1. Wisconsin Department of Health Services January 2014 P-00522K Healthiest Wisconsin 2020 Baseline and Health Disparities Report Nutrition

2. NUTRITION Background Overview of Healthiest Wisconsin 2020 Baseline and Health Disparities Report Healthiest Wisconsin 2020 objectives and indicators Rationale Key points Data Weight and dietary behaviors among youth Weight and dietary behaviors among adults Breastfeeding Access to healthy foods References Links to additional reports and resources Contacts Chapter Outline 2 Chapter outline

3. NUTRITION Report Overview This chapter is part of a larger report created by the Wisconsin Department of Health Services to track progress on the objectives of Healthiest Wisconsin 2020 (HW2020) and identify health disparities in the state. The full report is available at: http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf The report is designed to address the Health Focus Areas in HW2020. Where direct measures exist, data are presented; where direct measures are not available, related information may be included. Information about populations experiencing health disparities is provided in the Health Focus Area chapters and is summarized in separate chapters devoted to specific populations. Technical notes are available at: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf Report overview 3

4. NUTRITION Report Format Full Report Format: PDF Intended use: reference document Chapters Format: Annotated PowerPoint slide set Intended uses: presentations to –Decision-makers –Service providers –Community leaders –The public Sample annotated slide Report overview 4

5. NUTRITION Report Outline Executive Summary Section 1: Introduction Section 2: Demographic overview Section 3: Health focus areas Section 4: Infrastructure focus areas Section 5: Data summaries by population Section 6: Technical notes Report overview 5

6. NUTRITION Report Outline: Detail Section 3: Health focus areas Alcohol and other drug use Chronic disease prevention and management Communicable diseases Environmental and occupational health Healthy growth and development Injury and violence Mental health Nutrition and healthy foods Oral health Physical activity Reproductive and sexual health Tobacco use and exposure Section 4: Infrastructure focus areas Access to health care Report overview 6

7. NUTRITION Report Outline: Detail Section 5: Data summaries by population  Racial/ethnic minority populations o American Indians o Asians o Blacks o Hispanics  People of lower socioeconomic status  People with disabilities  Lesbian, gay, bisexual, and transgender populations  Geography Report overview 7

8. NUTRITION Data notes Please refer to the Technical Notes chapter for a more detailed description of limitations and methods: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf The 95% confidence intervals are denoted by error bars. Where confidence intervals do not overlap, as shown in the example on the right, differences are statistically significant. Larger confidence intervals may indicate less reliable estimates that should be interpreted with caution. Population estimates that are considered unreliable are excluded. Misclassification of racial/ethnic groups may affect the accuracy of rates. Unless otherwise indicated, the Hispanic population may include people of various races; Whites, Blacks, Asians, and American Indians are non- Hispanic. Report overview 8

9. NUTRITION Factors that influence health Social determinants of health Source: University of Wisconsin Population Health Institute. County Health Rankings 2013, http://www.countyhealthrankings.org/our-approach Report overview 9

10. NUTRITION Objective 1 By 2020, people in Wisconsin will eat more nutritious foods and drink more nutritious beverages through increased access to fruits and vegetables, decreased access to sugar-sweetened beverages and other less nutritious foods, and supported, sustained breastfeeding. Objective 1 Indicators Proportion of Wisconsin infants exclusively breastfed at 3 months, and breastfeeding duration of at least 6 months and 12 months. Proportion of Wisconsin census tracts with healthy food retailers. Number of farmers markets per 100,000 population. Proportion of Wisconsin and Milwaukee schools that do not sell candy, high-fat snacks, or soda and juice that is not 100% juice. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Adequate Nutrition Focus Area Profile. Healthiest Wisconsin 2020 objectives and indicators 10 HW2020 objectives

11. NUTRITION Objective 2 By 2020, all people in Wisconsin will have ready access to sufficient nutritious, high-quality, affordable foods and beverages. Objective 2 Indicators Proportion of Wisconsin infants exclusively breastfed at three months among racial/ethnic populations, low income and low education population groups. Proportion of Wisconsin farmers markets that accept payment from Electronic Benefit Transfer (EBT) and Women, Infants and Children (WIC) Farmers Market Nutrition Program Coupons. Proportion of Wisconsin households with low and very low food security. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Adequate Nutrition Focus Area Profile. 11 HW2020 objectives Healthiest Wisconsin 2020 objectives and indicators

12. NUTRITION Objective 3 By 2020, Wisconsin will reduce disparities in obesity rates for populations of differing races, ethnicities, sexual identities and orientations, gender identities, and educational or economic status. Objective 3 Indicators Proportion of adults who are obese or overweight by race and ethnicity. Proportion of Wisconsin and Milwaukee high school youth who are obese or overweight by race/ethnicity. Proportion of children aged 2-4 years in the Women, Infants and Children (WIC) program who are obese or overweight by race and ethnicity. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Adequate Nutrition Focus Area Profile. 12 HW2020 objectives Healthiest Wisconsin 2020 objectives and indicators

13. NUTRITION Rationale Adequate, appropriate and safe food and nutrition means the regular and sufficient consumption of nutritious foods across the life span, to support normal growth and development of children and promote physical, emotional, and social well-being for all people. Good nutritional practices can reduce the risk for a number of chronic diseases, such as type 2 diabetes, cancer, heart disease, and stroke, as well as chronic conditions such as obesity. Over the past several decades, cultural, social and individual changes have occurred to make healthful eating more difficult and obesity more likely. Changing environments and implementing policies to support healthful eating are likely to be critical for preventing obesity and improving overall health. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Adequate Nutrition Focus Area Profile. 13 Rationale

14. NUTRITION Key points Youth During 2007-2011, approximately 10% of high school students in Wisconsin were obese and 14% were overweight. In 2010, 14% of children (ages 2-4 years) enrolled in WIC were obese. Approximately one-quarter of students in each racial/ethnic group consumed soda daily. More than one in three infants is exclusively breastfed initially; however, only 15% are exclusively breastfed until six months, as recommended. Approximately 70% of all low-income children are ever breastfed. The highest percentage was among Hispanic children (81%) and the lowest was among Asian children (50%). 14 Key points

15. NUTRITION Key points Adults In 2009-2011, approximately two-thirds (65%) of Wisconsin adults were overweight or obese and 29% were obese. Significant disparities exist in the prevalence of adult obesity. For example: o Black and American Indian adults were significantly more likely to be obese compared to White adults. o Adults with the lowest household income were significantly more likely to be overweight or obese compared to middle- or high-income adults. o Among Wisconsin adults ages 18-64, those with a disability were more likely to be overweight or obese than those without a disability. Nearly one-quarter of Wisconsin adults ages 18-24 consumed less than two servings of vegetables per day, a significantly higher proportion than for adults over age 25. While Wisconsin has nearly twice the number of farmers markets per 100,000 as the U.S., farmers markets are less accessible to Supplemental Nutrition Assistance Program recipients in Wisconsin than in the nation. 15 Key points

16. NUTRITION Weight and dietary behaviors among youth 16

17. NUTRITION Overweight, obesity, and weight loss attempts among Wisconsin high school students, by race/ethnicity, 2007-2011 Weight and dietary behaviors among youth Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. 17

18. NUTRITION Overweight, obesity, and weight loss attempts among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Weight and dietary behaviors among youth 18

19. NUTRITION Consumption of fresh fruit, salad, and soda in the previous week among Wisconsin high school students, by race/ethnicity, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Weight and dietary behaviors among youth 19

20. NUTRITION Consumption of fresh fruit, salad, and soda in the previous week among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Weight and dietary behaviors among youth 20

21. NUTRITION Obesity among children ages 10-17, by disability status, Wisconsin, 2011-2012 Source: 2011-2012 National Survey of Children's Health Weight and dietary behaviors among youth 21

22. NUTRITION Obesity among children (ages 2-4 years) enrolled in WIC, by race/ethnicity, Wisconsin, 2001 and 2010 Source: Centers for Disease Control and Prevention (CDC) Pediatric Nutrition Surveillance Survey, 2010. Note: Based on >= 95 th growth chart percentiles for Body Mass Index for age. WIC is the Supplemental Nutrition Program for Women, Infants, and Children. Weight and dietary behaviors among youth 22

23. NUTRITION Weight and dietary behaviors among adults 23

24. NUTRITION Overweight and obesity among Wisconsin adults, by sex, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 landline-cellphone combined dataset. Weight and dietary behaviors among adults 24

25. NUTRITION Overweight and obesity among Wisconsin adults, by age, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 landline-cellphone combined dataset. Weight and dietary behaviors among adults 25

26. NUTRITION Age-adjusted rates of overweight and obesity among Wisconsin adults by race/ethnicity, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Weight and dietary behaviors among adults 26

27. NUTRITION Age-adjusted rates of overweight and obesity among Wisconsin adults, by household income, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Weight and dietary behaviors among adults 27

28. NUTRITION Age-adjusted rates of overweight and obesity among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Weight and dietary behaviors among adults 28

29. NUTRITION Rates of overweight and obesity by disability status, Wisconsin adults ages 18-64, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 land-line only dataset. 29 Weight and dietary behaviors among adults

30. NUTRITION Overweight and obesity among Wisconsin adults, by sexual orientation and sex, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Weight and dietary behaviors among adults 30

31. NUTRITION Low vegetable consumption among Wisconsin adults, by sex, 2009 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 landline-cellphone combined dataset. Note: Data from 2009 only. Weight and dietary behaviors among adults 31

32. NUTRITION Low vegetable consumption among Wisconsin adults, by age, 2009 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 landline-cellphone combined dataset. Note: Data from 2009 only. Weight and dietary behaviors among adults 32

33. NUTRITION Age-adjusted rate of low vegetable consumption among Wisconsin adults, by race/ethnicity, 2009 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Data from 2009 only. Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Weight and dietary behaviors among adults 33

34. NUTRITION Age-adjusted rate of vegetable consumption among Wisconsin adults by income level, 2009 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Data from 2009 only. Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Weight and dietary behaviors among adults 34

35. NUTRITION Age-adjusted rate of low vegetable consumption among Wisconsin adults, by education level, 2009 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Data from 2009 only. Weight and dietary behaviors among adults 35

36. NUTRITION Age-adjusted rate of low vegetable consumption among Wisconsin adults, by level of urbanization, 2009 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Data from 2009 only. Weight and dietary behaviors among adults 36

37. NUTRITION Low vegetable consumption among Wisconsin adults ages 18-64, by disability status, 2009 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Data from 2009 only. Weight and dietary behaviors among adults 37

38. NUTRITION Breastfeeding 38

39. NUTRITION Percentage of infants who were ever breastfed and exclusively breastfed, Wisconsin, 2007-2012 Source: Centers for Disease Control and Prevention (CDC), National Immunization Survey Report, 2007-2012. Note: Exclusive breastfeeding is defined as only breast milk, no solids, no water, and no other liquid. Years represent survey year. The birth cohort years are 2004-2008. Breastfeeding 39

40. NUTRITION Breastfeeding practices by maternal race/ethnicity, Wisconsin, 2009-2011 Breastfeeding Source: Wisconsin PRAMS, 2009-2011. Division of Public Health, Department of Health Services. Note: “Other” includes Asians and American Indians. 40

41. NUTRITION Breastfeeding practices by maternal income, Wisconsin, 2009-2011 Source: Wisconsin PRAMS, 2009-2011. Division of Public Health, Department of Health Services. Breastfeeding 41

42. NUTRITION Breastfeeding practices by maternal education, Wisconsin, 2009-2011 Breastfeeding Source: Wisconsin PRAMS, 2009-2011. Division of Public Health, Department of Health Services. 42

43. NUTRITION Access to healthy foods 43

44. NUTRITION Availability of healthier foods through access to farmers markets, Wisconsin and the United States, 2012 Source: Centers for Disease Control and Prevention (CDC), State Indicator Report on Fruits and Vegetables, 2013. Note: SNAP = Supplemental Nutrition Assistance Program; WIC = Women, Infants, and Children Supplemental Nutrition Program; FMNP = Farmers Market Nutrition Program. Access to healthy foods 44

45. NUTRITION Proportion of households that experience food insecurity, Wisconsin, 2010 Source: United States Department of Agriculture (USDA), Household Food Security in the United States, 2010. Access to healthy foods Secure Insecure 1 in 8 households experience food insecurity 45

46. NUTRITION Percentage of middle and high schools that sell less nutritious foods and beverages outside of the food service program, Wisconsin, Milwaukee, and the United States, 2010 Source: Centers for Disease Control and Prevention (CDC), School Health Profiles, 2010. *Milwaukee was one of 20 participating cities. Wisconsin Milwaukee* Median of U.S. states Median of U.S. cities* Access to healthy foods 46

47. NUTRITION References 1.University of Wisconsin Population Health Institute. County Health Rankings, 2013. http://www.countyhealthrankings.org/our-approach http://www.countyhealthrankings.org/our-approach 2.Center for Urban Population Health. Milwaukee Health Report, 2011. http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf 3.LaVeist TA, Gaskin DA, Richard P (2009). The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic% 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic% 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf 4.Thomas JC, Sage M, Dillenberg J, Guillory VJ (2002). A Code of Ethics for Public Health. Am Journal of Public Health. 92(7):1057–1059. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ 5.Wisconsin Department of Health Services (DHS). Healthiest Wisconsin 2020. http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf 6.Centers for Disease Control and Prevention (CDC). Adolescent and School Health: Childhood Obesity Facts. http://www.cdc.gov/healthyyouth/obesity/facts.htmhttp://www.cdc.gov/healthyyouth/obesity/facts.htm 7.CDC. Adolescent Health in the United States. http://www.cdc.gov/nchs/data/misc/adolescent2007.pdf http://www.cdc.gov/nchs/data/misc/adolescent2007.pdf 8.CDC. Adolescent and School Health: Nutrition Facts. http://www.cdc.gov/healthyyouth/nutrition/facts.htm http://www.cdc.gov/healthyyouth/nutrition/facts.htm 47 References

48. NUTRITION 9.U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Children with Special Health Care Needs in Context: A Portrait of States and the Nation 2007. Rockville, MD: U.S. Department of Health and Human Services, 2011. http://www.mchb.hrsa.gov/nsch/07cshcn/ http://www.mchb.hrsa.gov/nsch/07cshcn/ 10.CDC. Obesity Prevalence Among Low-Income, Preschool-Aged Children - United States, 1998-2008. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5828a1.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5828a1.htm 11.CDC. About BMI for adults. http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html#Definition http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html#Definition 12.Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, Prevalence and Trends Data. http://apps.nccd.cdc.gov/brfss/http://apps.nccd.cdc.gov/brfss/ 13.CDC. Disability and Obesity. http://www.cdc.gov/ncbddd/disabilityandhealth/obesity.html http://www.cdc.gov/ncbddd/disabilityandhealth/obesity.html 14.Boehmer U, Bowen DJ, Bauer GR. Overweight and obesity in sexual minority women: evidence from population-based data. American Journal of Public Health. 2007; 97: 1134–1140. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874217/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874217/ 15.National Eating Disorders Association. Eating Disorders in LGBT Populations. http://www.nationaleatingdisorders.org/sites/default/files/ResourceHandouts/LGBTQ. pdf http://www.nationaleatingdisorders.org/sites/default/files/ResourceHandouts/LGBTQ. pdf 16.CDC. State indicator report on Fruits and Vegetables, 2013. http://www.cdc.gov/nutrition/downloads/State-Indicator-Report-Fruits-Vegetables- 2013.pdf http://www.cdc.gov/nutrition/downloads/State-Indicator-Report-Fruits-Vegetables- 2013.pdf 17.U.S. Department of Agriculture. ChooseMyPlate.gov. http://www.choosemyplate.gov/food-groups/vegetables-amount.html http://www.choosemyplate.gov/food-groups/vegetables-amount.html 48 References

49. NUTRITION 18.American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. http://pediatrics.aappublications.org/content/129/3/e827 http://pediatrics.aappublications.org/content/129/3/e827 19.Wisconsin PRAMS. What Moms Tell Us: Breastfeeding (August 2012). http://www.dhs.wisconsin.gov/publications/p0/p00398.pdf http://www.dhs.wisconsin.gov/publications/p0/p00398.pdf 20.CDC. Breastfeeding Report Card. http://www.cdc.gov/breastfeeding/data/reportcard/reportcard2012.htm 21.CDC: PRAMS and Breastfeeding. http://www.cdc.gov/prams/Breastfeeding.htmhttp://www.cdc.gov/prams/Breastfeeding.htm 22.Public Health Reports. Socioeconomic Status and Breastfeeding Initiation Among California Mothers. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497787/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497787/ 23.DHS, Division of Public Health. Wisconsin PRAMS, 2009-2011. 24.CDC. State Indicator Report on Fruits and Vegetables, 2013. http://www.cdc.gov/nutrition/downloads/State-Indicator-Report-Fruits-Vegetables- 2013.pdf http://www.cdc.gov/nutrition/downloads/State-Indicator-Report-Fruits-Vegetables- 2013.pdf 25.United States Department of Agriculture (USDA). Household Food Security in the United States. http://www.ers.usda.gov/media/121076/err125_2_.pdfhttp://www.ers.usda.gov/media/121076/err125_2_.pdf 26.Institute of Medicine (IOM). Nutrition Standards for Foods in Schools: Leading the Way to Healthier Youth. http://www.iom.edu/Reports/2007/Nutrition-Standards-for- Foods-in-Schools-Leading-the-Way-toward-Healthier-Youth.aspxhttp://www.iom.edu/Reports/2007/Nutrition-Standards-for- Foods-in-Schools-Leading-the-Way-toward-Healthier-Youth.aspx 27.CDC. School Health Profiles 2010. http://www.cdc.gov/healthyyouth/profiles/2010/profiles_report.pdf http://www.cdc.gov/healthyyouth/profiles/2010/profiles_report.pdf 49 References

50. NUTRITION Links to additional reports and resources The Epidemic of Chronic Disease in Wisconsin: Why it Matters to the Economy and What You Can Do to Help: http://www.dhs.wisconsin.gov/publications/P0/P00238.pdf Obesity, Nutrition, and Physical Activity in Wisconsin: http://www.dhs.wisconsin.gov/physical-activity/ http://www.dhs.wisconsin.gov/physical-activity/ Breastfeeding Report Card-2012: http://www.cdc.gov/breastfeeding/pdf/2012breastfeedingreportcard.pdf http://www.cdc.gov/breastfeeding/pdf/2012breastfeedingreportcard.pdf Pediatric Nutrition Surveillance System: http://www.dhs.wisconsin.gov/wic/WICPRO/data/PedNSS/index.htm Household Food Security in the United States in 2010: http://www.ers.usda.gov/media/121076/err125_2_.pdf http://www.ers.usda.gov/media/121076/err125_2_.pdf Wisconsin Nutrition, Physical Activity and Obesity Program: http://www.dhs.wisconsin.gov/physical-activity/ http://www.dhs.wisconsin.gov/physical-activity/ Centers for Disease Control and Prevention (CDC). Nutrition: http://www.cdc.gov/nutrition/ 50 Links

51. NUTRITION Contact Kelli Stader, MPH, RD, CLS Nutrition Coordinator Chronic Disease Prevention Unit Bureau of Community Health Promotion Division of Public Health Wisconsin Department of Health Services Email: Kelli.Stader@dhs.wisconsin.govKelli.Stader@dhs.wisconsin.gov 51 Contacts