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Background: We evaluated students' perception of cancer causation among sixth-grade girls living in Wisconsin. Method: We asked female students to list up to 3 causes of cancer in a cross-sectional health survey. Results: A total of 141 answers were given by 53 students. The most frequently listed causes of cancer were cigarette smoking (91%), drugs (32%), an unhealthy diet (25%), and heredity (25%). Less than 10% of students listed other potentially modifiable risk factors such as exercise, sun exposure, or alcohol consumption. Conclusion: Students in this study appeared to link a range of high-risk behaviors with health consequences, although the specific health risks may not be understood. [ABSTRACT FROM AUTHOR]

OBJECTIVE: In 2000, the Wisconsin Strategic Plan for the Elimination of Tuberculosis (TB) sets goals of 90 percent treatment completion and 95 percent documentation of treatment improvement for all reported cases of TB. This study measures the success in achieving these goals. METHODS: Data were abstracted from charts of all 249 reported TB cases during 2000-2002. Treatment completion was considered for patients indicated for completion in 12 months or less. Documentation of treatment improvement included therapy adherence, sputum culture conversion, and chest radiograph improvement for pulmonary cases, and therapy adherence and clinical improvement for extrapulmonary cases. RESULTS: Treatment completion was measured in 204 of 249 TB cases; 87.1 percent completed treatment in 12 months or less. There was a significant difference in completion by site of disease, 89.9 percent for pulmonary cases and 66.1 percent for extrapulmonary cases (P < .01). Documentation of treatment improvement was 61.2 percent among pulmonary cases and 83.6 percent among extrapulmonary cases (P < .01). During the study period, there was a significant decrease in documentation rates for patients with pulmonary TB (P < .01). CONCLUSIONS: The goal of 90 percent treatment completion was nearly accomplished but the goal of 95 percent documentation of treatment improvement was not achieved. Barriers to TB treatment in Wisconsin need to be identified. Case management of TB is necessary for control and prevention of TB. [ABSTRACT FROM AUTHOR]

To identify effective strategies for improving epidemiology capacity in state chronic disease programs, staff epidemiologists and program directors from 25 states were interviewed using a structured questionnaire by phone or in person. Respondents reported three chief barriers to chronic disease epidemiology capacity: lack of institutional commitment and support for chronic disease epidemiology; lack of professional opportunities to engage with peers, colleagues, and scientists; and lack of trained epidemiology staff and resources to support chronic disease functions and activities. Epidemiology capacity in states would be improved by expanding the role and scope of staff placement programs; assisting states in establishing formal collaborations with academic institutions; and providing technical assistance to staff currently employed in states through training, consultation, and networking. [ABSTRACT FROM AUTHOR]

Although the role for epidemiology is widely accepted in public health programs in general, its role in chronic disease programs is not as widely recognized. One possible barrier to improving epidemiologic capacity in chronic disease prevention and health promotion programs is that chronic disease program managers and public health decision makers may have a limited understanding of basic chronic disease epidemiology functions. We describe the assessment process of data collection, analysis, interpretation, and dissemination, and, using examples from two states, illustrate how this approach can be used to support program and policy development in three areas: by defining the problem, finding programs that work, and evaluating the effects of the program over time. Given the significant burden of chronic diseases in the United States, the scientific guidance provided by epidemiology is essential to help public health leaders identify priorities and intervene with evidence-based and effective prevention and control programs. [ABSTRACT FROM AUTHOR]

Women diagnosed with breast cancer often experience early menopause secondary to treatment effects, yet physicians may be reluctant to prescribe hormone replacement therapy (HRT) because of the potential increased risk of recurrence. To assess the burden of menopausal symptoms, HRT use, and alternative treatments in recent breast cancer survivors, a population-based, case-control study was conducted among breast cancer survivors and age-matched controls. Wisconsin women 18-69 years old with a new diagnosis of breast cancer 8-11 months prior to interview (n = 110) and control subjects randomly selected from population lists (n = 73) responded to a standardized telephone questionnaire that elicited information on menopausal symptoms, estrogen and alternative therapies (prescription medications, vitamins, herbal preparations, soy products, acupuncture, chiropractic) used to alleviate symptoms. We used multivariate logistic regression to obtain odds ratios and 95% confidence intervals (CI) for symptoms of menopause, use of estrogen, and use of alternative therapies. Breast cancer survivors were 5.3 (95% CI 2.7-10.2) times more likely to experience symptoms, 25 (95% CI 8.3-100) times less likely to use estrogen, and 7.4 (95% CI 2.5-21.9) times more likely to use alternatives than controls. Soy, vitamin E, and herbal remedies were the most common alternative therapies reported by participants; use was greater in cases compared to controls. Most soy users reported increasing soy products specifically to reduce the chances of a diagnosis of recurrent breast cancer. Among cases, tamoxifen users (n = 62) reported a higher prevalence of symptoms and a higher prevalence of alternative treatments. This is the first population-based survey of menopausal symptoms and treatments that compares breast cancer cases with disease-free controls. Cases are both more likely to experience menopausal symptoms and less likely to use HRT than controls. Instead, cases treat menopausal symptoms with vitamin E and soy products, even though the safety and efficacy of these therapies are unproven. The increased use of soy products in this population has not been previously documented. [ABSTRACT FROM AUTHOR]

The Women's Health Alliance Intervention Study is a community-based intervention study designed to determine if county-based coalitions can increase breast and cervical cancer screening rates among women aged 40 and older in four rural Wisconsin counties. This article describes the intervention process and demonstrates the feasibility of rural volunteer coalitions to promote breast and cervical cancer screening in communities. An accompanying article in this issue describes the effectiveness of these interventions. [ABSTRACT FROM AUTHOR]

The Women's Health Alliance Intervention Study is a quasi-experimental intervention designed to test if county-based coalitions can increase breast and cervical cancer screening compliance among women aged 40 years and older living in rural communities. A number of interventions were designed and implemented by coalitions in four counties in north-central Wisconsin during a 2-year period. Four control counties in southwestern Wisconsin were identified for comparison. Judging from the results of this study, community-based intervention efforts can increase breast and cervical cancer screening compliance significantly among women living in rural communities. [ABSTRACT FROM AUTHOR]

A community cardiovascular disease prevention program was undertaken as a cooperative effort of the South Carolina Department of Health and Environmental Control and the Centers for Disease Control of the Public Health Service. As part of the evaluation of the project, a large scale community health survey was conducted by the State and Federal agencies. The successful design and implementation of the survey, which included telephone and in-home interviews as well as clinical assessments of participants, is described. Interview response rates were adequate, although physical assessments were completed on only 61 percent of those interviewed. Households without telephones were difficult and costly to identify, and young adults were difficult to locate for survey participation. The survey produced baseline data for program planning and for measuring the success of ongoing intervention efforts. Survey data also have been used to estimate the prevalence of selected cardiovascular disease risk factors. [ABSTRACT FROM AUTHOR]

Data from multiple studies suggest that depression plays a role in cigarette smoking. To obtain a national perspective on the role of depression in the dynamics of smoking, we analyzed data from the first National Health and Nutrition Examination Survey and the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. We used the Center for Epidemiologic Studies Depression Scale to assess symptoms of depression and used the standard cutoff (score, greater than or equal to 16) for defining persons as depressed. The cross-sectional analysis of the first National Health and Nutrition Examination Survey showed that the prevalence of current smokers increased as the Center for Epidemiologic Studies Depression Scale score increased, whereas the quit ratio (former smokers/ever smokers) decreased as the Center for Epidemiologic Studies Depression Scale score increased. Among the cohort of smokers in the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, the estimated incidence of quitting after 9 years of follow-up was 9.9% for depressed smokers and 17.7% for nondepressed smokers. When we adjusted for amount smoked, sex, age, and educational attainment by means of a Cox proportional hazards model, we found that depressed smokers were 40% less likely to have quit compared with nondepressed smokers (relative risk, 0.6). These findings suggest that depression plays an important role in the dynamics of cigarette smoking in the United States. [ABSTRACT FROM AUTHOR]

Objective: Characterize college student COVID-19 behaviors and attitudes during the early pandemic. Participants: Students on two university campuses in Wisconsin., Methods: Surveys administered in September and November 2020., Results: Few students (3-19%) participated in most in-person activities during the semester, with eating at restaurants as the exception (72-80%) and attending work (35%) and parties (33%) also reported more frequently. The majority wore masks in public (94-99%), but comparatively fewer (42%) did so at parties. Mask-wearing at parties decreased from September to November ( p  < 0.05). Students attending parties, or consuming more alcohol, were less concerned and more likely to take COVID-19-associated risks., Conclusions: Students were motivated to adhere to COVID-19 prevention measures but gathered socially. Though there was frequent public masking, mask-wearing at parties declined in November and may represent pandemic fatigue. High-yield strategies for decreasing viral spread may include changing masking social norms and engaging with students about creative risk-reduction strategies.

The fishing cat, Prionailurus viverrinus, faces a population decline, increasing the importance of maintaining healthy zoo populations. Unfortunately, zoo-managed individuals currently face a high prevalence of transitional cell carcinoma (TCC), a form of bladder cancer. To investigate the genetics of inherited diseases among captive fishing cats, we present a chromosome-scale assembly, generate the pedigree of the zoo-managed population, reaffirm the close genetic relationship with the Asian leopard cat (Prionailurus bengalensis), and identify 7.4 million single nucleotide variants (SNVs) and 23,432 structural variants (SVs) from whole genome sequencing (WGS) data of healthy and TCC cats. Only BRCA2 was found to have a high recurrent number of missense mutations in fishing cats diagnosed with TCC when compared to inherited human cancer risk variants. These new fishing cat genomic resources will aid conservation efforts to improve their genetic fitness and enhance the comparative study of feline genomes., (© 2024. The Author(s).)

Introduction: Social determinants are structures and conditions in the biological, physical, built, and social environments that affect health, social and physical functioning, health risk, quality of life, and health outcomes. The adoption of recommended, standard measurement protocols for social determinants of health will advance the science of minority health and health disparities research and provide standard social determinants of health protocols for inclusion in all studies with human participants., Methods: A PhenX (consensus measures for Phenotypes and eXposures) Working Group of social determinants of health experts was convened from October 2018 to May 2020 and followed a well-established consensus process to identify and recommend social determinants of health measurement protocols. The PhenX Toolkit contains data collection protocols suitable for inclusion in a wide range of research studies. The recommended social determinants of health protocols were shared with the broader scientific community to invite review and feedback before being added to the Toolkit., Results: Nineteen social determinants of health protocols were released in the PhenX Toolkit (https://www.phenxtoolkit.org) in May 2020 to provide measures at the individual and structural levels for built and natural environments, structural racism, economic resources, employment status, occupational health and safety, education, environmental exposures, food environment, health and health care, and sociocultural community context., Conclusions: Promoting the adoption of well-established social determinants of health protocols can enable consistent data collection and facilitate comparing and combining studies, with the potential to increase their scientific impact., (Published by Elsevier Inc.)

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: Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening., Methods: Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community., Results: The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status., Discussion: Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake., (Published by Elsevier 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.)

Introduction: The annual economic burden of chronic homelessness in the U.S. is estimated to be as high as $3.4 billion. The Permanent Supportive Housing with Housing First (Housing First) program, implemented to address the problem, has been shown to be effective. This paper examines the economic cost and benefit of Housing First Programs., Methods: The search of peer-reviewed and gray literature from inception of databases through November 2019 yielded 20 evaluation studies of Housing First Programs, 17 from the U.S. and 3 from Canada. All analyses were conducted from March 2019 through July 2020. Monetary values are reported in 2019 U.S. dollars., Results: Evidence from studies conducted in the U.S. was separated from those conducted in Canada. The median intervention cost per person per year for U.S. studies was $16,479, and for all studies, including those from Canada, it was $16,336. The median total benefit for the U.S. studies was $18,247 per person per year, and it was $17,751 for all studies, including those from Canada. The benefit-to-cost ratio for U.S. studies was 1.80:1, and for all studies, including those from Canada, it was 1.06:1., Discussion: The evidence from this review shows that economic benefits exceed the cost of Housing First Programs in the U.S. There were too few studies to determine cost-benefit in the Canadian context., (Copyright © 2021. Published by Elsevier Inc.)

Liver transplant centers in the United States retain great autonomy in determining eligibility criteria for a liver transplant. This study aims to define the availability and content of liver transplant centers' publicly available Internet policies regarding eligibility criteria for liver transplant. Three trained undergraduate students performed a structured pilot-tested assessment of official websites of the United Network for Organ Sharing-registered liver transplant centers. All 141 liver transplant centers had an accessible website. Some account of eligibility criteria was provided by 53% of centers, while 32% of centers discussed substance use. Only 17% discussed their policy regarding alcohol use in candidates with underlying alcohol use disorder, and only 2% stipulated that 6 months of abstinence was required. While exclusion based on substance use or age was discussed infrequently, insurance coverage requirements, the need for social support, and the need for adherence to medical care were mentioned in 21%, 37%, and 23% of centers, respectively. Conclusion: In 2018, half of liver transplant centers provided some information on their official websites regarding eligibility criteria for liver transplant. Detailed information regarding substance use disorders and social health requirements was rare. The Internet is infrequently used by liver transplant centers as a means to publicly share information regarding selection criteria., (© 2020 The Authors. Hepatology Communications published by Wiley Periodicals LLC on behalf of the American Association for the Study of Liver Diseases.)

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.)

Intimate partner violence (IPV) and sexual violence (SV) are preventable public health problems affecting millions in the United States. The Community Preventive Services Task Force (CPSTF), an independent panel of experts that develops evidence-based recommendations based on rigorous systematic reviews, recommends interventions that aim to prevent or reduce IPV and SV among youth aged 12-24 years. Decision makers can use these findings to select interventions appropriate for their populations, identify additional areas for research, and justify funding requests.

Background: Data are limited regarding emergency department visits and readmission rates beyond 30 days after bariatric surgery. We analyzed emergency department visits and readmissions to all facilities in Wisconsin within 1 year of bariatric surgery and identified their predictors., Methods: All adults who underwent a laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy from 2011-2014 were identified. Bivariate associations between patient/hospital factors and emergency department visits/readmissions were examined, and factors significant at P < .1 were included in multivariable logistic regression models., Results: Within 1 year of bariatric surgery, 36.9% of emergency department visits and 60.3% of readmissions were to the same institution in which bariatric surgery was performed. The frequency of emergency department visits ranged from 10.7% (postoperative days 0-30) to 5.7% (postoperative days 181-270). Readmission rates ranged from 4.4% (postoperative days 0-30) to 2.7% (postoperative days 91-180). Readmission within 1 year was associated with male sex, Roux-en-Y gastric bypass, ≥4 comorbidities, Medicare insurance, teaching hospitals, and inpatient complications (all P < .05)., Conclusion: Emergency department visits and readmissions persist throughout the first year at a relatively steady rate after 30 days and often do not occur where bariatric surgery was performed. Quality improvement efforts targeting these patients may improve outcomes and decrease hospital resource utilization., (Published by Elsevier Inc.)

Objectives: To evaluate trends in premature death rates by cause of death, age, race, and urbanization level in the United States., Methods: We calculated cause-specific death rates using the Compressed Mortality File, National Center for Health Statistics data for adults aged 25 to 64 years in 2 time periods: 1999 to 2001 and 2013 to 2015. We defined 48 subpopulations by 10-year age groups, race/ethnicity, and county urbanization level (large urban, suburban, small or medium metropolitan, and rural)., Results: The age-adjusted premature death rates for all adults declined by 8% between 1999 to 2001 and 2013 to 2015, with decreases in 39 of the 48 subpopulations. Most decreases in death rates were attributable to HIV, cardiovascular disease, and cancer. All 9 subpopulations with increased death rates were non-Hispanic Whites, largely outside large urban areas. Most increases in death rates were attributable to suicide, poisoning, and liver disease., Conclusions: The unfavorable recent trends in premature death rate among non-Hispanic Whites outside large urban areas were primarily caused by self-destructive health behaviors likely related to underlying social and economic factors in these communities.

Background: Understanding what proportion of the eligible population is undergoing bariatric surgery at the state level provides critical insight into characterizing bariatric surgery access. We sought to describe statewide trends in severe obesity demographics and report bariatric surgery volume in Wisconsin from 2011 to 2014., Methods: Self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to calculate prevalence rates of severe obesity (class II and III) in Wisconsin. Bariatric surgery volume data were analyzed from the Wisconsin Hospital Association. A survey was sent to all American Society for Metabolic and Bariatric Surgery member bariatric surgeons in Wisconsin to assess perspectives on bariatric surgery access, insurance coverage, and referral processes., Results: The prevalence of severe obesity in Wisconsin increased by 30% from 2011 to 2014 (10.4%-13.2%; P = .035); the odds of severe obesity nearly doubled for adults age 20-39 (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.3-3.0). During this time, the volume of bariatric surgery declined by 4.2%; (1432 to 1372; P < .001), whereas the rates of bariatric surgery per 1000 persons with severe obesity declined by 25.7% (3.5 to 2.6/1000). A majority (72%) of bariatric surgeon respondents felt bariatric surgery access either worsened or remained the same over the last 4 years., Conclusions: Severe obesity increased significantly in Wisconsin over a 4-year period, whereas bariatric surgery rates among severely obese persons have remained largely unchanged and are substantially below the national average. Combining the state-level obesity survey data and bariatric surgery administrative data may be a useful approach for tracking bariatric surgery access throughout the United States.

Introduction: The Institute of Medicine, Association of American Medical Colleges, and Centers for Disease Control and Prevention recommend population health training for medical students. Medical schools struggle to teach and evaluate population health curricula. We developed, implemented, and evaluated a community health assessment exercise (CHA) within a required clinical rotation to address this need., Methods: Descriptive statistics and t-test comparison of means were used to analyze student scores on curricular assignments and responses to pretest and posttest items assessing student-rated skill and likelihood of conducting a CHA in practice, and in finding evidence to support public health programs and policies., Results: Student-rated skill in conducting a CHA increased from 3.3 ± 1.2 on the pretest to 4.8 ± 0.9 on the posttest ( P < 0.01). Student-rated skill in finding evidence that supports public health programs and policies increased from 4.0 ± 1.1 to 5.1 ± 0.9 ( P < 0.01). There was no difference between pretest and posttest in the likelihood of participating in a CHA organized by others (4.7 ± 1.3 vs 4.9 ± 1.3, p = 0.4), or in initiating a CHA as a practicing physician (4.2 ± 1.4 vs 4.3 ± 1.4, P = 0.8). Asked if the CHA improved their educational experience, 56% of students agreed and 25% disagreed. Asked if the CHA improved their ability to provide patient care, 40% of students agreed and 37% disagreed., Conclusions: The addition of a CHA to a clinical rotation is feasible and develops key medical student public health competencies., (© 2017 by the Society of Teachers of Family Medicine.)

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.

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.

Background: Trials have shown efficacy of rigorous diet and physical activity promotion programs to reduce diabetes incidence and improve glycemic measures in adults at increased risk for type 2 diabetes., Purpose: To evaluate diet and physical activity promotion programs for persons at increased risk for type 2 diabetes, primarily to reduce diabetes risk and decrease body weight and glycemia., Data Sources: MEDLINE, the Cochrane Central Register of Controlled Trials, CAB Abstracts, Global Health, and Ovid HealthSTAR from 1991 through 27 February 2015, with no language restriction., Study Selection: 8 researchers screened articles for single-group or comparative studies of combined diet and physical activity promotion programs with at least 2 sessions over at least 3 months in participants at increased risk for type 2 diabetes., Data Extraction: 7 researchers extracted data on study design; participant, intervention, and outcome descriptions; and results and assessed study quality., Data Synthesis: 53 studies (30 of diet and physical activity promotion programs vs. usual care, 13 of more intensive vs. less intensive programs, and 13 of single programs) evaluated 66 programs. Compared with usual care, diet and physical activity promotion programs reduced type 2 diabetes incidence (risk ratio [RR], 0.59 [95% CI, 0.52 to 0.66]) (16 studies), decreased body weight (net change, -2.2% [CI, -2.9% to -1.4%]) (24 studies) and fasting blood glucose level (net change, -0.12 mmol/L [-2.2 mg/dL] [CI, -0.20 to -0.05 mmol/L {-3.6 to -0.9 mg/dL}]) (17 studies), and improved other cardiometabolic risk factors. Evidence for clinical events was limited. More intensive programs were more effective., Limitations: Wide variation in diet and physical activity promotion programs limited identification of features most relevant to effectiveness. Evidence on clinical outcomes and in children was sparse., Conclusion: Combined diet and physical activity promotion programs are effective at decreasing diabetes incidence and improving cardiometabolic risk factors in persons at increased risk. More intensive programs are more effective., Primary Funding Source: Centers for Disease Control and Prevention Community Preventive Services Task Force.

Description: Community Preventive Services Task Force recommendation on the use of combined diet and physical activity promotion programs to reduce progression to type 2 diabetes in persons at increased risk., Methods: The Task Force commissioned an evidence review that assessed the benefits and harms of programs to promote and support individual improvements in diet, exercise, and weight and supervised a review on the economic efficiency of these programs in clinical trial, primary care, and primary care-referable settings., Population: Adolescents and adults at increased risk for progression to type 2 diabetes., Recommendation: The Task Force recommends the use of combined diet and physical activity promotion programs by health care systems, communities, and other implementers to provide counseling and support to clients identified as being at increased risk for type 2 diabetes. Economic evidence indicates that these programs are cost-effective.

Objectives: The University of Wisconsin Population Health Institute has published the County Health Rankings since 2010. These rankings use population-based data to highlight health outcomes and the multiple determinants of these outcomes and to encourage in-depth health assessment for all United States counties. A significant methodological limitation, however, is the uncertainty of rank estimates, particularly for small counties. To address this challenge, we explore the use of longitudinal and pooled outcome data in hierarchical Bayesian models to generate county ranks with greater precision., Methods: In our models we used pooled outcome data for three measure groups: (1) Poor physical and poor mental health days; (2) percent of births with low birth weight and fair or poor health prevalence; and (3) age-specific mortality rates for nine age groups. We used the fixed and random effects components of these models to generate posterior samples of rates for each measure. We also used time-series data in longitudinal random effects models for age-specific mortality. Based on the posterior samples from these models, we estimate ranks and rank quartiles for each measure, as well as the probability of a county ranking in its assigned quartile. Rank quartile probabilities for univariate, joint outcome, and/or longitudinal models were compared to assess improvements in rank precision., Results: The joint outcome model for poor physical and poor mental health days resulted in improved rank precision, as did the longitudinal model for age-specific mortality rates. Rank precision for low birth weight births and fair/poor health prevalence based on the univariate and joint outcome models were equivalent., Conclusion: Incorporating longitudinal or pooled outcome data may improve rank certainty, depending on characteristics of the measures selected. For measures with different determinants, joint modeling neither improved nor degraded rank precision. This approach suggests a simple way to use existing information to improve the precision of small-area measures of population health.

Concerns about breast cancer overdiagnosis have increased the need to understand how cancers detected through screening mammography differ from those first detected by a woman or her clinician. We investigated risk factor associations for invasive breast cancer by method of detection within a series of case-control studies (1992-2007) carried out in Wisconsin, Massachusetts, and New Hampshire (n=15,648 invasive breast cancer patients and 17,602 controls aged 40-79 years). Approximately half of case women reported that their cancer had been detected by mammographic screening and half that they or their clinician had detected it. In polytomous logistic regression models, parity and age at first birth were more strongly associated with risk of mammography-detected breast cancer than with risk of woman/clinician-detected breast cancer (P≤0.01; adjusted for mammography utilization). Among postmenopausal women, estrogen-progestin hormone use was predominantly associated with risk of woman/clinician-detected breast cancer (odds ratio (OR)=1.49, 95% confidence interval (CI): 1.29, 1.72), whereas obesity was predominantly associated with risk of mammography-detected breast cancer (OR=1.72, 95% CI: 1.54, 1.92). Among regularly screened premenopausal women, obesity was not associated with increased risk of mammography-detected breast cancer (OR=0.99, 95% CI: 0.83, 1.18), but it was associated with reduced risk of woman/clinician-detected breast cancer (OR=0.53, 95% CI: 0.43, 0.64). These findings indicate important differences in breast cancer risk factors according to method of detection., (© The Author 2015. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Annually since 2010, the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation have produced the County Health Rankings-a "population health checkup" for the nation's over 3,000 counties. The purpose of this paper is to review the background and rationale for the Rankings, explain in detail the methods we use to create the health rankings in each state, and discuss the strengths and limitations associated with ranking the health of communities., Methods: We base the Rankings on a conceptual model of population health that includes both health outcomes (mortality and morbidity) and health factors (health behaviors, clinical care, social and economic factors, and the physical environment). Data for over 30 measures available at the county level are assembled from a number of national sources. Z-scores are calculated for each measure, multiplied by their assigned weights, and summed to create composite measure scores. Composite scores are then ordered and counties are ranked from best to worst health within each state., Results: Health outcomes and related health factors vary significantly within states, with over two-fold differences between the least healthy counties versus the healthiest counties for measures such as premature mortality, teen birth rates, and percent of children living in poverty. Ranking within each state depicts disparities that are not apparent when counties are ranked across the entire nation., Discussion: The County Health Rankings can be used to clearly demonstrate differences in health by place, raise awareness of the many factors that influence health, and stimulate community health improvement efforts. The Rankings draws upon the human instinct to compete by facilitating comparisons between neighboring or peer counties within states. Since no population health model, or rankings based off such models, will ever perfectly describe the health of its population, we encourage users to look to local sources of data to understand more about the health of their community.