has not implemented any of the evidence-based health policies., Conclusions and Relevance: This state of obesity report shows Wisconsin has marked room for improvement regarding obesity prevention, especially with obesity-related health policies. Physicians and health care systems can play a pivotal role in making progress on obesity prevention.

Background/significance: Obesity rates have increased dramatically, especially among children and disadvantaged populations. Obesity is a complex issue, creating a compelling need for prevention efforts in communities to move from single isolated programs to comprehensive multisystem interventions. To address these issues, we have established a childhood Obesity Prevention Initiative (Initiative) for Wisconsin. This Initiative seeks to test community change frameworks that can support multisystem interventions and provide data for local action as a means for influencing policies, systems, and environments that support individuals’ healthy eating and physical activity., Approaches/aims: The Initiative is comprised of three components: (1) infrastructure to support a statewide obesity prevention and health promotion network with state- and local-level public messaging and dissemination of evidence-based solutions (healthTIDE); (2) piloting a local, multisetting community-led intervention study in 2 Wisconsin counties; and (3) developing a geocoded statewide childhood obesity and fitness surveillance system., Relevance: This Initiative is using a new model that involves both coalition action and community organizing to align resources to achieve health improvement at local and state levels. We expect that it will help lead to the implementation of cohesive and sustainable policy, system, and environment health promotion and obesity prevention strategies in communities statewide, and it has the potential to help Wisconsin become a national model for multisetting community interventions to address obesity. Addressing individual-level health through population-level changes ultimately will result in reductions in the prevalence of childhood obesity, current and future health care costs, and chronic disease mortality.

Background: Measuring and ranking the health of counties helps raise awareness of health disparities based on where people live. Recently, there has been increasing interest in comparing the health of counties across state lines, to potentially measure the impact of local and state-level policies., Methods: The counties in Minnesota (n = 87) and Wisconsin (n = 72) were combined into a single 2-state region, and all 159 counties were ranked according to the County Health Rankings methods, with summary ranks for health outcomes and health factors. Multivariable regression analysis was then used to examine the potential impact of state-based programs and policies on health outcomes., Results: Minnesota was healthier overall than Wisconsin, with lower rates of premature death and better quality of life. Minnesota also performed better than Wisconsin for all 9 health behavior measures, 4 of 7 clinical care measures, 7 of 8 social and economic factors, and 3 of 5 physical environment measures. Furthermore, counties in Wisconsin were more likely to have lower (worse) ranks than counties in Minnesota for both health outcomes and health factors, as well as for the subcategories that make up these summary ranks. Regression analysis showed that Minnesota’s better health status was explained primarily by healthier behaviors and more desirable social and economic factors., Conclusions: Minnesota’s better health outcomes are largely explained by better social, economic, and behavioral factors. These findings suggest a need for examination of policies and strategies that may be influencing the observed differences across these 2 states.

Importance: Over the past 3 decades, rates of childhood obesity have tripled. Given the gravity of this health concern, it is important that physicians intervene early. However, physicians continue to underdiagnose and undertreat childhood overweight and obesity., Objective: The aim of this pilot study was to identify current tools and strategies used by pediatricians in regard to childhood obesity, as well as to reassess barriers to success, and to uncover areas for improvement., Design: One-on-one interviews were conducted with pediatricians during the summer of 2013. Seven of the interviews occurred in person, and 10 occurred via telephone. Each interview lasted 30 to 60 minutes. All interviewees (n = 17, 13.2% response rate) were Wisconsin pediatricians, representing 7 different health systems., Main Outcomes: Themes relating to pediatrician's experiences in addressing and managing childhood obesity., Results: Pediatricians interviewed in this survey are comfortable identifying and diagnosing pediatric obesity with the widespread use of electronic health records. They have several tools and strategies at their disposal for the treatment and management of obesity, but do not often achieve the desired outcome of achieving healthy body weight. Most of them lack connections to community resources and the ability to effectively communicate with referral systems outside of their clinic, such as with dietitians., Conclusions: Building stronger connections between physicians and dietitians, as well as between physicians and the local community, may allow physicians to feel more empowered when it comes to managing childhood obesity.

Background: The rate of cigarette smoking among US adults has declined over the past 50 years. Yet smoking remains the leading cause of preventable death and marked disparities now exist in smoking rates based on education level, socioeconomic status, race/ethnicity, and geographic location. In order to target resources to reduce these disparities, a summary measure comparing the relative burden of smoking among smaller populations is needed., Objective: To create a single summary measure that assesses the relative health burden from smoking in Wisconsin counties using age-adjusted mortality rates for smoking-attributable diseases, current adult smoking prevalence, and the current rate of mothers who smoked during pregnancy., Results: Rates varied significantly between counties for smoking-attributable deaths (2-fold), adult smoking prevalence (5-fold), and smoking in pregnancy (5-fold). The summary measure of relative smoking burden was highest in rural counties and in counties with less education, higher rates of poverty, and more veterans. The ranking of a county's smoking burden was highly correlated with its overall health ranking from the County Health Rankings., Discussion: The burden from smoking varied markedly across Wisconsin and was highest in the least advantaged counties in the state. Additional public health efforts must be directed toward the counties with the greater relative smoking burden in order to reduce these disparities.

Objective: To develop a method to assess long-term and recent progress for leading health indicators in Wisconsin., Methods: Data from state and national sources were compiled. Baseline (10-year) trends for 20 health indicators were measured and compared to the Healthy People 2020 improvement standard of 1% per year. Additionally, current rates were assessed by comparing the most recent year of data to the expected rate had the previous 10-year baseline trend continued. Where available, health indicator trends were reported by gender, race/ethnicity, geography, and socioeconomic status., Results: Wisconsin improved on 10 of the 20 indicators over the past decade, with decreasing mortality rates for all age groups. The largest improvement was a decline of 3.0% per year in deaths among ito 24 year olds. The rates of teen births and adult excessive drinking also improved by 2.5% per year and 1.4% per year, respectively. Other indicators worsened. For example, increasing rates of low birthweight (+ 0.6% per year), adults in fair or poor health (+1.6% per year), and all socioeconomic indicators worsened (high school dropouts [+0.9% per year], unemployment [+5.9% per year], children in poverty [+5.1% per year], and violent crime [+2.3% per year]). Health indicators varied substantially across subgroups within Wisconsin. For example, African Americans were twice as likely to experience low birthweight compared to other racial subgroups, and males experienced death rates higher than females across all ages., Conclusion: Reporting current estimates and 10-year trends of leading health indicators helps identify areas of progress and opportunities for improvement. Despite progress in reducing death rates and several other health factors, self-reported health status is worsening in Wisconsin. Worsening socioeconomic conditions and health disparities represent significant public health challenges for Wisconsin's future.

Objective: To assess trends in malignant melanoma incidence, survival, and mortality in Wisconsin., Methods: Incidence data for Wisconsin were obtained from the Wisconsin Cancer Reporting System Bureau of Health Information using Wisconsin Interactive Statistics on Health, while incidence data for the United States were obtained from the Surveillance, Epidemiology, and End Results system (SEER). The mortality to incidence ratio [1 - (mortality/incidence)] was used as a proxy to estimate relative 5-year survival in Wisconsin, while observed 5-year survival rates for the United States were obtained from SEER. Mortality data for both Wisconsin and the United States were extracted using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research., Results: During the past decade, malignant melanoma incidence rates increased 57% in Wisconsin (from 12.1 to 19.0 cases per 100,000) versus a 33% increase (from 20.9 to 27.7 cases per 100,000) in the United States during the same time period. The greatest Wisconsin increase in incidence was among women ages 45-64 years and among men ages 65 years and older. Overall relative percent difference in 5-year survival in Wisconsin rose 10% (from 77% to 85%) and was unchanged (82%) for the United States. Wisconsin overall mortality rates were unchanged at 2.8 deaths per 100,000, compared to a 10% increase in the United States (from 3.1 to 3.4 deaths per 100,000). Wisconsin mortality rates improved for women ages 45-64 and for men ages 25-44., Conclusion: Despite improvements in malignant melanoma survival rates, increases in incidence represent a major public health challenge for physicians and policymakers.

Background: Research shows that maternal obesity leads not only to adverse pregnancy outcomes but also can act as a predictor of poor health of future generations. The Public Health Madison & Dane County Fetal and Infant Mortality Review Board observed poor health associated with prepregnancy BMI > or = 25, prompting further exploration of this issue in the Dane County, Wisconsin population., Objective: This is a descriptive epidemiologic study of the problem of maternal overweight defined as prepregnancy BMI > or = 25 in Dane County., Methods: Data were abstracted from the Secure Public Health Electronic Records Environment (SPHERE) on births in Dane County in 2011. Risk ratios were used to determine associations between race, education, parity, gravidity, and place of residence and maternal overweight. A t test was completed to determine differences in mean age of overweight and healthy weight mothers., Results: Approximately half (50.6%) of Dane County mothers in 2011 were overweight or obese prepregnancy. Results showed increased risk of overweight for black mothers and multiparous/multigravidous mothers. There was no difference in mean age of overweight and healthy weight mothers. Overweight rates varied considerably by ZIP code of residence., Conclusion: Rates of maternal overweight vary significantly in Dane County by social and demographic factors. This information can be used to design and target interventions and monitor trends over time.

Objective: With over one-third of adults in the United States classified as obese, new recommendations call for screening all adults for obesity at outpatient visits. The UW Health Fox Valley Clinic does not actively screen for obesity. The objective of this project was to test the feasibility of an obesity screening and brief intervention protocol., Process: A modified version of the Promoting Healthier Weight in Primary Care toolkit was implemented into a family medicine practice for 6 weeks. Patients (N = 88) were asked about visit satisfaction and acceptability of weight-focused conversation. Providers (N = 22) were asked about acceptability and feasibility of use., Outcome: Almost all patients (97.7%) found the conversation acceptable. Providers found the toolkit helpful, not confusing for their patients, and easy to use. Time was the greatest barrier.

Background: Measuring trends in a county's premature death rate is a straightforward method that can be used to assess a county's progress in improving the health of the population., Methods: Age-adjusted premature death rate data from Wisconsin Interactive Statistics on Health for persons less than 75 years of age were collected for the years 2000-2010. Overall 10-year percent change was calculated, compared, and ranked for all Wisconsin counties during this time period. Progress was assessed as excellent (25.0% or greater decline), very good (20.0%-24.9% decline), good (10.0%-19.9% decline), fair (0.0%-9.9% decline), or poor (any increase)., Results: Overall, premature death rates in counties declined by 16.8% over the 10-year period 2000-2010 in Wisconsin. Trends varied by county, with 8, 15, 37, 9, and 3 counties having excellent, very good, good, fair, and poor progress, respectively. The most improvement was seen in Kewaunee County (decreasing 38.3%) and the least progress in Lafayette County (increasing 4.8%). Trends in premature death rates were not related to the county's initial death rate, population, rurality, or income., Conclusions: Although premature death rates declined overall in Wisconsin during the 2000s, this progress varied across counties and was not related to baseline mortality rates or other county characteristics.

Background: Despite recent declines in teen birth rates, teenage pregnancy remains an important public health problem in Wisconsin with significant social, economic, and health-related effects., Objective: Compare and contrast teen birth rate trends by race, ethnicity, and county in Wisconsin., Methods: Teen (ages 15-19 years) birth rates (per 1000 teenage females) in Wisconsin from 2001-2010 were compared by racelethnicity and county of residence using data from the Wisconsin Interactive Statistics on Health., Results: Teen birth rates in Wisconsin have declined by 20% over the past decade, from 35.5/1000 teens in 2001 to 28.3/1000 teens in 2010-a relative decline of 20.3%. However, trends vary by race, with declines among blacks (-33%) and whites (-26%) and increases among American Indians (+21%) and Hispanics (+30%). Minority teen birth rates continue to be 3 to 5 times greater than birth rates among whites. Rates varied even more by county, with an over 14-fold difference between Ozaukee County (7.8/1000) and Menominee County (114.2)., Conclusion: Despite recent declines, teen pregnancy continues to be an important public health problem in Wisconsin. Pregnancy prevention programs should be targeted toward the populations and counties with the highest rates.

Background: Although public and media attention has focused on the federal role in the regulation of tobacco products, state government remains an important arena for changing tobacco control policies. Lobbying state officials by public health and the tobacco industry is a commonly used mechanism to influence public policy., Methods: Major bills of the 2007-2008 and 2009-2010 Wisconsin legislative sessions related to tobacco use regulation were analyzed by the hours engaged in lobbying and the estimated expenditures by supporters and opponents of tobacco control legislation in reports submitted to the Government Accountability Board., Results: In the 2007-2008 legislative session, anti-tobacco control organizations reported lobbying expenditures of more than $2 million (2627 hours) while opposing bills to raise tobacco excise taxes and enact smoke-free legislation; pro-tobacco control organizations reported lobbying expenditures of $623,000 (3997 hours) while supporting these bills. In the first 6 months of the 2009 session, anti-tobacco control groups spent $1.25 million (1472 hours) and pro-tobacco control groups spent $172,000 (1727 hours)., Conclusion: In the 2007-2008 legislative session, the proposal to increase the tobacco tax by $1 per pack was passed. However, the smoke-free indoor air bill was defeated. Anti-tobacco control organizations outspent pro-tobacco control organizations by a margin of over 3:1. In 2009 anti-tobacco control groups outspent health groups by a ratio of 7:1. Legislation for smoke-free workplaces and an increase in the cigarette tax was enacted. However, funding for tobacco prevention and treatment programs was substantially reduced.

Background: Cancer incidence and mortality rates have decreased over the last few decades, yet not all groups have benefited equally from these successes. This has resulted in increased disparities in cancer burden among various population groups., Objective: This study examined trends in absolute and relative disparities in overall cancer incidence and mortality rates between African American and white residents of Wisconsin during the period 1995-2006., Methods: Cancer incidence data were obtained from the Wisconsin Cancer Reporting System. Mortality data were accessed from the National Center for Health Statistics' public use mortality file. Trends in incidence and mortality rates during 1995-2006 for African Americans and whites were calculated and changes in relative disparity were measured using rate ratios., Results: With few exceptions, African American incidence and mortality rates were higher than white rates in every year of the period 1995-2006. Although cancer mortality and incidence declined for both groups over the period, relative racial disparities in rates persisted over the period and account for about a third of African American cancer deaths., Conclusions: Elimination of cancer health disparities will require further research into the many contributing factors, as well as into effective interventions to address them. In Wisconsin, policymakers, health administrators, and health care professsionals need to balance resources carefully and set appropriate priorities to target racial inequities in cancer burden.

Background: The prevalence of morbid obesity is increasing throughout Wisconsin and the United States. In 2004, we published a study, "Trends in Bariatric Surgery for Morbid Obesity in Wisconsin." We determined that surgery rates were increasing but felt the demand exceeded the capacity of the surgeons. This is a 6-year follow-up., Methods: Data was gathered from 3 sources: the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, the Wisconsin Hospital Association, and a survey administered to Wisconsin bariatric surgeons., Results: From 2003-2008, an average of 2.8% of Wisconsin adults were morbidly obese. Although the number of bariatric surgeries performed in Wisconsin remained steady (1311 surgeries in 2003 and 1343 in 2008), the types of procedures shifted from open gastric bypass (73% in 2003) to laparoscopic gastric bypass (80% in 2008). The rate of surgery was 1 for every 100 morbidly obese adults. The majority of surgeons surveyed (70%) report that a lack of insurance benefits is the biggest barrier to performing bariatric surgery., Conclusion: The prevalence of morbid obesity continues to increase in Wisconsin compared to our previously published data. Bariatric surgery volumes have remained stable but the type of procedure has changed. Approximately 1% of bariatric surgery candidates have surgery each year.

Despite significant accomplishments in basic, clinical, and population health research, a wide gap persists between research discoveries (ie, what we know) and actual practice (ie, what we do). The University of Wisconsin Population Health Institute (Institute) researchers study the process and outcomes of disseminating evidence-based public health programs and policies into practice. This paper briefly describes the approach and experience of the Institute's programs in population health assessment, health policy, program evaluation, and education and training. An essential component of this dissemination research program is the active engagement of the practitioners and policymakers. Each of the Institute's programs conducts data collection, analysis, education, and dialogue with practitioners that is closely tied to the planning, implementation, and evaluation of programs and policies. Our approach involves a reciprocal exchange of knowledge with non-academic partners, such that research informs practice and practice informs research. Dissemination research serves an important role along the continuum of research and is increasingly recognized as an important way to improve population health by accelerating the translation of research into practice.

Introduction: Environmental factors-such as air and water pollution, lead exposure in homes, or aspects of urban design-influence the health of a community. Monitoring these environmental health influences is a core function of public health, making it necessary to identify critical priorities and effectively target outreach and intervention efforts. This paper reviews the methods used to develop a summary measure of the environmental health of Wisconsin's 72 counties and the city of Milwaukee., Methods: We collected publicly available data on 9 indicators of environmental health, divided into 3 constructs-air quality, water quality, and the built environment. We looked at how the counties ranked in each construct and then combined the estimates into a summary measure of environmental health. We ranked the summary measure from lowest to highest risk, with higher representing a worse physical environment., Results: In 2007, Wisconsin regions with major metropolitan areas had the worst environmental health risk. In contrast, the 10 counties with the best environmental health were all located in rural areas of the state., Conclusion: Publicly available data can be used to compare and contrast environmental health in Wisconsin's communities. Although the measures used to collect these data could be improved, the results can still be used in community health planning and improvement efforts.

Background: Local health departments contribute to population health improvement through the core functions of assessment, policy development, and assurance. Their capacity to perform these functions may be affected by funding and staffing., Objective: To describe local health department funding and staffing levels and determine the relationship between these measures and county-level health outcomes., Methods: Ten years of total funding, funding by revenue source, and staffing data from local health departments in all 72 Wisconsin counties were collected from the Department of Health and Family Services and analyzed. Summary measures for county health outcomes were obtained from the 2006 Wisconsin County Health Rankings, and a correlation matrix was created to determine associations between outcomes and measures of health department capacity., Results: On average, Wisconsin local health departments spend $20.60 per capita, ranging from $7.50 to $68.30 among counties. While total per capita funding in the state (adjusted for inflation) increased $0.82 per year, a closer look reveals 3 distinct periods: increases of $0.20 per year during 1995-1997 and $1.33 per year during 1997-2001; but a decrease of $0.27 during 2001-2004. Local health departments in counties with worse health outcomes had only slightly higher average funding and staffing levels during 2002-2004., Conclusion: Levels of health department funding in Wisconsin, already low by US standards, declined slightly in the past 3 years. Although counties with the worst health outcomes had slightly higher levels of public health funding, considerable disparities exist. State policymakers might consider investing more resources in counties with the greatest need, to support evidence-based public health programs and reduce existing geographic health disparities in Wisconsin.

Introduction: While heart disease, cancer, and injuries are leading proximate causes of death, research has demonstrated that about half of all deaths in the United States are actually due to preventable causes, including tobacco use, poor diet, and physical inactivity. Using state vital statistics data and findings from national studies, we report on the trends in the preventable causes of death in Wisconsin from 1992 to 2004., Methods: The leading proximate causes of death in Wisconsin were obtained from Wisconsin Interactive Statistics on Health (WISH) data derived from individual death certificates. Information on the preventable causes of death was either obtained from the underlying cause information on the death certificate or from peer-reviewed epidemiologic studies., Results: While the overall age-adjusted death rate declined from 837 to 744 per 100,000 from 1992 to 2004, the top 10 causes of death remain largely unchanged. Nearly half of the deaths in Wisconsin in 2004 resulted from 11 preventable causes, similar to the findings in 1992., Discussion: Epidemiologic research demonstrates that nearly half of all deaths in Wisconsin are due to preventable causes. Programs and policies must continue to address these preventable causes of disease if Wisconsin is to meet its goal of promoting and protecting population health.

Background: In 2006, the city of Milwaukee ranked worse than any Wisconsin county for health outcomes and worse than all but 1 county for health determinants., Methods: To further examine disparities in health, Milwaukee city ZIP codes were stratified into 3 groups (lower, middle, and upper) by socioeconomic status (SES). Health determinants (15 measures) and health outcomes (2 measures) were compared across these ZIP code groups, and to the rest of Wisconsin., Results: The risk ratio for the lower SES group in comparison to the upper SES group was at least 2.0 for 5 of the 17 measures examined, and was at least 1.5 for 13 of the 17 measures. The upper SES group in Milwaukee, while the healthiest in the city, was worse than the state average in 6 measures., Conclusions: Large health disparities within the city of Milwaukee are associated with geographic regions of differing socioeconomic status. As the state's largest urban center, Milwaukee's relatively poor health and significant health disparities have a considerable impact on the overall health of the state. To improve population health in Wisconsin, substantial efforts and resources are needed to address these disparities, and their related upstream factors.

Introduction: Successful approaches are needed to decrease the burden of obesity on America's youth. Researchers often look to the high school interscholastic sports experience as a promising area for intervention. The purpose of this paper is to examine trends in participation over the course of a 4-year educational period., Methods: Two research questions are posed in this study: (1) how does participation in interscholastic sports change over the high school interscholastic sports experience, and (2) how do gender and school size influence these patterns? To answer these questions, a panel study is used to prospectively follow 412 Wisconsin public high schools from freshman year (2000-2001) to senior year (2003-2004). Participation prevalence (percent participation) in freshman year and risk of attrition (defined as a reduction in prevalence) from freshman to senior year are reported for sport, gender, and school size characteristics., Results: Overall sports participation is greatest in smaller schools versus larger schools for both females (36% versus 20%) and males (38% versus 25%). Most high school sports exhibit declines in participation, including those sports with the highest prevalence of freshman participation. Compared to sports participants attending large schools, participants attending small schools have a lower risk of attrition from freshman to senior year. However, female attrition is much higher than male attrition in small schools, whereas this difference is not as apparent in large schools., Conclusion: The results of this research suggest school size and gender play important roles in initial and sustained involvement during high school. Despite the potential immediate and long-term benefits of high school interscholastic sports participation, there is limited research that prospectively examines patterns of participation through high school. Expanding the use of this measurement approach may effectively promote physical activity as youth grow into adults.

Context: Public health agencies have identified the elimination of health disparities as a major policy objective., Objective: The primary objective of this study is to assess changes in the association between education and premature adult mortality in Wisconsin, 1990-2000., Design, Setting, and Subjects: Wisconsin death records (numerators) and US Census data (denominators) were compiled to estimate mortality rates among adults (25-64 years) in 1990 and 2000. Information on the educational status, sex, racial identification, and age of subjects was gathered from these sources., Main Outcome Measure: The effect of education on mortality rate ratios in 1990 and 2000 was assessed while adjusting for age, sex, and racial identification., Results: Education exhibited a graded effect on mortality rates, which declined most among college graduates from 1990 to 2000. The relative rate of mortality among persons with less than a high school education compared to persons with a college degree increased from 2.4 to 3.1 from 1990-2000-an increase of 29%. Mortality disparities also increased, although to a lesser extent, among other educational groups., Conclusion: Despite renewed calls for the elimination of health disparities, evidence suggests that educational disparities in mortality increased from 1990 to 2000.

Objective: Compare incidence, mortality, and trends of oral cancer (including the pharynx) in Wisconsin and the United States by race and gender from 1999-2002., Methods: Age-adjusted incidence rates were compared using data from the Centers for Disease Control and Prevention (CDC WONDER). Mortality rates were compared using data from the Wisconsin Interactive Statistics on Health (WISH) and CDC US Cancer Statistics., Results: Incidence rates for oral cancer were higher among males than females in both Wisconsin and the United States. Trends in the incidence rate show the gender disparity has not changed. Furthermore, the incidence rate for African American males is higher in Wisconsin than in the United States. Mortality rates for males were approximately 2 times higher than females in Wisconsin and the United States. Additionally, African American males are more likely than white males to die from this form of cancer, and the likelihood is higher in Wisconsin than in the United States (2.4 versus 1.8, respectively)., Conclusion: Racial disparities in oral cancer for African American males are greater in Wisconsin than in the United States. This may result from variation in access to oral health care, tobacco and alcohol use, as well as limited resources in detection and prevention methods. Wisconsin should focus its oral cancer prevention activities on this high-risk group.

Objectives: In 2000, the Wisconsin Legislature allocated $20.8 million annually to establish a comprehensive tobacco control program. The purpose of this study was to evaluate the impact of Wisconsin's tobacco control program on reducing cigarette consumption during its first 2 years of operation., Methods: Per capita cigarette sales were used to estimate cigarette consumption. Trends in cigarette consumption in Wisconsin between 2001 and 2003 were compared with trends in the United States as a whole, with groups of states, and with Wisconsin's peer state group., Results: Cigarette consumption in Wisconsin declined 9.2% from 2001 to 2003. In the same time period cigarette consumption in the United States declined only 3.8%. Wisconsin also demonstrated a greater percent decline in its cigarette consumption rate than did 3 of the 4 state groups. Finally, compared to its peer state group Wisconsin performed better between 2001 and 2003, with a decline of 9.2% compared to only a 4.2% reduction in its peer state group., Summary: Wisconsin has shown progress in reducing cigarette consumption during the first 2 years of its tobacco control program. Greater declines in Wisconsin compared to the United States, most state groups and its own peer state group suggest early effectiveness of Wisconsin's tobacco control program. Wisconsin will require continued implementation of evidence-based policy initiatives and aggressive tobacco control activities in order to maintain its progress toward decreasing the public health burden of tobacco.

Background: In 1989, experts in cancer prevention, early detection, and treatment met in Madison to set the public health agenda for cancer control. Part of the plan defined target percent change in cancer mortality rates to be met by the year 2000. During the 1990s, public health and health care professionals developed programs and policies to reach these goals. The purpose of this analysis is to evaluate Wisconsin's progress in reducing cancer mortality and success in meeting the year 2000 objectives., Methods: Wisconsin mortality data for 1984-1986 and 1999-2001 were obtained from the Centers for Disease Control and Prevention, CDC Wonder. Percent change was calculated between the 2 time periods and compared to the 2000 target percent change for all-site cancer and site specific cancer mortality., Results: All-site cancer mortality decreased by 7% from 1984-1986 to 1999-2001 with a greater than 16% decline in age groups <65 years. Mortality from breast, colorectal, and cervical cancer each decreased by at least 25%. Lung cancer and malignant melanoma mortality rates increased by 5% and 17%, respectively. Among additionally analyzed cancers, mortality decreased in prostate, stomach, and childhood cancers and increased in liver cancer and non-Hodgkin's lymphoma., Conclusion: The results of the state's cancer control effort are mixed. The year 2000 objectives were met for breast and colorectal cancer. Progress was made in reducing mortality from cervical cancer and from all sites combined, but the other year 2000 objectives were not met. Mortality rates increased for lung cancer and malignant melanoma during the 15-year period.

Purpose: To examine the trends in the incidence of end-stage renal disease in Wisconsin from 1982 to 2003., Methods: De-identified incidence data for this study were supplied by the Renal Network of the Upper Midwest (Region 11). We examined trends in the incidence of end-stage renal disease by age, race, gender, and primary diagnosis from 1982 to 2003., Results: The incidence of end-stage renal disease increased more than 3-fold from 1982 to 2003. This increase was especially striking in persons with diabetes and hypertension, as well as among those aged > or = 75 years. The increase in the incidence of end-stage renal disease was also apparent among all racial groups and both genders., Conclusions: The continued increase in the incidence of end-stage renal disease in Wisconsin may result from a number of factors, such as an unintended consequence of better chronic disease management, which may predispose older individuals to end-stage renal disease. Resources aimed at decreasing the incidence of end-stage renal disease are needed to prevent unnecessary health care costs and negative health outcomes, including loss of life.

Objective: To review Wisconsin data on youth suicide mortality, hospitalizations from nonfatal self-inflicted injuries, and self-reported risk behaviors., Methods: Suicide mortality data for youth (defined here as persons 10-24 years of age) were obtained from the Centers for Disease Control and Prevention (CDC) for 1995-2001 and from the Wisconsin Division of Public Health for 2002. Hospitalization data for Wisconsin from 1995-2002 were obtained from the Wisconsin Division of Public Health. Survey data on self-reported risk behaviors were obtained from the CDC for 2001., Results: While the rate of youth suicide declined by 24% in the United States during the 9-year period studied, Wisconsin's rate declined only slightly (8%). Firearms accounted for 60% of completed youth suicides in Wisconsin. Medication overdoses and cutting accounted for 88% of self-inflicted injury hospitalizations for Wisconsin youth from 1995 to 2002. Wisconsin high school students reported similar rates of risk factor behaviors as youth in New Jersey (the state with the lowest suicide rates in the nation), but were more likely to use firearms (60% versus 32%)., Conclusion: Rates of suicide mortality, attempts, and self-reported risk behaviors among youth in Wisconsin continue to be unacceptably high. Physicians can play an important role in reducing youth suicide rates by acting within their clinical practices, as leaders in community suicide-prevention activities, and as advocates for policy change.

We conducted a cross-sectional, school-based survey of sixth-grade girls living in the Reedsburg, Wis area school district to explore factors associated with age at menarche. Data collection included parent and student questionnaires for demographic, menstrual, physical activity, and nutritional information. School nurses conducted physical examinations to provide anthropometric measurements. Salivary samples were obtained for laboratory analysis of estradiol, estrone, estriol, and progesterone levels. Students (n=59) were an average of 11.9 years of age (range: 10-13). Nineteen students (32%) reported menarche, with an average of 11.4 years of age (range: 8-12). Cycle length of the menstruating students averaged 32.0 days (range: 25-46 days). Students' age at menarche was positively correlated with their mothers' age at menarche (r=0.53, P=0.02). Total caloric intake, macronutrients, hormone levels, birthweight, and family size were not associated with menstrual status. We observed an inverse association between increasing weight and earlier age at menarche (P=0.03). Students past menarche watched more television (P=0.03) and participated in fewer hours of sporting activity (P=0.08) than students who had not yet reached menarche. These preliminary data suggest that further investigation of the determinants of menarche is both feasible and warranted.

Background: Adolescents giving birth represents an important public health issue with social, economic, and health-related consequences., Objective: Compare birth rates and trends in birth rates among adolescents age 15-19 years in Wisconsin and the United States by race/ethnicity., Methods: Teen birth rates from 1998-2002, and trends in birth rates from 1995-2002 for Wisconsin and the United States were compared by race/ethnicity using data from the Wisconsin Interactive Statistics on Health and data from the Centers for Disease Control and Prevention., Results: The general statewide birth rates and birth rates for Wisconsin white teens were lower than national rates, while birth rates for black, Hispanic, and American Indian teens were well above national rates from 1998-2002. Disparities between births to minority adolescents and white adolescents were higher in Wisconsin than in the United States. Although teen birth rates in general have declined nationally and in Wisconsin, rates among Hispanics in Wisconsin have increased during the 1995-2002 period., Discussion: Racial disparities in teen birth rates in Wisconsin far exceed national disparities. These disparities result from far-ranging, long-term social and environmental differences in underlying determinants of health that relate to ethnic and cultural beliefs, variation in access to health care that provides family planning and reproductive health services, decreased availability of school-based clinics, lack of role models, education, and variations in income and social status. Wisconsin should focus its teen pregnancy prevention activities on the groups at highest risk.

Background: Recent research has shown significant increases in the rates of obesity in US adults and children. Despite the widespread discussion about childhood overweight, relatively little discussion focuses on solutions., Methods: We reviewed the literature on school programs and policies that address competitive foods-commonly called "junk" foods. These foods tend to be high in sugar or fat and provide minimal nutritive value., Results: Sugar-sweetened beverages such as sodas contribute to weight gain and poor nutrition among students-the average student consumes 31 pounds of sugar in these drinks annually. The sale of competitive foods in schools often competes with the more nutritious school lunch programs. With minimal federal and state policies addressing the sale of competitive foods, individual school districts in Wisconsin and elsewhere have explored various alternatives to improve school nutrition. The evidence suggests that these policies can be effective and at the same time increase food sale revenue., Conclusion: Communities may be able to improve childhood nutrition through school-based nutrition programs and policies that address the sale of competitive foods.

Background: The rate of childhood overweight is increasing among our nation's youth. This epidemic has led to an increase of comorbidities such as high blood pressure and diabetes being treated in the pediatric population. This paper analyzes self-reported heights and weights to determine trends in the prevalence of overweight among US students in grades 9-12., Methods: Data from the Youth Risk Behavior Surveillance System from 1999 to 2003 were used to determine the prevalence of overweight--which is defined as a BMI < 85th percentile for age and gender--in 41 participating states. (Data from the "at risk of overweight" group [defined as BMI > or = 85 percentile and < 95 percentile] and the "overweight" group [defined as BMI > or = 95 percentile] were combined and labeled as "overweight" [BMI > or = 85 percentile] to make communication of results more clear.), Results: The prevalence of overweight adolescents in Wisconsin increased slightly during the past 4 years, from 22.6% in 1999 to 24.1% in 2003, with adolescent males 50% more likely than females to be overweight. In 2003, Wisconsin's rate of overweight was the 14th lowest among 41 states reporting to the Centers for Disease Control and Prevention. (Colorado is lowest at 15.7% and Mississippi is highest at 31.4%.) When examining races separately, Wisconsin's ranking decreases slightly, but remains in the top half of all states reporting., Conclusions: The prevalence of childhood overweight in Wisconsin appears to be rising, following the national trend. The prevalence of overweight among high school students is lowest in the Rocky Mountain states. Understanding reasons for these differences may shed light on strategies to decrease overweight in Wisconsin.

Introduction: Although county-level obesity estimates are necessary for planning and evaluating community-based interventions, the quality of these data has never been examined., Objectives: To evaluate the reliability of the county-level obesity prevalence estimates from Wisconsin's 72 counties and to highlight the variation of obesity among Wisconsin counties., Methods: Obesity prevalence data for each county in Wisconsin were obtained from the Wisconsin Behavioral Risk Factor Surveys (BRFS) from 1994 to 2003. During this 10-year period, 26,635 residents were interviewed by telephone, with sample sizes ranging from 6586 in Milwaukee County to 15 in Menominee County. The number of counties with reportable and reliable estimates, using criteria of sample sizes > or = 50 and > or = 300, respectively, was determined., Results: The 10-year obesity prevalence was reportable for 68 of Wisconsin's 72 counties, ranging from 9.7% in Bayfield County to 29% in Langlade County. By pooling data from the BRFS for 5-, 3-, and 1-year periods, estimates are reportable for 43, 24, and 4 counties, respectively. A sample size of at least 300 provides a more reliable estimate, but is available for only 5 counties for a 5-year period., Conclusions: By pooling 10 years of survey data, obesity rates can be estimated for most of Wisconsin's 72 counties, demonstrating marked variation in rates across the state. This surveillance system provides valuable data for larger counties for planning and program evaluation. Supplemental surveys can be conducted to provide more reliable and timely estimates.

Purpose: To investigate trends in mortality from chronic obstructive pulmonary disease (COPD) in Wisconsin., Methods: COPD mortality data for those 45 years of age and older were extracted from the Centers for Disease Control and Prevention WONDER database and analyzed. Rates were adjusted to the 2000 US Census., Results: In Wisconsin, the mortality rate from COPD increased by 88% between 1980 and 2000. A similar increase in COPD mortality occurred in the United States during this same period. Among Wisconsin males, the 33% increase from 1980-2000 was higher than the increase for US males. Likewise, the rate among Wisconsin females increased 3.9 times compared to an increase of 2.8 among US females. Unlike men, mortality increased in all age groups of women from 1980 to 2000., Conclusions: COPD mortality rates are increasing dramatically in Wisconsin, especially among women. Long-term trends in smoking do not explain the increases in COPD death rates among women. Other possible reasons include changes in the pattern of smoking or in the type of cigarette smoked, or women may be more susceptible to lung disease. Wisconsin physicians should target women for diagnosis and treatment of COPD and for smoking cessation and prevention.

Objective: To describe the nature and extent of workplace environmental tobacco smoke exposures in Wisconsin., Methods: Descriptive data and confidence intervals from the Current Population Survey tobacco supplements of 1995-1996 and 1998-1999 are presented., Results: The percent of indoor workers working under a smoke-free policy increased slightly, from 62% in 1995-1996 to 65% in 1998-1999. Respondents with a college degree were more likely to work under a smoke-free policy than those with a high school education or less. Among respondents with a work policy in 1998-1999, a complete ban on smoking reduced any workplace exposure in the past 2 weeks (4%) compared to a partial ban (26%) or an unrestricted policy (30%)., Conclusion: Wisconsin has seen a small increase in workplace policies that ban smoking in the workplace. These policies are more likely to protect workers of higher socioeconomic status and may increase health disparities in tobacco-related diseases in the future.

Background: Obesity is a national epidemic with rates in Wisconsin and the United States doubling over the past decade. Research of available treatments for morbid obesity (body mass index > or = 40 kg/m2) suggests that bariatric surgery may be the only modality that provides any significant long term weight loss., Methods: Using the data from Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, we analyzed self-reported information on body weight and height among adults in Wisconsin. We used the WITHIN database for inpatient hospitalization and surgeries in Wisconsin to evaluate trends in gastric bypass surgery. Finally, we surveyed bariatric surgeons in Wisconsin to assess trends in bariatric surgery in the state., Results: In Wisconsin, the percentage of the adults considered to be obese increased from 11% in 1990 to 22% in 2001. In 1999-2001, approximately 80,000 adults (2% of the population) were morbidly obese. The number of gastric bypass surgeries performed in Wisconsin more than doubled in 1 year, from 182 in 2001 to 426 in 2002. According to bariatric surgeons, gastric bypass accounts for approximately 90% of bariatric surgeries performed in Wisconsin. Thus, in 2002, there was roughly 1 bariatric surgery for every 200 morbidly obese Wisconsin adults. Most (84%) bariatric surgeons are planning to increase the number of procedures they perform, and 24% plan on adding an additional bariatric surgeon to their group., Summary: Bariatric surgery rates are increasing in Wisconsin, yet the demand for surgery far exceeds current capacity of surgeons in the state.

Introduction: Physicians advising their patients to quit smoking has been recognized as an effective component of smoking cessation treatment, yet evidence suggests that physicians are not consistently providing this type of counseling., Methods: Data from both the Current Population Survey's (CPS) Tobacco Use Supplements administered September 1998, January 1999, and May 1999 and from the 2000 Behavioral Risk Factor Survey System (BRFSS) were analyzed and compared. The weighted proportions and 95% confidence intervals of Wisconsin and US smokers who had seen a physician in the past year and reported receiving advice from them to quit smoking were calculated. Proportions were analyzed for the total population as well as for subgroups of gender, age, race, educational level, and income level., Results: CPS data showed that Wisconsin smokers who had seen a physician in the past year were significantly more likely to receive smoking cessation advice from their physician (64%) compared to US smokers (59%). Though not significant, a similar trend was seen in the BRFSS data. There were no consistent significant differences in rates analyzed by gender, age, race, educational level, or income level., Conclusions: Data from the CPS and BRFSS show that less than two thirds of Wisconsin smokers are receiving smoking cessation advice from their physicians. Increasing physician counseling of patients who smoke continues to be a priority public health goal for decreasing morbidity and mortality from tobacco-related illnesses.