Improve the health of the people of Wisconsin by supporting and strengthening physicians' ability to practice high-quality patient care in a changing environment.

Volume 104, Issue 5 (July 2005)

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Thomas C. Meyer, MD, Medical Editor, Wisconsin Medical Journal
Combatting obesity: What’s working, what’s not
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Obesity surely is and will continue to be one of the major medical scourges of this century. Equally surely, it is a malady that health professionals cannot deal with on our own. We need all the help we can get from many sources—from the community, through business and maybe even government—if significant inroads are to be made in managing such a widespread epidemic. Perhaps one of our major roles is to keep the issue in the foreground by whatever means we can devise.


Daniel J. McCarty, PhD
Glucose intolerance in Wisconsin’s Hmong population
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Rapid change from traditional to westernized lifestyles almost always results in higher rates of obesity and type 2 diabetes.1 Whether a population develops these metabolic problems is dependent on the interaction of their genetic susceptibility and the extent to which they adopt the high fat, high caloric diets and lower levels of physical activity characteristic of modern lifestyles. Many ethnic groups, such as North American Indians, Mexican Americans, Australian Aborigines, Pacific Islanders, Asian Indians, and Chinese are particularly susceptible to developing obesity and glucose intolerance. Immigrants of these ethnicities who settle in developed countries face a particularly high risk, especially offspring who may be more likely than their parents to adopt westernized diets and low levels of physical activity.

Amy Helwig, MD, MS; Dennis Schultz, MD, MSPH; Len Quadracci, MD
Obesity and corporate America: One Wisconsin employer’s innovative approach
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The United States has an obesity epidemic, and Wisconsin’s employers are not sheltered from its impact. Obesity, defined as a BMI greater than 30, has increased dramatically over the past 20 years. In 1991, only four states had obesity prevalence rates greater than 15%. By 2003, all states had rates of at least 15%, 31 states had a rate greater than 20%, and four had a rate greater than 25%.1 Employers have an interest in the obesity epidemic, since it has the potential to decrease worker productivity while increasing health care costs.2,3 Therefore, some companies have initiated incentive programs to promote wellness and combat obesity. Preliminary data suggests that well-designed programs can be effective.4 Recognizing that obesity is a public health issue, Wisconsin has set goals for employers, health plans, and health providers to actively address obesity management. The Wisconsin Nutrition and Physical Activity Workgroup (WINPAW) has identified key objectives related to obesity management in Wisconsin (Table 1).

Original Research

Casey L. Schumann, BS; Patrick L. Remington, MD, MPH
Using Local Data to Monitor Obesity Rates in Wisconsin Counties, 1994-2003
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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 >50 and >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.

Laura A. McCauley, MD; Angela Kempf, MA; Jon Morgan, MS; Murray L. Katcher, MD, PhD; Patrick Remington, MD, MPH
Overweight Among High School Children: How Does Wisconsin Rank?
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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 >85 percentile and <95 percentile] and the “overweight” group [defined as BMI >95 percentile] were combined and labeled as “overweight” [BMI >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.

Aaron L. Carrel, MD; David B. Allen, MD
Off the Growth Curve: The Challenge of Childhood Obesity
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Childhood obesity is an increasingly recognized problem. Health professionals caring for children and adolescents are in a key position to promote behavioral and environmental changes. Still, there is confusion regarding medical evaluation, communication with the family about the implications, and specific treatment goals. This review summarizes appropriate medical evaluation and common sequelae of childhood obesity, and presents a proactive multidiscipline approach to evaluate and treat childhood obesity.

Sarah Fox, MD; Amy Meinen, RD, CD; Mary Pesik, RD, CD ; Matthew Landis, MS; Patrick L. Remington, MD, MPH
Competitive Food Initiatives in Schools and Overweight in Children: A Review of the Evidence
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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.

Aaron Carrel, MD; Amy Meinen, RD; Charmaine Garry, BA, MES, CFT; Renee Storandt, BS, MT
Effects of Nutrition Education and Exercise in Obese Children: The Ho-Chunk Youth Fitness Program
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Background: Type 2 diabetes is increasingly common, primarily because of increases in the prevalence of a sedentary lifestyle and obesity. This is even more apparent in certain minority populations, such as Native Americans. Whether the risk of type 2 diabetes can be decreased by interventions that affect the lifestyles of children at high risk is not known.

Methods: The Ho-Chunk Youth Fitness Project, aimed at dietary and exercise instruction and intervention, consists of 38 native (Ho-Chunk Tribe, Wisconsin) and non-native children (ages 6-18 years). Children underwent evaluation including medical exam, nutrition, exercise assessment, metabolic testing of fasting plasma insulin, plasma glucose, plasma cholesterol, and percent body fat before and after a 24-week intervention. Intervention consisted of twice weekly classes with supervision for both nutrition and exercise.

Results: Mean fasting plasma insulin decreased from 22±7.7µIU/ml to 11±6µIU/ml (normal <15 µIU/ml) after 24 weeks of training (P<0.05). Percent body fat (30.2±6.4%), glucose (91±9 mg/dL), and total cholesterol (182±22 mg/dL) remained unchanged during this time. Conclusions: Risks for insulin resistance and type 2 diabetes, as measured by fasting insulin (an indirect measurement of insulin sensitivity in obese children), can be decreased by supervised nutrition and exercise intervention. Furthermore, hyperinsulinemia in overweight children can be reduced without decreasing body fat. James W. Burhop, MD, FACS; Manfred C. Chiang, MD, FACS; David J. Engstrand, MD, FACS; Megan O’Driscoll, RN
Laparoscopic Bariatric Surgery Can Be Performed Safely in the Community Hospital Setting
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Background: Bariatric surgery is being performed commonly in various practice settings. To evaluate safety and efficacy, we reviewed the results of our first 516 laparoscopic bariatric operations performed in a community hospital setting.

Methods: We reviewed retrospectively the results of our first 516 consecutive laparoscopic bariatric procedures.

Results: Between December 2001 and December 2004, we performed 516 bariatric surgical procedures. Ninety-nine percent of these were accomplished laparoscopically. Thirty-day mortality in our series of 516 patients is 0%. Of these patients, 431 had laparoscopic gastric bypass. The mean BMI in these patients was 51. Mean percent excess weight loss in the laparoscopic gastric bypass patients was 71% at 1 year, 75% at 2 years and 79% at 3 years. Complications in the laparoscopic bypass group requiring reoperation included 11 bowel obstructions (2.5%), 5 episodes of bleeding (1.1%), and 2 laparoscopies for benign reasons. There were 8 anastomotic leaks (1.9%)—7 requiring reoperation, 1 managed nonoperatively. Eighty-five patients had adjustable gastric banding. Mean BMI was 45. Mean percent excess weight loss in the adjustable gastric banding patients was 39% at 1 year and 57% at 2 years. Complications in the adjustable gastric band patients requiring reoperation included 3 access port malfunctions (3.5%), 3 prolapsed bands (3.5%), 1 punctured band requiring replacement (1.2%) and 1 band causing complete obstruction requiring removal (1.2%).

Conclusion: Laparoscopic bariatric surgery can be performed safely in the community hospital setting with a very low operative morbidity and mortality. This requires an experienced team of bariatric surgeons leading a multidisciplinary team of other health care professionals. Surgeon experience and super obesity can influence the risks.

Brenda L. Rooney, PhD; Lisa R. Gritt; Sarah J. Havens, BS; Michelle A. Mathiason, MS; Elizabeth A. Clough, MPH
Growing Healthy Families: Family Use of Pedometers to Increase Physical Activity and Slow the Rate of Obesity
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Objective: We conducted a study to determine if wearing a pedometer affects weight, body mass index (BMI), or mediators of physical activity among families.

Methods: Eighty-seven families were randomized to 1 of 3 treatments: pedometer plus education (PE), pedometer (P), or control (C). Participants in the PE and P groups wore pedometers and were encouraged to walk 10,000 steps daily for 12 weeks. PE group participants attended 6 sessions on healthy eating and exercise. Participants were surveyed about their knowledge and attitudes about healthy eating and physical activity prior to randomization, at the end of the intervention, and 9 months later. Their heights and weights were measured and BMI calculated.

Results: Children’s BMI percentile decreased from baseline to end of intervention (-0.18%) and at 9-month follow-up (-0.08%) but did not differ by treatment. Children’s BMI percentile varied by parental obesity status (average BMI percentile was 88.7% for children of obese parents and 78.5% for children of non-obese parents). Parents’ weight decreased slightly by intervention’s end (0.6 pounds) and at 9 months (1.2 pounds), but change was similar among groups. Attitudes about their physical activity level relative to their peers improved significantly among children and parents wearing the pedometer. Self-efficacy improved for parents wearing the pedometer. Both children and parents felt the pedometer increased their activity level, but most were unlikely to wear it beyond the intervention.

Conclusions: The pedometer had little impact on the activity level, weight, or BMI of participants.

Catherine A. McCarty, PhD, MPH, RD; Dave Scheuer, BS
Lessons Learned from Employee Fitness Programs at the Marshfield Clinic
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Purpose: To describe and evaluate employee fitness programs at the Marshfield Clinic.

Methods: A 16-week program was offered to employees from April-July 2004, and a 12-week program was offered from August-November, 2004. Weekly e-mails included suggestions to increase physical activity and eat a healthy diet. Incentives were offered for meeting program goals.

Results: A total of 1129 employees signed up for the first program (approximately 18% of all employees) and 610 for the second program. More than 95% of the participants in both programs were female. The activity program goal was met by 231 (20.5%) participants in the first program and 31% (n=190) of participants in the second program. There was a significant increase in the percent of people with good or excellent fitness levels from baseline (46.4%, 95%CL=40.5, 52.3) to follow-up (70.7%, 95%CL=65.3, 76.0) in the first program. In the second program, there was a significant association between the number of program goals met and self-report of having increased energy, better weight control, and feeling better overall and about body image.

Conclusion: Emphasis in future programs should be placed on increasing employee participation. Program evaluation could be expanded to include health care costs and employee absenteeism.

Catherine A. McCarty, PhD, MPH, RD; Laura Lee, PhD; J. Douglas Lee, MD
Food Offerings in Marshfield Area Businesses: A Survey Conducted in Collaboration with the Healthy Lifestyles – Marshfield Area Coalition
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Purpose: To survey Marshfield area businesses to determine the types of foods currently available to employees at the workplace and the potential need for nutrition information to facilitate the ordering of healthy food options at workplaces.

Methods: A 2-page self-administered questionnaire was mailed to all businesses registered with the Marshfield Area of Chamber of Commerce. Questionnaires were mailed a second time to non-responders to improve the response rate. The questionnaire included items about foods available to employees at the workplace, cooking and eating facilities available to employees, and reasons for food choices made. Data were entered into an Excel spreadsheet, verified against the hard copies and transferred to SPSS for analysis.

Results: Completed questionnaires were returned by 249 businesses (41.1% participation). The reported number of minutes that most employees take for their lunch ranged from 0 to 60 (median=30). Eighty-one percent of businesses (n=184) reported that most employees take 30 or more minutes for their lunch. Respondents were asked to list the most common menu items purchased for consumption on-site. One hundred fifteen respondents listed sandwiches (46.2%), 101 listed pizza (40.6%), 30 listed salad (12.0%), and 17 listed various sweets (6.8%). Employees were thought to be less likely than managers to select foods lower in calories if the foods are more expensive.

Discussion: There is great potential to improve the health of employees through the provision of nutrition information to businesses. The survey employed in the current study can be used again in the future to track changes after implementation of worksite initiatives through the Business and Industry Committee of the Healthy Lifestyles – Marshfield Area Coalition.

Cheng Her, MD; Marlon Mundt, MS
Risk Prevalence for Type 2 Diabetes Mellitus in Adult Hmong in Wisconsin: A Pilot Study
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Objective: To quantify the proportion that may be at risk for developing type 2 diabetes among a convenience sample of Hmong adults in Wisconsin using the 2000 American Diabetes Association (ADA) Clinical Practice Recommendations for community screening.

Methods: Design was a cross sectional survey. One hundred forty-four participants completed the survey, which consisted of a demographic questionnaire and the ADA Risk Test. Casual capillary whole blood glucose values, blood pressure, height, weight, and waist and hip circumference measures were also recorded. Predictors of positive casual capillary whole blood glucose value (>140 mg/dl) were identified using logistic regression.

Results: Forty-one percent demonstrated positive blood glucose screens on survey. Waist-to-hip ratio was a stronger predictor of a positive screen (Odds Ratio = 3.2 [95% CI: (1.5, 6.2)]) than the ADA Risk Test (Odds Ratio = 2.7 [95% CI: (1.4, 5.1)]).

Conclusions: Hmong adults in Wisconsin demonstrate an increased risk for type 2 diabetes. Present findings are consistent with studies demonstrating increased disease risk in newly arrived populations of industrialized countries.

Your Practice

J. Mark Bridges, MD; David A Feldstein, MD
Clinical Questions #3: Preventing contrast-induced nephropathy: A basic solution
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This is the third installment in a series of “Clinical Questions.” Readers are presented with a case and clinical question. An evidence-based answer is provided on a later page. The answer includes how the evidence was found and evaluated.

Brian H. Reamer, CFP, CSA, CFS, CRS
Save tax dollars following the real estate tax rules
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Did you know that two Internal Revenue Service (IRS) Code Sections can actually help you save tax dollars? The exclusion of gain from the sale or exchange of a personal residence under Section 121 and the ability to defer a gain from the exchange of business or investment property through a like-kind exchange under Section 1031 are both options you may want to take advantage of.

Your Profession

Michael J. Dunn, MD
Public health projects leap forward through Healthier Wisconsin Partnership Program
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Community health initiatives have long been a commitment of our institution, and the Medical College of Wisconsin is fortunate to have a new, well-funded instrument for improving public and community health. We recently approved 23 community-academic partnership projects statewide through the College’s Healthier Wisconsin Partnership Program (Program).

Ruth Heitz, JD
Wisconsin’s Immunization Registry
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Over the past several years, the United States, in partnership with state and world health agencies, has implemented an aggressive immunization program to diminish the impact of many debilitating and sometimes fatal childhood diseases.

Your Society

Michael J. Kretz, MD; Michele L. Bachhuber, MD; Cindy P. Helstad, PhD
Wisconsin Medical Society Obesity Task Force Summary
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The Wisconsin Medial Society recognizes the tremendous burden obesity places on patients, their families, and our health care system, and that physicians play an essential role in the prevention and management of this problem. Therefore, the Society’s Board of Directors created the Obesity Task Force in April, 2004.

H. Reineking, MD
The Radical Treatment of Cancer of the Stomach
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The radical treatment of cancer of the stomach can only mean what the radical treatment of cancer implies in other parts of the body—surgical removal of the primary growth, together with any tissues that may have become secondarily affected. There is no medical treatment of cancer other than alleviation of symptoms, and even in the palliative treatment surgical intervention may be of the greatest service, as, for example, in the relief of conditions due to pyloric obstruction by gastroenterostomy, or of obstruction esophageal orifice by gastrostomy, or the establishing of a permanent channel for the introduction of nutriment into the organ.