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Childhood obesity: an estimate of prevalence in Canada and an analysis of associated factors Limbert, Joanne Marie 1994

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CHILDHOOD OBESITY: AN ESTIMATE OF PREVALENCE IN CANADA AND AN ANALYSIS OF ASSOCIATED FACTORS by JOANNE MARIE LIMBERT B.Sc, Simon Fraser University, 1987 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCES in THE FACULTY OF GRADUATE STUDIES (School of Family and Nutritional Sciences) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August 1994 (c\ J o a n n e Marie Limbert, 1994 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of ^ / U l l M t M U T R l W / l t S t t ^ U C B S> The University of British Columbia Vancouver, Canada Date ^ 'irrry DE-6 (2/88) ABSTRACT Childhood obesity is a complex, multifaceted problem with genetic, biochemical, physiological and environmental components. A first step in determining appropriate treatment and prevention strategies for childhood obesity is an epidemiological diagnosis. Accordingly, the objectives of this study were to estimate the prevalence of childhood obesity in Canada using available data from two National surveys (Canada Fitness Survey, 1981 and Campbell's Survey on Well-being in Canada, 1988) and to determine if significant differences existed between the obese children (OC) and the non-obese children (NOC) with respect to specific lifestyle, physical and psychological factors as well as attitudes and goals concerning physical activity. In addition, parental data was analyzed to determine if significant differences existed between the parents and their children with regards to these same factors. Using the age and sex specific 85th percentile of the sum of 5 skinfolds from the Canada Fitness Survey as the criteria for obesity, the prevalence of obesity among children aged 7 to 12 years was shown to have risen from 15.4% in 1981 to 23.9% in 1988. This increase was larger among females (15.3% to 25.9%) than males (15.2% to 22.0%). As expected, the mean weight, BMI, triceps skinfold and sum of 5 skinfolds were significantly larger in the OC, compared to the NOC and the OC were significantly taller and had a significantly higher resting heart rate. The OC also appeared to be less fit as evidenced by their significantly inferior performance on the ii Canadian Standardized Test of Fitness Step Test. Results from energy expenditure data provided further evidence that the OC were less active than the NOC. Overall, the OC and NOC were similar with respect to their general eating habits with the only exception being that obese females ate breakfast significantly less often than non-obese females. The responses to several different questions indicated that significantly more of the OC were concerned with their weight and were trying to lose, or at least maintain, their weight. The obese females watched significantly less television than the non-obese females while no differences were found between obese and non-obese males. Significantly more of the OC identified "a lack of time due to work or school" as an important barrier to participating more regularly in physical activity. Several of the attitudes obese males had towards physical activity were significantly different from those of non-obese males with the obese males tending to have less positive attitudes. In addition, the obese males indicated a significantly lower level of support from their parents and close friends to participate in physical activity. Overall, the analysis of the parental data indicated that, compared to their children, the parents had less desirable eating habits, different goals with regards to their spare time, less positive attitudes towards physical activity and they were less active. These differences were often significant when the parents of non-obese children were compared to their children while they were less likely to be significant when the parents of iii obese children were compared to their children. As well, there was a high prevalence of obesity among the parents with a significantly higher proportion of the parents of obese children being obese compared to the parents of non-obese children. In general, the results of this study provide evidence that the prevalence of childhood obesity in Canada is increasing and that OC may differ from NOC with respect to certain lifestyle and physical factors. Additional research in this area is needed to further understand the behavioural and environmental factors that are contributing to this increasing health problem. iv TABLE OF CONTENTS Abstract ii Table of Contents v List of Tables vii I. INTRODUCTION 1 A) Rationale 1 B) Hypotheses 2 C) Objectives 3 II. LITERATURE REVIEW 4 A) Assessment of Obesity 4 B) Prevalence of Childhood Obesity 9 C) Etiology of Childhood Obesity 10 D) Risks Associated with Childhood Obesity 18 E) Treatment of Childhood Obesity 21 F) Summary 27 III. METHODS AND PROCEDURES 28 A) Description of Surveys 28 B) Description of Variables 31 1) Physical Variables 31 2) Fitness and Activity Variables 32 3) Nutrition Variables 33 4) Psychosocial Variables 35 5) Familial Variables 36 6) Leisure Time Variables 37 7) Influences on Participation in Physical Activity 37 C) Statistical Analysis of the Data 40 IV. RESULTS 44 A) Prevalence of Childhood Obesity 44 B) Pearson Correlation Coefficient Values 46 C) Comparison of Obese Children and Non-Obese Children 48 1) Physical Variables 48 2) Fitness and Activity Variables 50 3) Nutrition Variables 56 4) Psychosocial Variables 62 5) Socioeconomic Variables 63 6) Leisure Time Activities 65 7) Goals and Attitudes Related to Physical Activity 67 i) Goals of Spare Time 67 ii) Barriers to Being More Physically Active 69 v iii) Attitudes Towards Regular Participation in Vigorous Physical Activity 72 iv) Encouragement by Others to Participate Regularly in Vigorous Physical Activity 74 v) Contribution of Vigorous Physical Activity to the Achievement of Specific Goals 75 D) Comparison of Children with their Parents 79 1) Obesity Status 79 2) Fitness and Activity Variables 79 3) Nutrition Variables 82 4) Psychosocial Variables 86 5) Leisure Time Activities 88 6) Goals and Attitudes Related to Physical Activity 9 0 i) Goals of Spare Time 90 ii) Barriers to Being More Physically Active 93 iii) Attitudes Towards Regular Participation in Vigorous Physical Activity 96 iv) Contribution of Vigorous Physical Activity to the Achievement of Specific Goals 98 IV. DISCUSSION 102 V. CONCLUSIONS AND RECOMMENDATIONS 118 References 121 Appendix 1: Campbell's Survey on Well-being in Canada: Survey Questionnaire 135 vi LIST OF TABLES Frequencies and percentages of the sample classified as obese by the obesity indicators (Marshall et al, 1991) 7 Correlation coefficients between common indices of weight and percentage body weight as fat for children aged 6-12.9 years (Bandini and Dietz, 1987) 9 Prevalence of obesity in Canadian children aged 7-12 years 45 Age specific prevalence of obesity in Canadian children in 1988 46 Pearson correlation coefficient values for selected variables with sum of 5 skinfolds for Canadian children aged 7-12 years 47 Comparison of physical variables of obese and non-obese children aged 7-12 years 49 Canadian Standardized Test of Fitness Step Test: Results for obese and non-obese children aged 7-12 years 51 Canadian Standardized Test of Fitness Step Test: Results for obese and non-obese children aged 7-12 years 52 Estimates of activity levels for obese and non-obese children aged 10-12 years 54 Patterns of leisure activity of obese and non-obese children aged 10-12 years 55 Adherence to Canada's Food Guide - Obese and non-obese children aged 10-12 years 57 Summary of dietary habits of obese and non-obese children aged 10-12 years 58 Attempts to limit consumption of fat, sugar and salt -Obese and non-obese children aged 10-12 years 60 Dietary habits for weight control of obese and non-obese children aged 10-12 years 61 Measures of psychological well-being of obese and non-obese children aged 10-12 years 63 Family income levels of obese and non-obese children aged 10-12 years 64 vii Father's education level - Obese and non-obese children aged 10-12 years 64 Average time spent by obese and non-obese children aged 10-12 years doing various leisure time activities 66 Importance of achieving specific goals in spare time for obese and non-obese children aged 10-12 years 68 Factors identified by obese and non-obese children aged 10-12 years as barriers to being more physically active 70 Factors identified by obese and non-obese children aged 10-12 years as barriers to being more physically active 71 Attitudes of obese and non-obese children aged 10-12 years towards regular participation in virgorous physical activity 73 Perceived encouragement/suppport from others for obese and non-obese children aged 10-12 years to be physically active 75 Contribution of vigorous physical activity to the achievement of specific goals for obese and non-obese children aged 10-12 years 77 Contribution of vigorous physical activity to the achievement of specific goals for obese and non-obese children aged 10-12 years 78 Estimates of activity level for obese and non-obese children aged 10-12 years and their parents 81 Patterns of leisure activity of obese and non-obese children aged 10-12 years and their parents 82 Level of adherence to Canada's Food Guide of obese and non-obese children aged 10-12 years and their parents 84 Daily eating patterns of obese and non-obese children aged 10-12 years and their parents 85 Attempts to limit fat, sugar and salt intakes of obese and non-obese children aged 10-12 years and their parents 85 Modification of eating habits for the purposes of losing or maintaining weight of obese and non-obese children aged 10-12 years and their parents 8 6 Measures of psychological well-being of obese and non-obese children aged 10-12 years and their parents 87 viii 31. Average time spent by obese and non-obese children aged 10-12 years and their parents doing various leisure time activities 89 32. Importance of achieving specific goals in spare time for obese and non-obese children aged 10-12 years and their parents 92 33a. Factors identified by obese and non-obese children aged 10-12 years and their parents as barriers to being more physically active 94 33b. Factors identified by obese and non-obese children aged 10-12 years and their parents as barriers to being more physically active 95 34. Attitudes of obese and non-obese children aged 10-12 years and their parents towards regular participation in vigorous physical activity 97 35a. Contribution of vigorous physical activity to the achievement of specific goals for obese and non-obese children aged 10-12 years and their parents 100 35b. Contribution of vigorous physical activity to the achievement of specific goals for obese and non-obese children aged 10-12 years and their parents 101 ix (I) INTRODUCTION (A) Rationale Obesity in childhood is not only one of the most common nutritional disorders in children (Dietz, 1986; Coates & Thoresen, 1978), it is also one of the most complex and least understood clinical syndromes in pediatric medicine (Korsch, 1986). It is a condition which has a history of being resistant to treatment, suggesting that strategies for prevention may be more appropriate than the therapeutic efforts in current use. There are both physiological and psychological pathologies associated with childhood obesity and a large proportion of obese children become obese adults where these pathologies are further manifested (Stark et al., 1981). The prevalence of childhood obesity in the United States has been recently assessed (Dietz et al., 1985; Gortmaker et al., 1987) and many studies have examined the familial and behavioural correlates of childhood obesity in that country (Dietz, 1986; Gortmaker et al., 1990; Ross and Gilbert, 1985; Shear et al., 1988); similar studies have not been undertaken in Canada. Although many features of the American and Canadian cultures are similar, there is no reason to believe that either prevalence, or variables associated with childhood obesity should be the same in Canada as they are in the United States. Canada has a vastly different demographic profile of ethnicity and socio-economic status than the United States, as well as dissimilar education, 1 social welfare and health care systems. In order to develop effective prevention and/or treatment programs, there is a need for a basic understanding of the antecedents of the problem. While genetic determinants play a well defined role in the development of obesity (Bouchard, 1991), there may be environmental factors, amenable to intervention, which must be clearly identified. Further, obesity in children may present a more complex picture than it does in adults because of the combined and often compounded effects of individual behaviour and familial influence. (B) Hypotheses There are three general hypotheses that will be tested in this study and they are as follows: Hypothesis 1: that the prevalence of obesity among children aged 7-12 years in Canada has increased between the years 1981 and 1988. Hypothesis 2: that significant differences exist between obese and non-obese children with regards to familial factors (socioeconomic status, parental obesity status), physical factors (weight, skinfold thickness, blood pressure, fitness level, resting heart rate), individual behaviours (exercise habits, eating habits, leisure time activities -2 time spent watching television), psychological well-being and attitudes and goals concerning physical activity. Hypothesis 3: that there is a strong relationship between parental physical factors, lifestyle behaviours, psychological well-being and attitudes and goals concerning physical activity and those of their children. (C) Objectives The Campbell's Survey on Well-being in Canada contains detailed and comprehensive information pertinent to childhood obesity. It examines numerous lifestyle factors that may be related to the development of childhood obesity and it provides information for the assessment of individual and familial factors. Thus, the objectives of this study are to use this database to test the previous hypotheses as follows: 1) Estimate the prevalence of childhood obesity in Canadian children aged 7 to 12 years. 2) Determine if significant differences exist between obese children and non-obese children with respect to specific physical factors, individual behaviours, psychological well-being, as well as attitudes and goals concerning physical activity. 3 3) Determine if significant differences exist between parents and their children with respect to their physical factors, lifestyle factors, psychological well-being and goals and attitudes concerning physical activity and to determine if these differences are the same for both obese children and non-obese children. (II) LITERATURE REVIEW (A) Assessment of Obesity Ideally, since obesity is defined as an excess of body fat, any estimates of obesity should be based on some measure of body adiposity. A variety of methods from simple observation to complex laboratory methods are available. Simple observation is the easiest method to implement but it is also the least accurate. Hydrostatic weighing was once considered to be the "gold standard" to which other methods of body fat assessment were compared. However, now more technical and expensive methods such as dual energy X-ray absorptiometry (DEXA) may become the new gold standard. Hydrostatic weighing measures body density by determining the weight of the subject in air and immersed in water, with correction for residual air in the lung (Behnke et al., 1942). The percentage of the body that is fat can then be calculated based on the assumption that the density of the fat compartment, technically ether extractible lipid, is 0.901 and that of the nonfat compartment, or fat-free mass, is 1.097 4 (Forbes, 1962). The major shortcomings of this procedure are that it is time consuming and expensive and it can be uncomfortable for the subject. Also, in children, the density of the fat-free mass increases with age and therefore is not fixed (Durnin and Womersley, 1974). Thus, if hydrostatic weighing is used to estimate body fat in children it is important to use age specific equations. The other laboratory methods including potassium (4OK) counting, isotpic dilution, neutron activation and electrical impedence involve costly and specialized equipment and are impractical to implement. Furthermore, norms for children are not currently available for these laboratory methods. One of the more practical and accurate methods of assessing fat mass in children is by direct measurement of subcutaneous fat mass at various anatomic sites using skinfold calipers (Rosenbaum and Leibel, 1989). The triceps skinfold has generally been found to be the best single indicator of total body fat in children aged 6-12 years (Deurenberg et al., 1990; Roche et al., 1981; Slaughter et al., 1988). In a review of the literature, Bandini and Dietz (1987) found that the correlation coefficient of triceps skinfold with body fat measured by densitometry ranged from 0.4 to 0.98 (average=0.75) depending on the age and sex of the population studied. However, the triceps skinfold has also been found to be less reproducible in overweight subjects (Bandini and Dietz, 1987). Nonetheless, in most of the American 5 studies, children are defined as obese if their triceps skinfold is equal to or greater than the 85th percentile for their age and sex. Marshall et al. (1991) recently reported a validation study of convenient indicators of obesity in 540 Canadian children aged 7 to 14 years. The sensitivity, specificity, overall accuracy and positive and negative predictive values of relative BMI, relative weight, triceps skinfold and sum of five skinfolds (biceps, triceps, subscapular, suprailiac and calf) were determined. The authors concluded that the sum of 5 skinfolds was better at identifying true obesity than the other measures. However, the sum of five skinfolds did misclassify several non-obese subjects, mostly females, as obese (Table 1). This reduced specificity improved if the 90th percentile, instead of the standard 85th percentile, was used as the cut-off point for obesity. 6 Table 1: Frequencies and percentages of the sample classified as obese by the obesity indicators (Marshall et al., 1991) INDICATOR Relative Weight* Relative BMI** CSTF SUM*** Triceps Skinfold % Body Fat **** FEMALES % (n) 10.9 (30) 16.1 (44) 19.3 (53) 13.5 (37) 11.3 (31) MALES % (n) 12.4 (33) 17.7 (47) 22.2 (59) 15.4 (41) 16.9 (45) TOTAL % (n) 11.7 (63) 16.9 (91) 20.7 (112) 14.4 (78) 14.1 (76) ** Relative Weight was determined for height, age and gender at the 50% percentile using the following formula and the National Center for Health Statistics percentiles (Hamill et al., 1979): Relative Weight=(Subject Weight/Expected Weight)*100 Relative BMI was determined using the following formula: Relative BMI= (Actual BMI/BMI50) *100 Where BMI is defined by the equation: BMI=Weight(kg) /Height2 (metres) And BMI50 is the BMI when the 50th percentile of height and weight for the same age and gender are used. CSTF SUM is the sum of the following five skinfolds (in mm): biceps, triceps, subscapular, suprailiac and calf **** % Body Fat as determined by hydrostatic weighing and the use of Lohman's (1986) age and gender specific regression equations *** In Canada, the most recent recommendations from Health and Welfare Canada (1988) regarding the assessment of "healthy weights" in children, state that a combination of weight for height values and anthropometric measurements (ie. skinfolds) should be used to assess any deviations in growth patterns. In the absence of skinfold data, weight-for-height percentile (WHP) alone, is commonly used to establish whether a child is overweight based on the National Center for Health Statistics (NCHS) norms (Gortmaker et al., 1987; Hamill et al., 1977). In children, WHP has an advantage over the Body Mass Index (Weight/Height2) in that it is based on the actual weight and height data from a large nationally representative sample of children (Hamill et al., 1977), rather than on a ratio which roughly estimates the geometric change in weight expected with differences in stature (Gortmaker et al., 1987; Ross et al., 1988) . However, as they take no direct account of body fat, neither the BMI nor weight-for-height are accurate indices of adiposity (Gam et al., 1986; Gortmaker et al., 1987; Ross et al., 1988). Table 2 summarizes the correlation coefficients of various methods of assessing obesity in children and adolescents. Considering these values and the data obtained by Marshall et al. (1991), obesity in children should be assessed by either the triceps skinfold or the Canadian Standardized Test of Fitness Sum of 5 Skinfolds. If neither of these are available, reasonable estimates of obesity may be obtained by using measurements of height and weight. 8 Table 2: Correlation coefficients between common indices of weight and percentage body weight as fat for children aged 6-12.9 years (Bandini & Dietz, 1987) INDEX Weight Relative Weight Weight/(Height)2 Weight/(Height)3 Triceps Skinfold MALES (n=68) 0.33 0.73 0.68 0.74 0.84 FEMALES (n=49) 0.23 0.69 0.55 0.62 0.83 (B) Prevalence of Childhood Obesity In the United States the prevalence of childhood obesity has increased dramatically over the last few decades. Gortmaker et al. (1987) found that over a 10 to 15 year period, obesity increased from approximately 18% to 3 0% in 6 to 11 year old males and from 17% to 25% in 6 to 11 year old females. In Canada, valid estimates of prevalence have been confounded by the lack of a universally accepted methodology to assess childhood obesity and by the absence of representative studies of the pediatric population. Accordingly, the Canadian Dietetic Association (1988) reported that between 5% and 25% of children are obese depending on the criteria or standards used for comparison. The prevalence of obesity has also been reported to be higher in certain groups of children. Gortmaker et al. (1990) found that 9 28% of wealthy children were obese compared to only 21% of children living in poverty. In addition, Gortmaker et al. (1990) found the prevalence of childhood obesity in the North Eastern United States to be twice that of the Western United States. Similar class and geographical relationships to obesity are found in the Bogalusa Heart Study (Shear et al., 1988) and the National Children and Youth Fitness Study (Ross and Gilbert, 1985). On the other hand, Lissau-Lund-Sorensen (1992) found that a child reared in a poor area was 2.4 times more likely to be overweight as an adult than a child reared in a more affluent area. Childhood obesity has also been found to be more prevalent in families with obese parents. For example, children with two obese parents were found to have two to three times the triceps skinfold thickness of children with two lean parents (Gam and Clark, 1976). These authors found that the level of fatness of the child rose progressively with the level of fatness of the parental mating combinations. Similarly, in a study of 7600 school children aged 11-16, Darwish et al. (1985) found that 85% of the obese children had obese parents, 63% percent of the obese children had obese mothers, siblings and grandmothers while 47% had obese fathers, siblings and grandfathers. (C) Etiology of Childhood Obesity The ultimate cause of primary obesity is an imbalance between energy intake and energy expenditure. However, the cause(s) of 10 this energy imbalance is not clear and varies among individuals. In addition, it is often impossible to determine if the proposed factor is a cause or a consequence of the obesity. Nevertheless, probable causes of energy imbalance have been investigated and they include genetics, excessive energy intake, decreased resting metabolic rate, inactivity or decreased activity level, excessive television viewing, family problems and/or family or other social variables. It is generally recognized that there are genetic differences in one's susceptibility to obesity under given behavioural and lifestyle conditions (Bouchard, 1991). These genetic differences likely affect one's metabolism in a manner that results in the energy imbalance associated with obesity. Studies of twins suggest that as much as 80% of the variance in skinfold thicknesses or weight-for-height may be attributable to genotype (Rosenbaum and Leibel, 1989). Similarly, Stunkard et al. (1986) found no relationship between adoptees' weight and BMI and that of their adoptive parents but found a significant relationship between adoptees' weight and BMI and that of their biological parents. The early identification of individuals genetically susceptible to obesity may be useful with respect to the application of preventative measures. Some studies have found few differences between the dietary intakes of obese and non-obese children (Stefanik et al., 1959; 11 Maxfield and Konishi, 1966; Corbin and Pletcher, 1968; Johnson et al., 1956; Perusse et al., 1984; Shapiro et al., 1984; Patterson et al., 1986; Rolland-Cachera and Bellisle, 1986) while others report that obese children eat more rapidly and/or consume more food than average weight children (Birch et al., 1981; Drabman et al., 1977; Waxman and Stunkard, 1980; Cook et al., 1973; Maffeis et al., 1992; Barkeling et al., 1992). These conflicting results have limited comparative value without knowledge of the energy requirements of the subjects. In addition, different methods have been used to collect energy intake data and some are more accurate than others (Barrett-Connor, 1991). Klesges et al. (1991) examined the effect of parental influence on food selection in young children. They found that both the threat of parental monitoring and actual parental monitoring lowered the number of non-nutritious foods chosen and the total caloric content of the meal. However, these results did not differ when the obesity status of the children or the parents were considered. It should also be noted that the investigators only looked at what a child or mother would put on a tray for lunch and not what the child actually consumed. Seagren and Terry (1991) found that the mothers of obese children were more dissatisfied with the types of food their children ate for meals and snacks then were mothers of normal weight children. The mothers of obese children were also more likely to agree that their children ate too much food between meals. Compared to the 12 mothers of normal weight children, the mothers of obese children were less likely to agree their children should play less while eating and were less likely to encourage their children to eat all of their food on their plate or to eat as much food as they would like. On the other side of the energy equation is energy expenditure which includes energy expended at rest and during activity as well as that associated with the thermic effect of food. Basal metabolic rate (BMR) represents about 65-75% of total energy expenditure in sedentary individuals and therefore may be an important factor in the development of obesity (Maffeis et al., 1991). Epstein et al. (1989b) found that the weight of a child was significantly correlated with resting metabolic rate and weight accounted for 72% of the variance. In this study the obese children, although having higher resting metabolic rates, did not have an energy intake greater than the lean children. Waxman and Stunkard (1980) found that obese children expended more energy both at rest and during activity than non-obese children. On the other hand, Maffeis et al. (1991) found that obese and normal weight children had similar BMR's, both in absolute values and in values adjusted for fat free mass, age and gender. They found the most important variable to predict BMR was fat free mass. Other studies have not shown a significant difference in BMR between obese children and controls (Molnar et al., 1985; Katch et al., 1985; Bandini et al., 1987; Elliot et 13 al., 1989). Bandini and Dietz (1992) suggest that more information is needed with regards to BMR and the preobese state as a study on adult Pima Indians found greater weight gains over a two year period in obese Pima Indians with lower BMR's (Ravussin et al., 1988) but when their weight increased, their BMR normalized as well. This finding is supported by a cross-sectional study that found that children of obese parents, who were thus at a high risk for obesity, had relatively low resting metabolic rates, suggesting that they had a propensity for obesity themselves (Griffiths and Payne, 1976). On the other hand, Gutin et al. (1993) found that resting metabolic rate did not predict increases in skinfold fatness over a three year period in 3 to 7 year olds. Over the years the data indicate a gradual decrease in energy intake and an increasing incidence of overweight and obesity, suggesting that decreased activity may be an important cause of obesity (Stern, 1984). In particular, the prevalence of obesity has doubled since 1900 with a 10% reduction in caloric consumption (Thompson et al., 1982). Without longitudinal prospective studies, it is difficult to determine, however, whether inactivity is a cause or a consequence of obesity or a combination - a consequence that further enables obesity. The assessment of the role of physical activity in the development and/or maintenance of obesity is further complicated by the large variety of techniques used to estimate energy expenditure in 14 physical activity. Saris (1985 and 1986) reviewed the various techniques of assessing children's physical activity levels including self-reports, direct observation, mechanical and electronic monitors, doubly labeled water and others and reported that all of them have problems with no one measure being suitable for all purposes. In large studies, self-report of some kind is typically the method of choice due to the advantage of low cost. Waxman and Stunkard (1980) found that obese children spent significantly more time in sedentary activities inside and outside the home than the non-obese children, however there was no difference in activity levels at the school playground. In a 9 year longitudinal study, activity scores were found to be consistently negatively related to the sum of skinfolds (Shapiro et al., 1984). Overall, when children have rated their participation in different activities there have been variable results with some studies finding significant differences between obese and non-obese children (Johnson et al. 1956; Reybrouck et al., 1987) and some finding no differences (Stefanik et al., 1959; Huenemann et al., 1967). Recently, it was reported that virtually nothing is known about the physical activity patterns, preferences, opportunities and behaviours of Canadian children aged 5 to 9 years (Russell et al., 1992). In a study using doubly labeled water to assess total energy expenditure, Roberts (1988) found that infants who subsequently 15 gained the most weight were those having the least energy expenditure three months previously and the difference in weight gain was primarily attributed to physical activity. When looking at energy expenditure it may be best to combine physical activity measures with measures of total energy expenditure such as doubly labeled water since, ideally, all components of energy expenditure including BMR, the thermic effect of food and physical activity should be considered. It may also be important to look at sex differences as Vuille and Mellbin (1979) found that the prime predictors for obesity in 10 year old girls were "heredity and physical inactivity" whereas in boys, "appetite and environmental conditions" explained the most variance in obesity. Finally, one must remember that because more energy is reguired to move a larger mass, lower activity levels among obese children may produce levels of energy expenditure comparable to those in more active, non-obese children. Although the thermic effect of food constitutes only about 10% of total energy expenditure, small daily variations can accumulate over time (Gutin and Manos, 1993). Cross-sectional studies on the thermic effect of food in children and adolescents do not provide clear evidence that already established obesity is associated with a low thermic effect of food (Gutin and Manos 1993) and no prospective studies have been reported concerning whether a blunted thermic effect of food leads to obesity in children. 16 The amount of time children spend watching television may also be contributing to the development of obesity. Dietz and Gortmaker (1985) have shown a strong causal connection between the amount of time children and youth spend watching television and the prevalence of obesity. This relationship may be due, in part, to the commercials which promote the consumption of high calorie foods. Food advertising accounts for the largest proportion of advertising during weekday and weekend commercial programming directed at children (Barcus and McLaughlin, 1978; Cotugna, 1988) and Cotugna (1988) found that 80% of these commercials were for foods of low nutritional value. Television advertising has also been found to directly influence family food purchases and the snacking behaviour of children (Palumbo and Dietz, 1985). In addition, Klesges et al. (1993) recently found that the metabolic rate of 8 to 12 year old females was significantly lower during television viewing than it was at rest with obese children having a larger, but not significant, decrease. It is thus postulated that children who frequently watch television are more likely to eat more and to eat more non-nutritious foods while being less physically active - a combination that inevitably leads to obesity. Another possible indirect cause of energy imbalance is the state of family relationships (Lucas, 1988). It has been suggested that increasing severity of obesity is associated with increasing family dysfunction (Lucas, 1988). A rapid increase in weight is 17 strongly correlated with psychosocial problems, and a child may use food and eating in response to a myriad of feelings (anger, loneliness, frustration, isolation, depression, anxiety, etc.) just as the adult does (Mellbin and Vuille, 1989; Carey et al, 1988). However, Bandini and Dietz (1992) argue that while children may eat in response to boredom they rarely eat when they are angry or depressed. It has also been reported that obese children are often involved in disturbed family interactions, have a poor self-image, a sense of failure and a passive external approach to life situations while expressing feelings of inferiority and rejection (Leung and Robson, 1990). In a prospective study, Lissau and Sorenson (1993) found that children who had learning difficulties in grade three had an odds ratio of 4.2 for obesity as a young adult. This result was independent of social background, BMI in childhood and gender. They found no difference, however, in percent overweight in childhood among children with or without learning difficulties at school. (D) Risks Associated With Childhood Obesity The physiological health risks that may be associated with childhood obesity include hypertension (Ashley et al., 1974; Dyer et al., 1982; Kotchen et al., 1980; Gutin et al. 1990; Gillum et al., 1982; Higgins et al., 1980; Kuller et al., 1980; Hsu et al., 1977; Johnson et al., 1973; Kannel et al., 1967; Noppa, 1980; Oberman et al., 1967; Rosenbaum and Leibel, 1989), 18 hyperinsulinemia, diabetes mellitus (Legido et al., 1987; Rosenbaum and Leibel, 1989), hyperlipidemia, hyperlipoproteinemia (Hubert, 1986; Epstein et al., 1989a; Freedman et al., 1985), other endocrine abnormalities (Rosenbaum and Leibel, 1989) and orthopedic disorders (Rosenbeaum and Leibel, 1989). With the exception of the orthopedic disorders, virtually all of the above abnormalities normalize with weight reduction (Rosenbaum and Leibel, 1989). The psychological risks associated with childhood obesity are perhaps more disabling than any of the physiological consequences although it is difficult to determine if the psychological risks are causes or consequences of the obesity (Bray, 1983). Obese children may have emotional and psychological consequences that can scar them for the rest of their lives (Mahan, 1987). Regardless of age, sex, race or socioeconomic status, there is a strong prejudice against the obese in North America (Wadden and Stunkard, 1985). Numerous studies have been done which have children rate drawings of obese and non-obese individuals. In general, the obese individuals depicted in the pictures are viewed as least likeable, stupid, ugly, lazy and dirty (Counts et al., 1986; Staffieri, 1967; Staffieri, 1972; Richardson et al., 1961; Maddox et al., 1968; Strauss et al., 1985). Society's perception of obesity intensifies any psychological problems the obese child may already be experiencing. The psychological well-being of obese children is often measured through an assessment 19 of self-esteem and several studies report that obese children have lower levels of self-esteem when compared to their non-obese peers (Strauss et al., 1985; Banis et al., 1988; Duckro et al., 1983; Atkinson and Ringuette, 1967; Werkman and Greenberg, 1967). On the other hand, two other studies using the Piers-Harris Self-Concept Scale found no significant differences between normal weight and overweight children (Wadden et al., 1984; Kaplan and Wadden, 1986). Using Battle's Cultural Free Self-Esteem Inventory, Marshall (1993) found that obese females (25% fat or more, using hydrostatic weighing and Lohman's age- and gender-specific regression equations) had relatively lower scores on the social subscale compared to their non-obese peers but their scores in the other subscales were relatively high. Interestingly, those girls who thought they were "fat" generally demonstrated lowered self-esteem, particularly in the social and academic subscales. Obese males (20% fat or more, using hydrostatic weighing and Lohman's age- and gender-specific regression equations) had relatively high self-esteem and scored only slightly lower than non-obese males on the social subscale. Another risk of childhood obesity is that the obese child will become an obese adult. Longitudinal studies have investigated this risk and Stark et al. (1981) found that 40% of obese 7 year olds become obese adults and 70% of obese adolescents become obese adults. Mahan (1987) similarly reported that 80% of children who are obese at age 10 to 13 years were obese in the 20 fourth decade of life. Other researchers have reported similar trends (Abraham and Nordsiek, 1960; Charney et al., 1976; Freedman et al., 1987; Mossberg, 1989). (E) Treatment of Childhood Obesity Ideally, childhood obesity should be prevented with the primary prevention strategy being the development of both healthy eating behaviours and healthy exercise behaviours at an early age (American Dietetic Association, 1989). However, for those children who are already obese, treatment intervention programs should be readily available. In essence, when childhood obesity is successfully treated, adult obesity is subsequently prevented. This is particularly important since treatment programs for obese adults have proven to be largely unsuccessful. In fact, only 10-3 0% of adult patients achieve and maintain weight loss regardless of the type of therapy used (Canadian Dietetic Association, 1988). Theoretically, obese children should be easier to "cure" than obese adults. First, children's eating and exercise habits are not yet firmly established and as such will be more susceptible to change. Second, if obesity is treated earlier it may be possible to prevent excessive adipocyte hyperplasia, which may be one reason obese adults find it difficult to maintain weight loss. Third, children's eating habits are largely controlled by their parents, particularly younger children and thus may be easier to change. 21 Overall, a successful treatment program should bring about social, psychological and physical benefits to the child. Treatment programs that focus on only one or two aspects of weight control have had limited success. Sasaki et al. (1987) utilized a long-term supervised aerobic exercise program for obese eleven year olds and found that over a period of one year there were significant decreases in body fat and increases in HDL-cholesterol. Unfortunately, the use of exercise therapy alone in treating obese children has generally been unsuccessful (Dietz, 1983) . Short term success has also been found with treatment programs that focus on a hypocaloric diet. Possible negative side effects associated with the use of a low calorie diet include loss of lean body mass, permanent drop in metabolic rate, interruption of growth, cold intolerance, constipation, dizziness, fatigue and dry skin (Wile and Mclntyre, 1993). Maffeis et al. (1992) assessed the effectiveness of a hypocaloric diet on children and found that after 6 months there were significant decreases in weight, percent fat, fat free mass and body mass index. After weight loss the resting metabolic rate of the obese children was lower by 7 +- 1 % but after adjusting for fat free mass it was not significantly different. This finding suggests that if weight loss includes a loss of fat free mass, as it often does on hypocaloric diets, then it will be necessary to reduce one's caloric intake in order to avoid a relapse of weight gain. 22 Figueroa-Colun et al. (1993) compared the effectiveness of two hypocaloric diets and found that obese children on a Protein-Sparing Modified Fasting Diet had a significantly greater weight loss after 10 weeks than those on a hypocaloric balanced diet. This greater loss in weight persisted at 6 months but after 14.5 months, the body weight of both dietary groups had returned to baseline values, although they still had a significant decrease in degree of overweight due to increases in height. Wile and Mclntyre (1992) assessed an outpatient program at a Canadian hospital where the focus was on counselling the obese children with respect to diet. This program had a very high drop out rate as 49% of the children never returned after their initial assessment. The success rate of the program was also quite low as only 5 of 65 children achieved an ideal body weight and only one of these was followed by the clinic. In addition, 49% of the patients gained weight. It was hypothesized that one of the reasons the program was so ineffective was because it used current standards of nutrition practice as opposed to current principles of nutrition education theory. Thus, behavioural procedures such as contracting, self-monitoring, social reinforcement, modeling and contingency management were not utilized and these have been found to be related to long-term success in the treatment of obese children (Epstein et al,, 1990). Overall, childhood obesity has not been treated successfully with diet alone (Garner and Wooley, 1991; Hall, 23 1989; Reybrouck et al., 1990; Nuutinen, 1991). Treatment programs that have combined exercise therapy with nutrition education have experienced some short-term success (Epstein et al., 1985). Hills and Parker (1988) provided ten obese children with an exercise program and nutrition education for sixteen weeks. The obese children showed a significant decrease in the sum of their skinfolds while the control group showed an increase in the sum of their skinfolds. The weight of the experimental group also decreased but not significantly. This observation is important since many studies have used only weight or body mass index as the sole indicators of reductions in obesity. Reybrouck et al, (1990) found that after 4 months of therapy, the children treated with diet and exercise had decreased their percent overweight significantly more than those on a diet only program (-25% vs -15.8%). However, for the next 4 months, the mean decrease in percent overweight was much less and it was similar between the two groups. It has been suggested that instead of treating obesity itself it is the symptoms associated with obesity (eating attitudes and behaviors, negative health attitudes and behaviors, social isolation and low self-esteem) that need to be treated (Brownell, 1982). Accordingly, some programs have added a behaviour modification component to the nutrition education and exercise therapy and have presented this package in a family-based 24 approach. The inclusion of the family in child obesity treatment programs is now considered critical as a child's food preferences, activity habits and psychological state are strongly influenced by family (Epstein et al,, 1986a; Klesges et al,, 1991). Parental "encouragement to be active" was significantly correlated with child activity and child relative weight (Epstein et al., 1986a). Furthermore, how food is presented early in life can affect a child's food habits. For example, if food is presented as a reward then a child's liking of food increases (Striegel-Moore and Rodin, 1985). Importantly, decreases in relative weight have been maintained over a five year period using a comprehensive family based approach (Epstein et al., 1987). In another study using a similar treatment protocol, the children aged fourteen to seventy months decreased their percent overweight by 18.1% after one year and by 14.3% after two years (Epstein et al., 1986b). Although it appears to be important to include the family in treatment programs, Cohen et al. (1980) found that the maintenance of weight loss in children was directly related to the amount of self-regulation of food intake and weight management utilized. This emphasizes the importance of allowing the child to make decisions concerning his/her diet and activity habits as he/she begins to learn more about his/her body and what is required to achieve a healthy body and mind. In summary, all these studies strongly suggest that childhood obesity needs to be viewed as a multifaceted problem that requires a multidisciplinary team approach to treatment (Wile and 25 Mclntyre, 1993). One of the fears that accompanies the treatment of childhood obesity is that one's preoccupation with weight and dieting will be increased and the child may begin to overvalue thinness and possibly develop a strong prejudice toward the obese. In other words, the treatment of one disorder, obesity, may result in the development of other disorders, namely anorexia nervosa and/or bulimia. Several studies have revealed that a high proportion of children are trying to lose weight or are worried about their weight. Rosin and Gross (1987) found that about two thirds of high school girls were trying to lose weight while Gustafson-Larson and Terry (1992) reported that 60% of girls and 38% of boys in the fourth grade expressed a desire to be thinner. In a Canadian study, 36% of adolescent girls and 14% of boys were worried about being overweight (Feldman et al., 1986). These figures contrast sharply against those of Sternlieb and Munan (1972) who found that in the 1970's only 6% of adolescents were worried about obesity and there were no sex differences. Due to the inherent risk of increasing the preoccupation with one's weight it is imperative that treatment programs for the obese child be designed and delivered with great care. In consideration of this, the American Dietetic Association (1989) recommended that obesity treatment intervention programs for children incorporate the following principles: 26 1) Be adaptable to individual needs 2) Develop nutritionally sound and sensible eating patterns 3) Use psychologically sound and family oriented approaches and bring about positive behaviour modification 4) Be supportive of social needs 5) Include a physical activity component 6) Be coordinated with medical care 7) Continue for a long enough time period to establish attitude and behaviour changes 8) Promote a positive attitude toward life and self 9) Recognize there is a wide range of acceptable body sizes and shapes In reviewing the literature, there are very few treatment intervention programs that provide all of the above components. In fact, in Canada, recent Health and Welfare Canada studies on the treatment of obesity have not even cited children as a priority. Similarly, Garner and Wooley (1991) summarized that it is difficult to find any scientific justification for the continued use of dietary treatments of obesity. They further recommend that the emphasis should be on trying to improve lifestyle health risk factors, body image and self-esteem of the obese without requiring weight loss. (F) Summary In the United States it is clear that the prevalence of childhood obesity has reached a level that can no longer be ignored. In 27 Canada, the prevalence of childhood obesity has not been determined. Past and current treatment strategies have generally been ineffective which suggests we do not have a clear understanding of the etiology and pathogenesis of this disease. Inconsistencies in the design of studies and inevitably in the results of studies make it impossible to draw any firm conclusions about the epidemiology and etiology of childhood obesity. It is therefore imperative to conduct studies that will enhance our understanding of childhood obesity and will thus facilitate the development of future programs and services. (Ill) METHODS AND PROCEDURES The prevalence of childhood obesity in Canada was estimated from data collected in two national surveys: The 1981 Canada Fitness Survey and the 1988 Campbell's Survey on Well-being in Canada. The analysis of other physical variables, lifestyle factors and familial patterns was performed only on data contained in the Campbell's Survey on Well-being in Canada (1988). (A) Description of Surveys The Canada Fitness Survey (CFS) was initiated by Fitness Canada in 1981 in order to acquire reliable statistics, establish baseline levels for monitoring trends and provide other data on fitness, physical activity and lifestyle. Details regarding the survey are described elsewhere (Canada Fitness Survey, 1983). Anthropometric measures were obtained on persons aged 7 to 69 28 years using standardized techniques as outlined in the Canadian Standardized Test of Fitness Operations Manual (Fitness Canada, 1987). For the purposes of analysis, the frequency data were adjusted by applying population weighting factors normalized to the n of the sample using the following formula: NWF = (OWF * n)/SUM of OWF where, NWF = Normalized Weighting Factor OWF = Original Weighting Factor n = Sample Size SUM of OWF = Sum of the Original Weighting Factors for the sample size A total of 22,992 individuals participated in the CFS with 2601 in the age range of 7 to 12 years. The Campbell's Survey on Well-being in Canada (CSWB) was completed between April and June of 1988 and was a complex, stratified multi-stage cluster design. It was designed to update information from the 1981 Canada Fitness Survey with specific investigation of the role of exercise in the health of Canadians. Persons 7 years of age and older from the ten provinces of Canada, excluding those living in institutions or in remote areas, were surveyed. The geographical clusters used in the CFS were sub-sampled with a probability proportional to their CFS sample weights. A copy of the CSWB questionnaire is located in the appendix and further details of the survey can be obtained 29 elsewhere (CSWB, 1988). The data from this survey was also adjusted with population weighting factors normalized to the n of the sample using the same formula as outlined above. A total of 337 children aged 7 to 12 years participated in this survey. The data from both the CFS and the CSWB were obtained from data tapes provided by the Data Library at the University of British Columbia. The skinfold, height and weight variables were manually reviewed to assess any gross errors; one case from the CSWB was removed from any analyses involving height as the child's height was recorded as being 51.6 centimetres. With respect to the parental data, the data was also manually reviewed and sorted to ensure that only children with data for two parents were included in the familial analyses. This review found one case of a child with two fathers and one mother in the same household. However, due to the age differences between the child and these two fathers, it was possible to eliminate one of the supposed fathers. Numerous other variables were manually reviewed and the remainder of the data appeared to be free of any gross errors. Specific information regarding the pilot testing of the questionnaire and the procedures for administering the questionnaire was requested but it was not made available. The only information available concerning these issues was that published by Stephens and Craig (1990) as well as some additional 30 verbal clarification from the Canadian Fitness and Lifestyle Research Institute. (B) Description of Variables The age, sex and sum of five skinfolds of children aged 7 to 12 years were isolated from the CFS while the following variables for children aged seven to twelve years and their parents were isolated from the CSWB: (Variables denoted with an asterisk (*) were only available for children aged 10 to 12 years and their parents). (1) PHYSICAL VARIABLES a) Age - specified in years. b) Sex c) Weight - measured in kilograms to the nearest 0.1 kilogram; weight was estimated if necessary. d) Height - measured using gentle traction, in centimetres to the nearest 0.1 centimetre; height was estimated if necessary. e) Sum of 5 Skinfolds - the sum of the following skinfold measurements in millimeters: biceps, triceps, subscapular, suprailiac, medial calf. Measurements were made with Harpenden Skinfold Calipers and were repeated twice and then a third time if the difference exceeded 4 mm. The mean of the two closest measurements was used. f) Blood Pressure - both systolic and diastolic blood pressure 31 measurements (mmHg) were taken in a sitting position after five minutes of rest, g) Body Mass Index - body mass index (BMI) was determined from the weight and height measurements as follows: BMI = Weight(kg)/Height2 (m) h) Resting Heart Rate - determined after five minutes of rest. (2) FITNESS & ACTIVITY VARIABLES a) Step Test Results - all subjects were screened to ensure there were no physical or other reasons that would preclude them from participating in the Canadian Standardized Test of Fitness Step Test. The details of this test can be obtained elsewhere (Fitness Canada, 1987). Briefly, participants step up and down two stairs, at an age and sex specific pace, for a period of three minutes. Their heart rate is then recorded and if it is below a pre-set criteria the participant then performs another bout of stepping at a faster pace. This continues for a maximum of five bouts. For children aged 7-12 years, maximum oxygen uptake values were not predicted and thus the only outcome measurement that could be used to estimate the child's fitness level was the number of bouts the child was able and/or willing to complete. b) Energy Expenditure Data (*) - based on an estimation of the energy they expended in their leisure time activities (question 9 in the survey), the average daily energy 32 expenditure was determined for each participant. If this value exceeded 3.0 kilocalories/kilogram body weight/day then they were classified as being "sufficiently active" whereas if it was less than 1.5 kilocalories/kilogram body weight/day they were classified as "sedentary or inactive". Individuals with values in between 1.5 and 3.0 were classified as "minimally or moderately active". Patterns of Leisure Activity (*) - this was an estimate of participation in leisure activities according to intensity (low, moderate, high, very high), frequency (regular - every other day on average or irregular) and duration (in minutes). The MET value (exercise metabolic rate/resting metabolic rate) of the activities (question 9 in the survey) were used to determine the age specific intensity level with a low intensity representing activities of less than 35% of the average aerobic capacity for the age group. A moderate intensity represents 35-50% and a high intensity represents 50-75% of the average age specific aerobic capacity while a very high intensity represents over 75% of the age specific aerobic capacity. NUTRITION VARIABLES Adherence to Canada's Food Guide (*) - an index based on answers to question 25 was calculated. This index was arbitrarily designed and has never been used before. It was based on the responses related to the quantity and 33 variety consumed of different food groups. Specifically, each of the four food groups (meat and alternates, dairy, fruit and vegetables, breads and cereals) had a maximum of 5 points allocated as follows: 0-2 points - number of daily servings within group 0-2 points - variety of selection within group 1 point - "bonus" point for selection (ie. high fibre) Three categories were arbitrarily created based on the total combined score: 1-13 - "LOW ADHERENCE" 14-16 - "PARTIAL ADHERENCE" 17-20 - "HIGH ADHERENCE" b) Weekly Eating Patterns (*) - participants were asked how many days per week they did the following (question 27 in survey): - eat out at a restaurant, take-out or snack bar - eat breakfast - eat three regular meals - eat small amounts all day rather than any regular meals c) Limiting Sugar Intake (*) - an index based on self-reported consumption of foods varying in sugar content (questions 25, 34 28 and 32). The index ranges from 0 to 3 with a 3 indicating one is limiting their sugar intake. d) Limiting Salt Intake (*) - an index based on self-reported consumption of foods varying in salt content (questions 25, 28 and 32). The index ranges from 0 to 3 with a 3 indicating one is limiting their salt intake. e) Limiting Fat Intake (*) - an index based on self-reported consumption of foods varying in fat content (questions 25, 28 and 32). The index ranges from 0 to 4 with a score of 3 or 4 indicating one is limiting their fat intake. f) Diet to Lose Weight (*) - participants were asked if they watch what they eat in order to lose weight (question 30). g) Diet to Maintain Weight (*) - participants were asked if they watch what they eat in order to maintain their weight (question 30). h) Eat Second Helpings - (*) participants were asked how often they eat second helpings (question 32). (4) PSYCHOSOCIAL VARIABLES a) Bradburn Balance Scale (*) - the Bradburn Balance Scale (Bradburn, 1969) asks the individual to rate the frequency of 5 positive and 5 negative feelings (question 34). The lowest or most negative score is 21 while the highest or most positive score is 1. "Positive Well-being" is defined as a score of 1-6 and is calculated by subtracting the negative affect scale from the positive and adding eleven. 35 b) Depression Score (*) - the CES-Depression Scale (Radloff and Locke, 1986) asks the respondent to rate the frequency of depressive symptoms (question 44). Each item is scored from 0 to 3, depending on frequency and the total score ranges from 0 to 60. Individuals are classified as depressed if they have a score of 16 or greater. (5) FAMILIAL VARIABLES a) Father's Education Level (*)- participants were asked what the highest level of education was that their father reached (question 57). Mother's education level was not used due to insufficient data. b) Obesity Status of Parents - this was defined by their sum of 5 skinfolds according to the criteria outlined in The Well-being of Canadians - Highlights of the 1988 Campbell's Survey (Stephens and Craig, 1990). Specifically, males and females aged 20-24 years were considered obese if their sum of 5 skinfolds was 61 mm or more or 75 mm or more, respectively. For males aged 25 and over this value was 65 mm and for females aged 25 and over this value was 85 mm. The obesity status of parents was also assessed subjectively according to question 37 where each child was asked if their mother or father had ever been overweight(*). c) Family Income Level (*) - participants were asked what the approximate total household income was for the previous year (question 60). 36 (6) LEISURE TIME VARIABLES Participants were asked to estimate how many hours (0, 1-2, 3-4, 5-9, 10-14 or 15+) they spend each week doing the following activities (question 1):(*) a) Watching television b) Reading c) Doing crafts or hobbies d) Visiting friends e) Visiting relatives f) Attending Cultural Events In order to estimate the average number of hours spent in each activity, the participant's response was converted to actual hours by using the mid-point for each of the estimates. Specifically, an estimate of 1-2 hours became 1.5 hours, 3-4 hours became 3.5 hours, 5-9 hours became 7 hours, 10-14 hours became 13 hours and 15 or more hours was left at 15 hours. (7) INFLUENCES ON PARTICIPATION IN PHYSICAL ACTIVITY a) Importance of reaching certain goals in one's spare time (*) - participants were asked to rate, on a 5 point continuum, how important it was to reach the following goals during their spare time (question 2): - to relax, forget about your cares - to get together with other people - to have fun 37 - to earn money - to get outdoors - to compete/win - to feel independent - to feel better mentally - to feel better physically - to improve/maintain physical fitness - to challenge your abilities, learn new things - to look better/control weight - to take risks, seek adventure Perceived barriers to being more physically active (*) -participants were asked to rate, on a 5 point continuum, how important the following were in preventing them from being more physically active (question 18): - lack of time due to work or school - lack of time due to family obligations - lack of time due to other interests - lack of energy, too tired - lack of athletic ability - lack of programs, leaders or accessible facilities - lack of a partner - lack of support from family or friends - lack of babysitting services - cost - lack of self-discipline or willpower 38 - self-conscious, ill at ease - long-term illness, disability or injury - fear of injury c) Attitudes toward participating regularly in vigorous physical activity (*) - participants were asked to rate, on a 5 point continuum, whether they thought regular participation in vigorous activity was (question 19): - boring fun - beneficial harmful - unpleasant pleasant - convenient inconvenient - painful not painful - easy difficult d) Encouragement to participate in vigorous physical activity (*) - participants were asked to rate, on a 5 point continuum, how much they felt their parents, other family members and close friends encouraged them to participate regularly in vigorous physical activity (question 21). e) Goals achievable or achieved by participating in vigorous physical activity (*) - participants were asked to rate, on a 5 point continuum, how much they felt participation in vigorous physical activity would help them to achieve the following goals (question 22): - relax, forget about your cares 39 - get together with other people - have fun - earn money - get outdoors - compete/win - feel independent - feel better mentally - feel better physically - challenge your abilities, learn new things - look better - control/lose weight - take risks, seek adventure - improve/maintain overall physical fitness - improve/maintain cardiovascular fitness - improve/maintain muscular strength and endurance - improve/maintain flexibility (C) Statistical Analysis of the Data The CFS contained data on a total of 2 601 children aged 7 to 12 years and 2437 (1264 males and 1173 females) of these had the skinfold data required to classify them as obese or non-obese. The CSWB provided data on a total of 337 children aged 7-12 years and 3 09 (158 males and 151 females) of these children had sufficient data to classify them as obese or non-obese. The parental data available for these 309 children was varied, 40 depending on the variable being examined. The data was analyzed using the PC version of the Statistical Package for the Social Sciences (SPSS:X). All analyses were performed on data that was weighted with factors that had been normalized to the n of the sample. The prevalence of childhood obesity was determined by the child's sum of 5 skinfolds value. Specifically, data from the CFS was used to establish a baseline level of obesity prevalence whereby children were classified as obese if their sum of 5 skinfolds value was greater than or equal to the 85th percentile for their age and sex. These age and sex specific values were then applied to the data in the CSWB. As such, the prevalence of obesity in the 1981 CFS was automatically set at approximately 15%. The actual prevalence values are slightly higher than 15% because the definition included those individuals whose sum of 5 skinfolds were equal to the 85th percentile as well as those greater than the 85th percentile. Differences in the prevalence of obesity between the 1981 and 1988 national samples were determined by Chi-Square analysis for homogeneity of proportions. A two-tailed t-test was performed to determine if there was any statistical difference between the obese children and the non-obese children with respect to age. As well, a chi-square test was performed to determine if there was any significant difference between the two groups of children with respect to the 41 proportion of males and females. The sum of 5 skinfolds value was also designated as the dependent outcome variable for all other integer variables assessed and Pearson Product Moment Correlation Coefficients were determined. In addition, with the children divided into obese and non-obese groups, a two-tailed t-test was used to determine the significance of differences in anthropometric variables as well as in resting heart rate, blood pressure, weekly eating patterns and the average time spent doing other leisure activities including reading, watching television, visiting friends, visiting relatives, doing hobbies/crafts and attending cultural events. The anthropometric variables were also converted to Z-scores to account for possible age and sex differences and a t-test was performed on the Z-scores. The Chi-Square test was also used to determine the significance of any differences between the obese children and the non-obese children with respect to the following variables: - Step Test Results - Energy Expenditure Data - Patterns of Leisure Activity - Nutrition Variables Including: - Limiting Sugar, Fat and Salt Intakes - Diet to Lose Weight - Diet to Maintain Weight 42 - Frequency of Having Second Helpings - Bradburn Balance Scale - Depression Scale - Father's Education Level - Obesity Status of Parents - Leisure Time Variables - Variables related to goals and attitudes about physical activity Finally, using the same statistical tests outlined above, the parental values for the above mentioned variables were compared to those of their children and to each other using the following groupings: - Parents of non-obese children (PNOC) compared to their non-obese children - Parents of obese children (POC) compared to their obese children - Parents of obese children compared to parents of non-obese children In all of the above situations, only those families that had data available for both parents were included in the analyses, unless otherwise specified. 43 (IV) RESULTS: (A) Prevalence of Childhood Obesity3 As Table 3 clearly indicates, the prevalence of obesity among Canadian children aged 7 to 12 years has increased substantially since 1981. In 1988, 23.9% of children aged 7-12 years were considered obese compared to a baseline level of 15.4% in 1981 (p<.001). More specifically, obesity increased to 22.0% in males (p<.05) and to 25.9% in females (p<.001). No age specific trends emerged although differences clearly existed (Table 4). In males, 31.7% of the 8 year olds, 27.8% of the 12 year olds and 25.1% of the 9 year olds were obese compared to only 15.4% of the 7 year olds, 17.8% of the 10 year olds and 19.5% of the 11 year olds. In females, 42.5% of the 9 year olds were obese followed by 31.1% of the 11 year olds, 24.7% of the 7 year olds, 22.0% of the 12 year olds, 20.6% of the 8 year olds and only 12.7% of the 10 year olds. aThis chapter (as part of a larger study) has been accepted for publication: Limbert, J., Crawford, S., McCargar, L. Estimates of the prevalence of obesity in Canadian children. Obesity Research 1994;2:321-327. 44 Table 3: Prevalence of obesity in Canadian children aged 7-12 years Percentage Classified as Obese1 (%) (n) SUBJECTS MALES FEMALES ALL CANADA FITNESS SURVEY (1981) 15.5 (1264) 15.3 (1173) 15.4 (2437) CAMPBELL'S SURVEY OF WELL-BEING (1988) 22.0 (158) 25.9 (151) 23.9 (309) % INCREASE FROM 1981 TO 1988 41.9** 69.3* 55.2* Obesity determined by the sum of 5 skinfolds (triceps, biceps, subscapular, suprailiac, medial calf): a child was classified as obese if their sum of 5 skinfolds value was greater than or equal to the 85th percentile value for their age and sex. The 85th percentile values were determined from the Canada Fitness Survey (1981) data. Significance of change in prevalence of obesity from 1981 to 1988 using Chi-Square Test: * p<.001 **p<.05 45 Table 4: Age specific prevalence of obesity in Canadian children in 1988 Prevalence (%) (n) AGE ( y e a r ) 7 8 9 10 1 1 12 MALES 1 5 . 4 (17 ) 3 1 . 7 (16) 2 5 . 1 (13 ) 1 7 . 8 (42 ) 1 9 . 5 (37 ) 2 7 . 8 (33 ) FEMALES 2 4 . 7 ( 1 5 ) 2 0 . 6 (14) 4 2 . 5 (22 ) 1 2 . 7 ( 2 7 ) 3 1 . 1 (40 ) 2 2 . 0 (33 ) (B) Pearson Correlation Coefficient Values Weight, height, triceps skinfold and BMI were all found to be significantly (one-tailed, p<.001) correlated with the SUM5 skinfolds (Table 5). The strongest correlations were found with the triceps skinfold (r=0.95), BMI (r=0.72) and weight (r=0.67). Resting heart rate was also significantly correlated with the SUM5 skinfolds but only in males (r=0.19; p<.01). Systolic blood pressure, diastolic blood pressure and energy expenditure were not significantly correlated with the SUM5 skinfolds. 46 Table 5: Pearson correlation coefficient values for various variables with SUM51 skinfolds for Canadian children aged 7 to 12 years Pearson Correlation Coefficient Values VARIABLE Weight (kg) Height (cm) Triceps Skinfold (mm) Body Mass Index (Wt (kg) /Height2 (m)) Diastolic Blood Pressure (mmHg) Systolic Blood Pressure (mmHg) Energy Expenditure2 (kcaT/k?"body wt/day) Resting Heart Rate (beats/minute) MALES 0.68* 0.32* 0.95* 0.62* -0.03 0.11 -0.03 0.19** FEMALES 0.66* 0.25** 0.94* 0.81* -0.08 -0.04 -0.07 -0.09 ALL 0.67* 0.27* 0.95* 0.72* -0.07 0.0006 -0.06 0.11 1SUM5 Skinfolds (mm) =Triceps + Biceps + Subscapular + Suprailiac + Medial Calf 2Children aged 10 to 12 years only * One-tailed; p<.001 ** One-tailed; p<.01 47 (C) Comparison of Obese Children and Non-Obese Children 1) Physical Variables The obese children (OC) did not differ significantly from the non-obese children (NOC) with respect to age and sex. Specifically, 48% of the OC were males compared to 53.3% of the NOC while the mean age of the OC was 10.1 (+-1.6) years, the same as the NOC (10.1 +- 1.6). As expected, the mean weight, BMI, triceps skinfold and sum of five skinfolds were significantly (p<.001) larger in the OC compared to the NOC (Table 6). In addition, the OC were significantly (p<.05) taller than the NOC and their resting heart rate was significantly higher (83 beats/minute vs 80 beats/minute; p<.05). The two groups did not differ significantly in either systolic blood pressure or diastolic blood pressure. The values for weight, BMI, triceps skinfold, sum of 5 skinfolds and height were also transformed to Z-scores and a two-tailed t-test was performed on the Z-scores. The results of this analysis were the same as the results on the original, non-transformed data. 48 Table 6: Comparison of physical variables of obese and non-obese children aged 7-12 years Mean Values (Standard Deviation) VARIABLE (n Of OC,n of NOC) Weight (kg) (74,235) Body Mass Index (74,234) Triceps Skinfold (mm) (74,235) SUM5 Skinfolds (mm) (74,235) Height (cm) (74,234) Systolic BP (mmHg) (72,233) Diastolic BP (mmHg) (72,216) Resting Heart Rate (beats/minute) (72,230) OBESE CHILDREN 45.5 (10.9) 21.5 (3.2) 19.2 (4.8) 85.6 (23.6) 144.2 (11.2) 104 (17) 72 (10) 83 (12) NON-OBESE CHILDREN 34.5* (7.7) 17.1* (2.3) 10.3* (2.8) 40.5* (11.1) 141.0** (12.1) 106 (12) 75 (10) 80** (12) * p< 0.001 (Obese vs non-obese) ** p< 0.05 (Obese vs non-obese) 49 (2) Fitness and Activity Variables The result of the Canadian Standardized Test of Fitness Step Test was the only objective estimate of fitness available. As Table 7 outlines, the OC appear to be significantly less fit than the NOC (p<.00001). Specifically, almost 8% of the OC were not able to complete stage 1 of the test compared to only 3.4% of the NOC. The first stage was completed by 39.1% of the OC and 14.4% of the NOC while 53.3% of the OC and 45.3% of the NOC were able to complete the second stage of the test. However, not one of the OC completed the third stage of the test while 36.9% of the NOC completed this stage. These results remained significant when obese males (OBM) were compared to non-obese males (NOBM) (p<.00001) and when obese females (OBF) were compared to non-obese females (NOBF) (p<.001). As well, the results remained significant for each of the three group comparisons when the cells of the table were collapsed as in Table 8. Overall, the OBF appear to be the least fit group with 12.7% unable or unwilling to complete the first stage of the test. On the other hand, the NOBM appear to be the most fit group with 45.7% completing the third stage of the test compared to 26.2% of the NOBF and not one of the OBM or OBF. 50 Table 7: Canadian Standardized Test of Fitness Step Test: Results for obese and non-obese children aged 7-12 years Last Stage of Test Completed SUBJECTS All OC* (n=71) All NOC (n=211) Obese Females** (n=37) Non-obese Females (n=97) Obese Males** (n=34) Non-obese Males (n=114) NONE1 7.6% 3.4% 12.7% 1.2% 2.1% 5.1% FIRST 39.1% 14.4% 31.2% 24.1% 47.7% 6.5% SECOND 53.3% 45.3% 56.1% 48.5% 50.2% 42.7% THIRD 0.0% 36.9% 0.0% 26.2% 0.0% 45.7% Unable to complete stage 1 of the test * Pearson Chi-Square for obese vs non-obese counterparts: p<.00001 ** Pearson Chi-Square for obese vs non-obese counterparts:p<.001 51 Table 8: Canadian Standardized Test of Fitness Step Test: Results for obese and non-obese children aged 7-12 years Last Stage of Test Completed SUBJECTS All OC* (n=71) All NOC (n=211) Obese Females** (n=37) Non-obese Females (n=97) Obese Males* (n=34) Non-obese Males (n=114) STAGE 1 OR LESS 46.7% 17.8% 43.9% 25.4% 49.8% 11.6% STAGE TWO OR THREE 53.3% 82.2% 56.1% 74.6% 50.2% 88.4% * Pearson Chi-Square for obese vs non-obese counterparts: p<.00001 ** Pearson Chi-Square for obese vs non-obese counterparts: p<.05 52 According to the energy expenditure data recorded in the questionnaires (children aged 10 to 12 only), the OC appear to be less active than the NOC (Table 9, p<.05). Specifically, about 60% of both the OC and the NOC were classified as being sufficiently active but 27.2% of the OC were considered sedentary compared to only 12.2% of the NOC. Compared to their non-obese counterparts, greater percentages of the OBF and OBM were classified as sedentary but these differences were only significant when the results of the males and females were combined. However, it is interesting to note that the results indicate the females were less active than the males with almost 40% of the OBF and 19.7% of the NOBF classified as sedentary compared to 16.1% of the OBM and 6.2% of the NOBM (the significance of any differences between males and females was not tested). The patterns of leisure activity recorded in the questionnaires were similar among OC and NOC (see table 10) with over 50% of the OC and NOC being active at a low intensity for at least 30 minutes every other day. Only 13.3% of the OC and 12.8% of the NOC were active at a moderate or higher intensity for at least 30 minutes every other day. The females were the least active group with respect to the higher intensity activities with less than 6% of the OBF and NOBF being active at a moderate or higher intensity for at least 30 minutes every other day compared to 20.2% of OBM and 18.7% of NOBM. 53 Table 9: Estimates of activity levels for obese and non-obese children aged 10-12 years Estimate of Activity Level SUBJECTS All OC* (n=35) All NOC (n=123) Obese Females (n=15) Non-obese Females (n=56) Obese Males (n=20) Non-obese Males (n=67) SEDENTARY 27.2% 12.2% 39.7% 19.7% 16.1% 6.2% MINIMALLY ACTIVE 13.0% 28.1% 21.8% 31.0% 5.2% 25.7% SUFFICIENTLY ACTIVE 59.8% 59.7% 38.5% 49.3% 78.7% 68.1% Activity Level (AL) Estimation was based on energy expenditure (EE) data as follows: If EE < 1.5 kcal/kg body wt/day then AL=Sedentary If EE >= 1.5 and EE <= 3.0 then AL=Minimally Active If EE > 3.0 kcal/kg body wt/day then AL=Sufficiently Active * Pearson Chi-Square for obese vs their non-obese counterparts: p<=0.05 54 Table 10: Patterns of leisure activity of obese and non-obese children aged 10-12 years SUBJECTS All OC (n=34) All NOC (n=122) Obese Females (n=15) Non-obese Females (n=55) Obese Males (n=19) Non-obese Males (n=67) ANY I* IRREG. F** <30 MINUTE D*** 9.7% 18.3% 16.0% 21.0% 4.0% 16.2% ANY I REGULAR F 30 MIN D 18.8% 16.7% 19.3% 19.4% 18.3% 14.6% LOW I REGULAR F 30 MIN D 58.1% 52.2% 58.9% 54.3% 57.5% 50.6% MODERATE I REGULAR F 30 MIN D 13.3% 12.8% 5.8% 5.4% 20.2% 18.7% * I=Intensity of activity (Moderate Intensity is 50% or greater of age specific capacity). ** F=Frequency of activity (Regular Frequency is every other day, on average) *** D=Duration of activity in minutes 55 (3) Nutrition Variables Approximately one third of both the OC and the NOC had a high adherence to Canada's Food Guide while about 17% had a low adherence and the majority (52.1% of OC and 48.0% of OC) had a partial adherence (Table 11). These results were similar for both males and females. With respect to daily eating patterns, the OC and NOC were quite similar (Table 12). Both OC and NOC ate out less than one day a week on average and both groups of children reported "eating small amounts throughout the day" an average of less than one day per week. The OC ate three regular meals an average of 5.3 days per week compared to 5.9 days per week for the NOC but this difference was not significant. The only significant difference was with their breakfast eating patterns whereby the OC ate breakfast an average of 4.8 days/week compared to 5.9 days per week for the NOC (p<.05). However, this difference was due to the difference between the OBF and NOBF as the OBF ate breakfast an average of 3.5 days per week compared to 5.8 days per week for NOBF (p<.01). One reason the OBF had such a low weekly average for eating breakfast was because 35.2% of the OBF reported that they never ate breakfast compared to 3.9% of NOBF (p<.01). Both the OBM and NOBM ate breakfast about 6 days per week. 56 Table 11: Adherence to Canada's Food Guide - Obese and non-obese Children aged 10-12 years SUBJECTS All OC (n=32) All NOC (n=106) Obese Females (n=14) Non-obese Females (n=48) Obese Males (n=18) Non-obese Males (n=58) LOW ADHERENCE 17.5% 16.6% 16.9% 14.4% 18.0% 18.6% PARTIAL ADHERENCE 52.1% 48.0% 49.4% 58.3% 54.6% 39.7% HIGH ADHERENCE 30.5% 35.2% 33.8% 27.2% 27.4% 41.7% No significant differences between groups 57 Table 12: Summary of dietary habits of obese and non-obese children aged 10-12 years Mean Number of Days/Week (Standard Deviation) SUBJECTS All OC (n=35) All NOC (n=115) Obese Females (n=15) Non-obese Females (n=52) Obese Males (n=20) Non-obese Males (n=63) THREE REGULAR MEALS 5.3 (2.1) 5.9 (1.7) 5.2 (1.9) 6.0 (1.7) 5.5 (2.3) 5.9 (1.8) EAT BREAKFAST 4.8* (2.8) 5.9 (2.1) 3.5** (3.0) 5.8 (2.1) 6.1 (2.1) 5.9 (2.1) NIBBLE THROUGHOUT DAY 0.6 (1.3) 0.6 (1.1) 1.1 (1.8) 0.7 (1.1) 0.3 (0.6) 0.6 (1.1) HAVE MEALS OUTSIDE OF HOME 0.8 (0.9) 0.9 (1.1) 1.0 (1.1) 1.0 ( 1 . 1 ) 0.7 (0.7) 0.8 (1.0) * p<.05 (Obese children vs their non-obese counterparts) ** p<.01 (Obese children vs their non-obese counterparts) 58 There were no significant differences in the attempts of OC and NOC to limit their consumption of fat, sugar and salt (Table 13) although it is interesting to note that the majority of OC (69.2%) and NOC (57.6%) were attempting to limit their fat intake while only a small portion were attempting to limit either their sugar (0% of OC and 8.3% of NOC) or salt intakes (13.0% of OC and 15.2% of NOC). In addition, 80.4% of the OBF were attempting to limit their fat intake but this was not significantly different from the 55.5% of NOBF that were doing the same. With regards to eating second helpings, the OC and the NOC did not differ significantly with 21.0% of OC and 34.0% of NOC indicating they "often" had second helpings while 48.6% of OC and 29.4% of NOC indicated they "sometimes" had second helpings and 30.4% of OC and 36.6% of NOC indicated they "rarely or never" had second helpings. Lastly, compared to NOC, a significantly greater proportion of OC indicated they diet to lose weight (29.7% vs 9.5%; p<.01) or they diet to maintain weight (26.4% vs 12.6%; p<.05) (Table 14). However, when the males and females were analyzed separately some sex differences did emerge. Compared to the NOBF, significantly more of the OBF stated that they diet to lose weight (40.5% vs 11.2%, p<.05) but similar proportions of the NOBF and OBF stated that they diet to maintain their weight. Conversely, compared to the NOBM, significantly more of the OBM stated that they diet to maintain their weight (39.0% vs 11.3%, p<.05) while similar 59 Table 13: Attempts to limit consumption of fat, sugar and salt -Obese and non-obese children aged 10-12 years SUBJECTS All OC (n=35) All NOC (n=117) Obese Females (n=15) Non-obese Females (n=53) Obese Males (n=20) Non-obese Males (n=64) LIMIT FAT 69.2% 57.6% 80.4% 55.5% 59.3% 60.0% LIMIT SUGAR 0.0% 8.3% 0.0% 8.9% 0.0% 8.0% LIMIT SALT 13.0% 15.2% 16.1% 11.3% 10.4% 18.6% No significant differnces between groups 60 proportions of the OBM and NOBM stated that they diet to lose weight. Table 14: Dietary habits for weight control of obese and non-obese children aged 10-12 years SUBJECTS All OC (n=36) All NOC (n=116) Obese Females (n=16) Non-obese Females (n=53) Obese Males (n=20) Non-obese Males (n=63) DIET TO LOSE WEIGHT 29.7%* 9.5% 40.5%* 11.2% 19.6% 8.2% DIET TO MAINTAIN WEIGHT 26.4%** 12.6% 12.9% 14.3% 39.0%* 11.3% * Pearson Chi-Square for obese vs their non-obese counterparts p<.01 ** Pearson Chi-Square for obese vs their non-obese counterparts p< .05 61 (4) Psychosocial Variables The OC did not differ significantly from the NOC with respect to the following two measurements of psychological wellbeing (Table 15): Bradburn Balance Scale and Depression Score. According to the Bradburn Balance Scale, 23.1% of the OC and 24.9% of the NOC scored highly, indicating a "positive wellbeing" or generally good mood and positive feelings. On the CES-Depression Scale, 13.6% of the OC and 12.0% of the NOC were rated as "Depressed". Interestingly, 18.5% of the OBM were classified as depressed which was the highest of the subgroups although it was not significantly different from the 13.6% of the NOBM that were similarly classified. 62 Table 15: Measures of psychological well-being of obese and non-obese children aged 10-12 years SUBJECTS All OC All NOC Obese Females Non-obese Females Obese Males Non-obese Males PERCENTAGE RATED AS HAVING A POSITIVE WELL-BEING* % (n) 23.1 (35) 24.9 (117) 19.5 (15) 20.7 (53) 26.2 (20) 28.3 (64) PERCENTAGE RATED AS DEPRESSED** % (n) 13.6 (35) 12.0 (112) 8.1 (15) 10.0 (50) 18.5 (20) 13.6 (62) No significant differences between groups * Bradburn Balance Scale: Bradburn, NM. The Structure of Psychological Well-being. Chicago: Aldine Publishing Co., 1969. ** CES-Depression Scale: Radloff, LS and Locke, BZ. The Community Mental Health Assessment Survey and the CES-D Scale. In Weisman, MM, Myers, JK, Ross CE. (eds). Community Surveys of Psychiatric Disorders. New Brunswick, NJ: Rutgers U Press, 1986. (5) Socioeconomic Variables There were no significant differences between the two groups with respect to family income or father's education level (Table 16 and Table 17). The majority of both OC (59.4%) and NOC (62.6%) had family incomes of $35,000 or more while their fathers' education level was quite varied. 63 Table 16: Family income levels of obese and non-obese children aged 10-12 years FAMILY INCOME LEVEL <$10,0000 $10,000-$14,000 $15,000-$19,000 $20,000-$24,000 $25,000-$34,000 $35,000-$54,000 $55,000 and over OBESE CHILDREN (n=29) 2.5% 3.4% 6.9% 4.7% 23.1% 38.4% 21.0% NON-OBESE CHILDREN (n=117) 2.5% 0.9% 3.4% 8.2% 22.5% 31.6% 31.0% No significant differences between groups Table 17: Father's education level - Obese and non-obese children aged 10-12 years HIGHEST LEVEL OF EDUCATION REACHED BY FATHER Elementary or Less Some Secondary Secondary Diploma Some Post-Secondary Post-Secondary Diploma One or More University Degrees OBESE CHILDREN (n=36) 2.7% 23.7% 20.3% 6.3% 29.3% 17.7% NON-OBESE CHILDREN (n=129) 8.2% 16.1% 16.7% 10.8% 19.8% 28.3% No significant differences between groups 64 (6) Leisure Time Activities The OC and the NOC aged 10-12 years did not differ significantly with respect to the time they spent visiting friends, visiting relatives, doing hobbies and crafts, reading or attending cultural events (Table 18). The OC did, however, watch significantly less television than the NOC with the OC watching television an average of 7.5 hours/week compared to 9.6 hours/week for the NOC (p<.05). This difference was due to the difference observed between the OBF and the NOBF as the OBM and NOBM watched a similar amount of television. Specifically, the OBF watched an average of 5.7 hours of television per week compared to 9.5 hours per week for the NOBF (p<.05). 65 Table 18: Average time spent by obese and non-obese children aged 10-12 years doing various leisure time activities Mean Values (Hours/Week) (Standard Deviation) SUBJECTS All OC All NOC Obese Females Non-Obese Females Obese Males Non-Obese Males VISIT FRIENDS 7.4 (4.6) 6.6 (4.7) 6.7 (4.8) 6.3 (4.7) 8.2 (4.5) 6.8 (4.8) VISIT RELA-TIVES 2.3 (3.4) 2.6 (3.3) 2.4 (4.3) 2.4 (3.0) 2.1 (2.5) 2.7 (3.6) READING 4.8 (4.8) 4.6 (4.0) 3.8 (4.3) 6.0 (4.4) 5.7 (5.2) 3.5 (3.4) DOING HOBBIES OR CRAFTS 3.6 (4.5) 2.8 (3.4) 2.2 (2.8) 2.4 (2.4) 4.9 (5.4) 3.1 (4.0) ATTEND CULTURAL EVENTS 0.6 (1.3) 1.0 (1.9) 0.6 (1.6) 1.3 (2.4) 0.5 (0.7) 0.7 (1.3) WATCH T.V. 7.5* (4.4) 9.6 (4.5) 5.7* (3.9) 9.5 (4.5) 9.2 (4.3) 9.6 (4.4) * p<.05 (Obese vs their non-obese counterparts) 66 (7) Goals and Attitudes Related to Physical Activity (i) Goals of Spare Time The OC and NOC aged 10-12 years responded similarly when asked how important it was for them to achieve specific goals in their spare time (Table 19). The only significant difference observed was that 94.6% of OBF thought it was important to look better or lose weight during their spare time compared to 68.9% of NOBF (p<.05). Most of the children (89.0% of OC and 84.3% of NOC) thought it was important to challenge their abilities and learn new things during their spare time and a similar proportion (89.1% of OC and 85.9% of NOC) rated having fun as an important goal to be achieved during their spare time. A greater proportion of the OC (82.1% of OC vs 67.0% of NOC) thought it was important to be with other people during their spare time but this difference was not significant. A large portion of both the OC and the NOC (between 65% and 83%) also thought it was important to achieve the following goals in their spare time: - to get outdoors - to improve or maintain their physical fitness - to look better or control their weight - to feel better physically Almost two thirds of the children thought it was important to feel better mentally during their spare time and more than half of the children thought it was important to achieve the following goals during their spare time: 67 Table 19: Importance of achieving specific goals in spare time for obese and non-obese children aged 10-12 years Percentage Rating Goal as Important or Very Important GOAL DESCRIPTION To Relax To Be With People To Have Fun To Compete or Win To Get Outdoors To Earn Money To Feel Independent To Feel Better Mentally To Feel Better Physically To Improve Fitness To Challenge Abilities To Look Better or Lose Weight To Take Risks or Seek Adventure ALL OC (n=36) 38.8 82.1 89.1 58.7 79.5 54.6 54.9 65.5 73.7 80.0 89.0 78.8 61.3 ALL NOC (n=121) 39.8 67.0 85.7 41.7 75.2 53.6 69.5 64.3 82.3 83.5 84.3 65.8 56.4 FEMALE OC (n=16) 46.2 89.3 87.5 61.3 87.0 62.0 68.7 70.6 79.5 87.0 84.9 94.6* 57.7 FEMALE NOC (n=55) 36.6 67.2 84.9 35.5 75.8 56.0 66.8 64.1 93.2 83.5 92.6 68.9 49.7 MALE OC (n=20) 31.8 75.5 90.5 56.3 72.5 47.7 41.9 60.7 68.3 73.5 92.8 64.0 64.6 MALE NOC (n=66) 42.6 66.8 86.3 46.8 74.7 51.8 71.7 64.5 73.5 83.5 77.7 63.3 61.8 * Pearson Chi-Square for obese vs their non-obese counterparts: p<.05 68 - to feel independent - to take risks/seek adventure - to earn money More OC than NOC (58.7% of OC vs 41.7% of NOC) viewed competing and/or winning as an important goal of their spare time but this difference was not significant. Finally, only 38.8% of OC and 39.8% of NOC viewed relaxing as an important goal to be achieved during their spare time. (ii) Barriers to Being More Physically Active The factor most frequently identified as a barrier to being more physically active was the same for both OC and NOC: "a lack of time due to work or school" (Tables 20a and 20b). However, significantly more of the OC identified this as an important barrier when compared to the NOC (45.2% of OC vs 25.3% of NOC; p<.05). This difference was the strongest for females where 53.6% of OBF cited this particular barrier as being important compared to 27.2% of NOBF (p<.05). Compared to the NOBM, a greater proportion of the OBM also cited this barrier as being important but the difference was not significant (37.4% of OBM vs 23.8% of NOBM). The second most frequently identified barrier was "a lack of time due to other interests" as this was rated as an important factor by 35.3% of OC and 21.9% of NOC. For OBM this was the most frequently identified barrier as it was cited as being important by 40.7% of OBM. Most of the other factors were identified as being important barriers to being more 69 physically active by 25% or less of both the OC and NOC with no significant differences between the OC and NOC, OBF and NOBF or between OBM and NOBM (Tables 20a and 20b). Table 20a: Factors identified by obese and non-obese children aged 10-12 years as barriers to being more physically active Percentage Rating the Factor as a Very Important or Important Barrier FACTORS PERCEIVED AS BARRIERS Lack of Time Duet to Work/School Lack of Time Due to Family Lack of Time Due to Other Interests Lack a Partner Lack of Support Cost Lack Programs ALL OC % (n) 45.2* (36) 15.9 (35) 35.3 (36) 13.6 (36) 25.6 (36) 21.9 (36) 22.0 (36) ALL NOC % (n) 25.3 (120) 20.4 (118) 21.9 (119) 19.7 (119) 18.2 (119) 17.6 (119) 14.6 (119) FEMALE OC % (n) 53.6* (16) 22.3 (15) 29.5 (16) 24.0 (16) 18.6 (16) 20.6 (16) 23.5 (16) FEMALE NOC % (n) 27.2 (55) 21.8 (53) 20.0 (54) 17.5 (54) 9.2 (54) 16.8 (54) 16.7 (54) MALE OC % (n) 37.4 (20) 10.4 (20) 40.7 (20) 3.8 (20) 32.2 (20) 23.2 (20) 20.7 (20) MALE NOC % (n) 23.8 (65) 19.3 (65) 23.5 (65) 21.6 (65) 25.3 (65) 18.3 (65) 12.9 (65) * Pearson Chi-Square for obese vs their non-obese counterparts: p<.05 70 Table 20b: Factors identified by obese and non-obese children aged 10-12 years as barriers to being more physically active Percentage Rating the Factor as a Very Important or Important Barrier to Being More Physically Active FACTORS PERCEIVED AS BARRIERS Lack Babysitting Lack Energy Lack Ability Lack Self-Discipline Feel 111 at Ease Illness or Injury Fear of Injury ALL OC % (n) 9.1 (36) 21.2 (36) 19.3 (36) 19.9 (36) 16.7 (36) 11.7 (36) 14.6 (36) ALL NOC % (n) 3.3 (117) 19.3 (119) 14.0 (119) 15.6 (119) 14.8 (117) 9.2 (119) 14.6 (119) FEMALE OC % (n) 13.2 (16) 7.5 (16) 13.0 (16) 25.9 (16) 23.5 (16) 13.2 (16) 20.6 (16) FEMALE NOC % (n) 3.8 (53) 17.2 (54) 12.9 (54) 12.5 (54) 15.3 (54) 8.7 (54) 14.8 (54) MALE OC % (n) 5.2 (20) 34.1 (20) 25.2 (20) 14.2 (20) 10.4 (20) 10.4 (20) 9.0 (20) MALE NOC % (n) 2.9 (64) 21.0 (65) 15.0 (65) 18.1 (65) 14.4 (63) 9.5 (65) 14.4 (65) No significant differences between the groups 71 (iii) Attitudes Towards Regular Participation in Vigorous Physical Activity Compared to NOC, significantly less OC thought that regular participation in vigorous physical activity (VPA) was "not painful" (51.8% of OC vs 70.5% of NOC; p<.05) (Table 21). This difference was due to the fact that only 35.4% of OBM viewed VPA as "not painful" compared to 78.9% of NOBM (p<.001). The OBF and NOBF responded similarly with 70.4% of OBF and 60.1% of NOBF viewing VPA as "not painful". In addition, compared to NOC, significantly less of the OC viewed regular participation in VPA as fun (60.6% of OC vs 78.0% of NOC; p<.05). Again, this was due to the difference between OBM and NOBM with 51.7% of OBM viewing VPA as "fun" compared to 79.5% of NOBM (p<.05). Over 70% of the OBF and NOBF also viewed VPA as "fun". Similarly, significantly less of the OC viewed regular participation in VPA as easy (29.1% of OC vs 50.1% of NOC; p<.05). Compared to their non-obese counterparts, less of the OBF and OBM viewed VPA as easy but these differences were only significant when the results of both sexes were combined. With respect to other feelings about regular participation in VPA, the OC and NOC responded similarly with the majority (between 63% and 78%) viewing it as pleasant and beneficial and about half viewing it as convenient (Table 21) . 72 Table 21: Attitudes of obese and non-obese children aged 10-12 years towards regular participation in vigorous physical activity Percentage of Children Identifying Specific Attitudes ATTITUDE Easy Fun Not Painful Pleasant Beneficial Convenient ALL OC % (n) 29.1* (35) 60.6* (35) 51.8* (35) 77.6 (35) 63.4 (35) 49.9 (35) ALL NOC % (n) 50.1 (114) 78.0 (116) 70.5 (114) 75.7 (114) 70.7 (113) 59.0 (115) FEMALE OC % (n) 29.3 (15) 70.6 (15) 70.4 (15) 88.4 (15) 73.8 (15) 48.9 (15) FEMALE NOC % (n) 46.1 (52) 76.1 (53) 60.1 (52) 69.2 (52) 71.2 (51) 57.7 (53) MALE OC % (n) 28.9 (20) 51.7* (20) 35.4** (20) 68.1 (20) 54.1 (20) 50.9 (20) MALE NOC % (n) 53.4 (62) 79.5 (63) 78.9 (62) 80.9 (62) 70.3 (62) 60.1 (62) * Pearson Chi-Square for obese vs their non-obese counterparts: p<.05 ** Pearson Chi-Square for obese vs their non-obese counterparts: p<.001 (iv) Encouragement by Others to Participate Regularly in VPA Compared to the NOC, a smaller proportion of the OC indicated they had support or were encouraged by others to participate regularly in VPA but these differences were largely due to the differences observed between the OBM and NOBM (Table 22). Most of the children felt their parents were supportive (66.0% of OC and 80.5% of NOC) while about half of the children felt that other family members were supportive. However, only 54.5% of the OBM felt their parents were supportive compared to 80.6% of NOBM (p<.05). Over 60% of the OBF and NOBF felt their close friends were supportive or encouraged them to participate regularly in VPA but only 36.6% of OBM felt this way compared to 64.3% of NOBM (p<.05). 74 Table 22: Perceived encouragement/support from others to be physically active for obese and non-obese children aged 10-12 years Percentage Rating Others as Being Supportive ENCOURAGED OR SUPPORTED BY: Parents Other Family Members Close Friends ALL OC % (n) 66.0 (34) 49.1 (32) 52.3 (29) ALL NOC % (n) 80.5 (113) 59.7 (105) 64.8 (108) FEMALE OC % (n) 78.3 (15) 55.6 (13) 68.2 (13) FEMALE NOC % (n) 80.4 (50) 58.7 (46) 65.5 (51) MALE OC % (n) 54.2* (19) 43.9 (19) 36.6* (16) MALE NOC % (n) 80.6 (63) 60.5 (59) 64.3 (57) * Pearson Chi-Sguare for obese vs their non-obese counterparts: p<.05 (v) Contribution of VPA to the Achievement of Specific Goals With the exception of the goals of relaxing and earning money, 50% or more of both the OC and the NOC felt that participation in VPA would help them to achieve their goals (Tables 2 3a and 2 3b). Over 80% of the children felt that participation in VPA would , or does, help them to achieve the goal of having fun. Similarly, between 71% and 83% of the children felt that participation in VPA would, or does, help them to achieve the goals of: - feeling better physically - improve/maintain flexibility - improve/maintain strength 75 - improve/maintain fitness - to get outdoors However, compared to NOC, a significantly greater proportion of the OC felt that participation in VPA would help them to achieve the goal of losing or controlling their weight (70.2% of OC vs 50.6% of NOC; p<.05). This difference was due to the fact that 86.2% of OBF felt VPA would or does help them to achieve the goal of losing or controlling weight compared to 50.5% of NOBF (p<.05). The OBM and NOBM responded similarly with 56.1% of the OBM and 50.7% of the NOBM stating that VPA helps or would help them to lose or control their weight. However, a significantly greater proportion of NOC felt that participation in VPA would help them to achieve the goal of getting together with other people (78.9% of NOC vs 60.5% of OC; p<.05). Smaller proportions of the children felt that participation in VPA would help them to achieve the goals of earning money (22.6% of OC and 19.4% of NOC) and relaxing (50.9% of OC and 38.5% of NOC). 76 Table 23a: Contribution of vigorous physical activity to the achievement of specific goals for obese and non-obese children aged 10-12 years Percentage of Children Who Believe Vigorous Physical Activity Contributes Somewhat or A Great Deal to Attaining the Goal GOAL DESCRIPTION To Compete or Win To Be Outdoors To Feel Better Physically To Take Risks To Relax To Lose or Control Weight To Improve Looks To Earn Money To Have Fun To Be With Others ALL OC % (n) 50.6 (35) 78.3 (35) 79.5 (35) 62.9 (35) 50.9 (35) 70.2* (35) 67.2 (35) 22.6 (35) 80.2 (35) 60.5* (35) ALL NOC % (n) 53.4 (116) 71.0 (116) 82.6 (116) 53.3 (116) 38.5 (116) 50.6 (116) 59.1 (116) 19.4 (117) 82.7 (117) 78.9 (117) FEMALE OC % (n) 55.9 (15) 78.4 (15) 86.3 (15) 69.1 (15) 62.3 (15) 86.2* (15) 70.3 (15) 22.0 (15) 86.4 (15) 68.2 (15) FEMALE NOC % (n) 41.9 (54) 62.6 (54) 86.6 (54) 52.7 (54) 39.3 (54) 50.5 (54) 61.7 (54) 12.9 (54) 81.2 (54) 79.6 (54) MALE OC % (n) 45.9 (20) 78.1 (20) 73.5 (20) 57.5 (20) 40.8 (20) 56.1 (20) 64.5 (20) 23.2 (20) 74.8 (20) 53.6* (20) MALE NOC % (n) 63.0 (62) 78.0 (62) 79.3 (62) 53.9 (62) 37.9 (62) 50.7 (62) 56.9 (62) 24.9 (63) 83.9 (63) 78.3 (63) * Pearson Chi-Square for obese vs their non-obese counterparts: p<.05 77 Table 23b: Contribution of vigorous physical activity to the achievement of specific goals for obese and non-obese children aged 10-12 years Percentage of Children Who Believe Vigorous Physical Activity Contributes Somewhat or a Great Deal to Attaining the Goal GOAL DESCRIPTION To Feel Independent To Challenge Abilities To Improve or Maintain Cardio-vascular Fitness To Feel Better Mentally To Improve or Maintain Overall Fitness To Improve or Maintain Strength & Endurance To Improve or Maintain Flexibility ALL OC % (n) 55.5 (35) 64.5 (35) 69.2 (35) 71.0 (35) 87.5 (35) 75.5 (35) 79.5 (35) ALL NOC % (n) 45.1 (115) 77.1 (115) 60.2 (115) 60.3 (115) 74.8 (116) 79.8 (116) 78.3 (116) FEMALE OC % (n) 48.8 (15) 66.6 (15) 80.4 (15) 68.1 (15) 72.5 (15) 84.1 (15) 92.1 (15) FEMALE NOC % (n) 39.3 (54) 75.5 (54) 60.0 (54) 58.8 (54) 78.7 (54) 75.7 (54) 83.2 (54) MALE OC % (n) 61.5 (20) 62.7 (20) 59.3 (20) 73.5 (20) 63.1 (20) 67.8 (20) 68.3 (20) MALE NOC % (n) 50.1 (61) 78.4 (61) 60.3 (61) 61.6 (61) 71.5 (62) 83.3 (62) 74.2 (62) No significant differences between groups 78 (D) COMPARISON OF CHILDREN WITH THEIR PARENTS (1) Obesity Status Compared to the NOC's parents, significantly more of the OC's parents were classified as obese (55.4% vs 37.7%, p<.01). Specifically, 51.2% of the OC's mothers were obese compared to 34.2% of NOC's mothers (p<.05) and 59.9% of of the OC's fathers were obese compared to 41.2% of the NOC's fathers (p<.05). Similarly, 46.3% of the OC aged 10-12 years indicated their mother was or had been overweight compared to 20.6% of the NOC (p<.01). In addition, 32.4% of the OC aged 10-12 years indicated their father was or had been overweight compared to 13.5% of the NOC (p<.05). When only those children that had data available for both parents were examined, compared to the NOC, a higher percentage of the OC had either two obese parents (28.3% of OC vs 17.5% of NOC, not significant) or at least one obese parent (78.9% of OC vs 61.7% of NOC, p<.05). A significantly greater proportion of the NOC had two non-obese parents (38.3% of NOC vs 21.1% of OC, p<.05). When the analysis included all children that had obesity data on one or more of their parents, significantly more of the OC had at least one obese parent (84.1% of OC vs 65.6% of NOC, p<.05) (2) Fitness and Activity Variables Almost half of the parents of non-obese children (PNOC) and the parents of obese children (POC) were classified as sedentary 79 according to their energy expenditure data. Only 15.9% of the NOC were classified as sedentary and this was significantly different from their parents (Table 24, p<.00001). On the other hand, 32.3% of the OC were classified as sedentary and this was not significantly different from the 44.2% of their parents that were similarly classified. With respect to their patterns of leisure activity both groups of parents were significantly less active than their respective children with only 50.6% of the PNOC and 69.7% of the POC participating in some form of activity of any intensity, at least three times per week for at least 30 minutes each time compared to 81.5% of the NOC (p<.00001) and 91.0% of the OC (p<=.05) having this pattern (Table 25). Further, according to their patterns of leisure activity the PNOC were also significantly less active than the POC (p<.05). 80 Table 24: Estimates of activity level for obese and non-obese children aged 10-12 years and their parents Estimate of Activity Level' Sedentary Minimally or Sufficiently Active Non-Obese Children (n=87) 15.9%* 84.1% Parents of Non-Obese Children (n=174) 49.4% 50.6% Obese Children (n=22) 32.3% 67.7% Parents of Obese Children (n=44) 44.2% 55.8% 'Activity Level (AL) Estimation was based on energy expenditure (EE) data as follows: If EE < 1.5 kcal/kg body wt/day then AL=Sedentary If EE >= 1.5 and EE <= 3.0 then AL= Minimally Active If EE > 3.0 kcal/kg body wt/day then AL=Sufficiently Active *p<.00001 (Pearson Chi-Square for parents vs their children) 81 Table 25: Patterns of leisure activity for obese and non-obese children aged 10-12 years and their parents Pattern of Activity Any I', Regular F2 30 Min. D3 Any I, Irregular F, < 30 Minute D Non-Obese Children (n=87) 81.5% 18.5%* Parents of Non-Obese Children (n=174) 50.6% 49.4%*** Obese Children (n=22) 91.0% 9.0%** Parents of Non-Obese Children (n=44) 69.7% 30.3% I=Intensity of Activity 2 F=Frequency of Activity (Regular=every other day, on average) 3 D=Duration of activity in minutes * p<.00001 (Pearson Chi-Square for parents vs their children) ** p<=.05 (Parents vs their children) ***p<.05 (Parents of NOC vs parents of OC) (3) Nutrition Variables Approximately 40% of both groups of parents had a high adherence to Canada's Food Guide with about 50% having a partial adherence and about 17% having a low adherence (Table 26). These values were not significantly different from their respective children. With respect to daily eating patterns, the POC were similar to the PNOC but in three of the four areas assessed, the PNOC differed significantly from their NOC (Table 27). Specifically, the PNOC ate three regular meals an average of only 4.4 days/week compared to 6.0 days/week for their children (p<.001) and the 82 PNOC ate breakfast an average of 4.7 days/week compared to 6.1 days/week for their NOC (p<.001). Finally, the PNOC ate meals outside of the home more frequently than their NOC, averaging 1.3 days/week compared to 0.8 days/week for their children (p<.01). The same pattern existed with the POC and their OC whereby the POC ate three regular meals and breakfast less frequently than their OC while eating out more often but these differences were not significant. The PNOC were not significantly different from their NOC when it came to limiting their fat, sugar and salt intakes but a significantly smaller proportion of the PNOC were limiting their sugar intake when compared to the POC (Table 28; 15.4% vs 29.6%, p<.05). Furthermore, compared to their OC, significantly more of the POC were limiting their sugar intake (29.6% vs 0.0, p<.01). However, there were no significant differences between the POC and their OC with respect to limiting fat and salt intakes. Compared to their NOC, a significantly smaller proportion of the PNOC stated that they often had second helpings (13.5% vs 37.4%, p<.0001). Similarly, only 14.1% of the POC stated they often had second helpings compared to 29.3% of their OC but this difference was not significant. Finally, compared to their NOC, significantly more of the PNOC stated they watch what they eat in order to lose weight (Table 83 29; 34.6% vs 9.0%, p<.0001) or to maintain weight (33.3% vs 16.0%, p<.01). A similar pattern was observed with the OC and their parents with a greater proportion of the POC stating they watched what they ate in order to lose or maintain weight but this difference was not significant. Table 26: Level of adherence to Canada's Food Guide for obese and non-obese children aged 10-12 years and their parents Level of Adherence to Canada•s Food Guide Low Partial High Non-Obese Children (n=61) 10.6% 51.9% 37.5% Parents of Non-Obese Children (n=122) 16.5% 55.0% 28.5% Obese Children (n=16) 21.8% 42.8% 41.2% Parents of Obese Children (n=32) 17.3% 41.2% 41.6% No significant differences between groups 84 Table 27: Daily eating patterns of obese and non-obese children aged 10-12 years and their parents Mean Number of Days Per Week (Standard Deviation) Eating Pattern Eat 3 Regular Meals Eat Breakfast Nibble Throughout Day Have Meals Outside of Home Non-Obese Children (n=82) 6.0* (1.6) 6.1* (1.9) 0.7 (1.2) 0.8** (1.1) Parents of Non-Obese Children (n=164) 4.4 (2.8) 4.7 (2.8) 0.5 (1.1) 1.3 (1.4) Obese Children (n=21) 5.5 (2.0) 4.7 (3.0) 0.5 (1.0) 0.8 (0.9) Parents of Obese Children (n=42) 4.8 (2.3) 3.9 (3.0) 0.3 (0.9) 1.2 (1.5) * p<.001 (Parents vs their children) **p<.01 (Parents vs their children) Table 28: Attempts to limit fat, sugar and salt intakes of obese and non-obese children aged 10-12 years and their parents Dietary Habit Limiting Fat Limiting Sugar Limiting Salt Non-Obese Children (n=82) 59.3% 9.4% 17.3% Parents of Non-Obese Children (n=164) 61.9% 15.4%* 14.7% Obese Children (n=22) 63.7% 0.0%** 16.1% Parents of Obese Children (n=44) 58.4% 29.6% 8.2% * p<.05 (Pearson Chi-Square for parents of NOC vs parents of OC) **p<.01 (Pearson Chi-Square for parents vs their children) 85 Table 29: Modification of eating habits for the purposes of losing or maintaining weight for obese and non-obese children aged 10-12 years and their parents Dietary Habit Diet to Lose Weight Diet to Maintain Weight Non-Obese Children (n=79) 9.0%* 16.0%** Parents of Non-Obese Children (n=158) 34.6% 33.3% Obese Children (n=21) 26.4% 18.0% Parents of Obese Children (n=42) 42.2% 34.3% * p<.0001 (Pearson Chi-Square for parents vs their children) **p<.01 (Pearson Chi-Square for parents vs their children) (4) Psychosocial Variables Similar proportions of both groups of parents were found to have a positive well-being (36.8% of PNOC and 28.2% of POC) and these values were not significantly different from their respective children (Table 30). In addition, similar proportions of both groups of parents were classified as depressed (5.7% of PNOC and 10.7% of POC) and, again, these were not significantly different from their children. 86 Table 30: Measures of psychological well-being for obese and non-obese children aged 10-12 years and their parents Measure of Well-being Bradburn Balance Scale:* Positive Well-being CES-Depression Scale:** Depressed Non-Obese Children (%) (n) 28.2 (85) 12.7 (80) Parents of Non-Obese Children (%> (n) 36.8 (170) 5.7 (160) Obese Children (%) (n) 18.6 (22) 10.2 (22) Parents of Obese Children (%) (n) 28.2 (44) 10.7 (44) No significant differences between groups * Bradburn, NM. The Structure of Psychological Well-being. Chicago: Aldine Publishing Co., 1969. ** Radloff, LS, Locke, BZ. The Community Mental Health Assessment Survey and the CES-D Scale. In Weisman, MM, Myers, JK, Ross, CE. (eds). Community Surveys of Psychiatric Disorders. New Brunswick, NJ: Rutgers U Press, 1986. 87 (5) Leisure Time Activities The two groups of parents did not differ significantly from each other or from their respective children with regards to the time they spend reading or doing hobbies or crafts (Table 31). However, both groups of parents spend significantly less time each week visiting friends than their respective children with the PNOC and the POC visiting friends an average of 3.1 hours/week and 2.6 hours/week, respectively, compared to 6.3 hours/week for the NOC and 7.6 hours per week for the OC (p<.001). Compared to their respective children, the PNOC and the POC spend similar amounts of time each week visiting relatives but the POC spend significantly less time visiting relatives than the PNOC (Table 31, p<.001). The OC, POC and the PNOC spend approximately 0.5 hours/week attending cultural events. However, the NOC spend 1.1 hours/week attending cultural events and this was significantly more than their parents (Table 32, p<.05). Finally, the POC and their OC watched a similar amount of television with the POC watching an average of 7.8 hours each week compared to 6.9 hours/week for their children. On the other hand, compared to their NOC, the PNOC watched significantly less television (8.1 hours/week for PNOC vs 9.7 hours/week for NOC, p<.05). 88 Table 31: Average time spent by obese and non-obese children aged 10-12 years and their parents doing various leisure time activities Mean Values (Hours/Week) (Standard Deviation) Leisure Time Activity Visiting Friends Visiting Relatives Reading Doing Hobbies or Crafts Attending Cultural Events Watching Television Non-Obese Children (n=87) 6.3* (4.6) 2.7 (3.4) 4.7 (4.2) 2.8 (3.4) 1.1** (2.2) 9.7** (4.5) Parents of Non-Obese Children (n=184) 3.1 (3.1) 2.1*** (2.4) 5.5 (4.7) 3.2 (4.3) 0.5 (0.9) 8.1 (4.5) Obese Children (n=22) 7.6* (4.9) 2.5 (4.0) 4.6 (5.2) 3.5 (4.2) 0.6 (1.5) 6.9 (4.3) Parents of Obese Children (n=44) 2.6 (2.1) 1.0 (1.3) 6.9 (5.1) 3.3 (3.7) 0.4 (0.7) 7.8 (4.5) * p<.001 (Parents vs their children) ** p<.05 (Parents vs their children) ***p<.001 (Parents of NOC vs parents of OC) 89 (6) Goals and Attitudes Related to Physical Activity (i) Goals of Spare Time The POC and the PNOC responded similarly when asked how important it was to achieve specific goals during their spare time (Table 32). The two groups of parents differed only in their response to two goals whereby significantly more of the POC rated the goals of "feeling better mentally" and "getting outdoors" as important (94.5% vs 80.9%, p<=.05; 77.4% vs 61.9%, p<=.05, respectively). Alternatively, the parent's responses to several of the goals were significantly different from their respective children. Specifically, compared to their respective children, a significantly greater proportion of the POC and the PNOC thought it was important to achieve the goals of relaxing (74.0% of PNOC VS 42.2% of NOC, p<.00001; 75.5% of POC VS 34.2% of OC, p<.05). and feeling better mentally (80.9% of PNOC vs 66.4% of NOC, p<.05; 94.5% of POC vs 66.6% of OC, p<.05) during their spare time. Furthermore, compared to their children, significantly less of the parents felt it was important to achieve the following goals during their spare time: - to have fun (57.4% of PNOC vs 87.9% of NOC, p<.00001; 61.6% of POC vs 96.2% of OC, p<.05) - to compete/win (30.9% of PNOC vs 44.1% of NOC, p<.05; 19.4% of POC vs 56.6% of OC; p<.05) 90 - to challenge abilities (71.0% of PNOC vs 83.5% of NOC; p<.05; 60.4% of POC vs 88.2% of OC, p<.05) - to take risks (20.8% of PNOC vs 62.5% of NOC, p<.00001; 26.0% of POC vs 65.6% of OC, p<.05) In addition, compared to their OC, significantly less of the POC felt it was important to be with people during their spare time (52.0% vs 83.1%; p<.05). Finally, compared to their NOC, significantly less of the PNOC felt it was important to get outdoors (61.9% vs 80.6%, p<.05), to earn money (36.1% vs 52.5%, p<.05), to improve their fitness (65.7% vs 88.3%, p<.001) or feel better physically (76.6% vs 87.4%, p<.05) during their spare time. 91 Table 32: Importance of achieving specific goals in spare time for obese and non-obese children aged 10-12 years and their parents Percentage Rating Goal as Important or Very Important GOAL DESCRIPTION To Relax To Be With People To Have Fun To Compete/Win To Be Outdoors To Earn Money To Feel Independent To Feel Better Mentally To Feel Better Physically To Improve Fitness To Challenge Abilities To Look Better or Lose Weight To Take Risks NOC % (n) 42.2** (86) 63.6 (86) 87.9** (86) 44.1* (86) 80.6* (86) 52.5* (85) 72.0 (85) 66.4* (86) 87.4* (86) 88.3*** (85) 83.5* (85) 69.8 (86) 62.5 (86) PNOC % (n) 74.0 (172) 59.1 (172) 57.4 (172) 30.9 (172) 61.9* (172) 36.1 (170) 61.2 (170) 80.9* (172) 76.6 (172) 65.7 (170) 71.0 (170) 66.4 (172) 20.8 (172) OC % (n) 34.2* (22) 83.1* (22) 96.2* (22) 56.6* (22) 92.6 (22) 52.7 (22) 51.8 (22) 66.6* (22) 76.5 (22) 79.7 (22) 88.2* (22) 74.9 (22) 65.6* (22) POC % (n) 75.5 (44) 52.0 (44) 61.6 (44) 19.4 (44) 77.4 (44) 45.4 (44) 58.1 (44) 94.5 (44) 83.3 (44) 68.7 (44) 60.4 (44) 68.1 (44) 26.0 (44) * p<.05 (Pearson Chi-Square for parents vs their children) ** p<.00001 (Parents vs their children) ***p<.001 (Parents vs their children) *p<=.05 (Parents of NOC vs Parents of OC) 92 (ii) Barriers to Being More Physically Active The two groups of parents responded similarly when asked to rate the importance of various barriers to being more physically active but there were several differences between the parents and their children (Table 33). First, as was the case with the children, "a lack of time due to work or school" was the barrier most frequently identified by the parents with over 50% of the POC and the PNOC identifying it as an important barrier. In addition, compared to their NOC, significantly more of the PNOC identified this lack of time due to work or school as an important barrier (57.5% vs 25.9%, p<.00001). Other barriers identified by a significantly greater proportion of the PNOC, when compared to their NOC, included: - a lack of time due to family (55.6% vs 21.1%, p<.00001) - a lack of self-discipline (29.8% vs 16.6%, p<.05) Compared to their NOC, significantly less of the PNOC identified the following barriers as important: - lack of a partner (5.8% vs 15.6%, p<.05) - lack of support (3.9% vs 18.9%, p<.0001) The POC differed from their OC with respect to just two of the barriers whereby significantly more of the POC rated a "lack of time due to family" as an important barrier (50.6% vs 16.9%, p<=.01) and significantly less of the POC rated a "lack of support" as an important barrier (4.3% vs 25.0%, p<.05). 93 Table 33a: Factors identified by obese and non-obese children aged 10-12 years and their parents as barriers to being more physically active Percentage Rating the Factor as a Very Important or Important Barrier to Being More Physically Active FACTORS PERCEIVED AS BARRIERS Lack of Time Due to Work/School Lack of Time Due to Family Lack of Time Due to Other Interests Lack a Partner Lack of Support Cost Lack Programs Non-Obese Children % (n) 25.9** (83) 21.1** (83) 21.6 (82) 15.6* (82) 18.9* (82) 19.1 (84) 11.2 (84) Parents of Non-Obese Children % (n) 57.5 (166) 55.6 (166) 23.6 (164) 5.8 (164) 3.9 (164) 17.2 (168) 7.5 (168) Obese Children % (n) 52.2 (22) 16.9* (21) 30.9 (22) 9.0 (22) 25.0* (22) 23.5 (22) 22.5 (22) Parents of Obese Children % (n) 53.8 (44) 50.6 (42) 20.8 (44) 11.1 (44) 4.3 (44) 29.2 (44) 6.7 (44) * p<.05 (Pearson Chi-Square for parents vs their children) **p<.00001 (Parents vs their children) 94 Table 33b: Factors identified by obese and non-obese children aged 10-12 years and their parents as barriers to being more physically active Percentage Rating the Factor as a Very Important or Important Barrier to Being More Physically Active FACTORS PERCEIVED AS BARRIERS Lack Babysitting Lack Energy Lack Ability Lack Self-Discipline Feel 111 at Ease Have an Illness or Injury Fear of Injury Non-Obese Children % (n) 3.6 (81) 17.6 (83) 14.5 (82) 16.6* (83) 14.0 (79) 10.2 (82) 15.1 (81) Parents of Non-Obese Children % (n) 6.4 (162) 24.4 (166) 11.6 (164) 29.8 (166) 10.2 (158) 9.3 (164) 8.6 (162) Obese Children % (n) 10.2 (22) 26.6 (22) 19.2 (22) 23.4 (22) 13.9 (22) 5.9 (22) 11.6 (22) Parents of Obese Children % (n) 3.4 (44) 30.0 (44) 10.5 (44) 34.4 (44) 15.8 (44) 5.8 (44) 13.2 (44) *p<.05 (Pearson Chi-Square for parents vs their children) 95 (iii) Attitudes Towards Regular Participation in Vigorous Physical Activity The PNOC viewed participation in vigorous physical activity (VPA) quite differently from their NOC with significant differences seen in five of the six attitudes surveyed (Table 34). Specifically, compared to their NOC, significantly less of the PNOC viewed VPA as: - not painful (48.1% vs 74.3%, p<.001) - fun (54.5% vs 81.9%, p<.001) - easy (22.3% vs 51.9%, p<.00001) - pleasant (59.5% vs 79.4%, p<.01) - convenient (26.3% vs 61.5%, p<.00001) The attitudes of the POC were significantly different from their OC in two areas whereby significantly less of the POC viewed VPA as pleasant (48.9% vs 78.1%, p<.05) and significantly more of the POC viewed VPA as beneficial (91.4% vs 64.8%, p<.01). The POC did not differ significantly from the PNOC on any of the attitudes surveyed. 96 Table 34: Attitudes obese and non-obese children aged 10-12 years and their parents have towards regular participation in vigorous physical activity Percentage of Children and Parents Identifying Specific Attitude ATTITUDE Easy Fun Not Painful Pleasant Beneficial Convenient Non-Obese Children % (n) 51.9*** (80) 81.9** (81) 74.3* (80) 79.4+ (80) 69.8 (78) 61.5*** (81) Parents of Non-Obese Children % (n) 22.3 (160) 54.5 (162) 48.1 (160) 59.5 (160) 80.3 (156) 26.3 (162) Obese Children % (n) 33.2 (22) 54.4 (22) 50.4 (22) 78.1" (22) 64. 8* (22) 41.6 (22) Parents of Obese Children % (n) 19.4 (44) 56.2 (44) 39.4 (44) 48.9 (44) 91.4 (44) 25.1 (44) * p<.001 (Pearson Chi-Square for parents vs their children) ** p<.0001 (Parents vs their children) ***p<.00001 (Parents vs their children) +p<.01 (Parents vs their children) ++ p<.05 (Parents vs their children) 97 (iv) Contribution of Vigorous Physical Activity to the Achievement of Specific Goals With the exception of the goals of being with other people, earning money, taking risks and being independent, 50% or more of both groups of parents felt that participation in VPA would help them to achieve their goals (Tables 35a and 35b). Overall, the two parent groups responded similarly when asked how much they felt participation in VPA would contribute to the achievement of specific goals with signficant differences between them on only two goals. First, compared to the PNOC, significantly more of the POC thought that participation in VPA would or does help them to achieve the goals of taking risks (33.3% vs 19.6%, p<=.05) and improving their flexibility (91.4% vs 78.6%, p<=.05). The PNOC responded significantly different from their NOC with respect to many of the goals. Specifically, compared to their NOC, significantly less of the PNOC thought that participation in VPA would help them to achieve the following goals: - be with others (39.7% vs 77.6%, p<.00001) - to earn money (9.2% vs 21.3%, p<.01) - to have fun (58.4% vs 81.8%, p<.001) - to win (18.0% vs 57.1%, p<.00001) - to challenge abilities (51.8% vs 77.2%, p<.001) - to take risks (19.6% vs 57.1%, p<.00001) 98 In addition, compared to their NOC, significantly more of the PNOC felt that participation in VPA would or does help them to achieve these goals: - to relax (67.3% vs 40.3%, p<.001) - to improve looks (70.7% vs 58.4%, p<=.05) - to lose weight (73.2% vs 56.6%, p<.01) - to improve cardiovascular fitness (79.8% vs 61.6%, p<.01) The above patterns of differences found with the PNOC and their NOC were found when the POC were compared with their OC but they were only significantly different in three areas. Compared to their OC, signficantly less of the POC thought participation in VPA would or does help them to win (15.9% vs 58.6%, p<.001), or take risks (33.8% vs 68.2%, p<.01). Also, significantly more of the POC thought that participation in VPA would or does help them to improve their cardiovascular fitness (92.0% vs 63.7%, p<.01). 99 Table 35a: Contribution of vigorous physical activity to the achievement of specific goals for obese and non-obese children aged 10-12 years and their parents Percentage Who Believe Vigorous Physical Activity Contributes Somewhat or a Great Deal to Attaining the Goal GOAL DESCRIPTION To Compete/Win To Be Outdoors To Feel Better Physically To Take Risks To Relax To Lose/Control Weight To Improve Looks To Earn Money To Have Fun To Be With Others NOC % (n) 57.1*** (82) 73.3 (82) 86.1 (82) 57.1*** (82) 40.3* (82) 56.6** (82) 58. 4+ (82) 21.3** (83) 81.8 (83) 77.6*** (83) PNOC % (n) 18.0 (164) 67.3 (164) 83.8 (164) 19. 6" (164) 67.3 (164) 73.2 (164) 70.7 (164) 9.2 (166) 58.4* (166) 39.7 (166) OC % (n) 58.6* (22) 78.1 (22) 82.4 (22) 68.2** (22) 61.7 (22) 75.4 (22) 65.9 (22) 13.4 (22) 76.5 (22) 63.3 (22) POC % (n) 15.9 (44) 69.6 (44) 86.6 (44) 33.8 (44) 67.0 (44) 77.8 (44) 74.5 (44) 3.9 (44) 52.8 (44) 42.8 (44) * p<.001 (Pearson Chi-Square for parents vs their children) ** p<.01 (Parents vs their children) ***p<.00001 (Parents vs their children) * p<=.05 (Parents vs their children) ++ p<=.05 (Parents of NOC vs Parents of OC) 100 Table 35b: Contribution of vigorous physical activity to the achievement of specific goals for obese and non-obese children aged 10-12 years and their parents Percentage Who Believe Vigorous Physical Activity Contributes Somewhat or a Great Deal to Attaining the Goal GOAL DESCRIPTION To Feel Independent To Challenge Abilities To Improve/Maintain Cardiovascular Fitness To Feel Better Mentally To Improve Fitness To Improve Strength To Improve Flexibility NOC % (n) 50.1 (79) 77.2* (81) 61.6** (81) 58.8 (81) 74.5 (82) 79.8 (82) 78.2 (82) PNOC % (n) 41.3 (158) 51.8 (162) 79.8 (162) 70.1 (162) 81.5 (164) 76.3 (164) 78.6*** (164) OC % (n) 62.4 (21) 75.4 (22) 63.7** (22) 73.4 (22) 65.3 (22) 70.7 (22) 76.5 (22) POC % (n) 48.0 (42) 51.6 (44) 92.0 (44) 78.3 (44) 82.8 (44) 86.6 (44) 91.4 (44) * p<.001 (Pearson Chi-Square for parents vs their children) ** p<.01 (Parents vs their children) ***p<=.05 (Parents of NOC vs parents of OC) 101 (IV) DISCUSSION The data clearly show that the prevalence of childhood obesity in Canada has increased significantly between 1981 and 1988. This trend is similar to that observed in the United States by Gortmaker et al. (1987) although the criteria used to define obesity in this study was different from that used in the American studies. However, a recent study using the same Canadian data and the American criteria defining childhood obesity still found significant increases in the prevalence of childhood obesity in Canada between 1981 and 1988 (Limbert et al., 1994). As expected, this study (Limbert et al., 1994) also found that different indicators of obesity generated different prevalences of childhood obesity. Thus, in order to effectively monitor the prevalence of childhood obesity in Canada, specific standards for determining obesity need to be defined. According to their energy expenditure data, the OC appear to be less active than the NOC as significantly more of the OC were classified as sedentary and, overall, the obese females were the least active group. This difference in the activity level of OC and NOC is consistent with that found by others (Reybrouck et al., 1987; Matsui et al., 1987; Johnson et al., 1956). It is also interesting to note that almost 80% of the obese males were classified as "sufficiently active" compared to less than 40% of the obese females. Stephens and Craig (1990) similarly found that males tended to be more active than females, particularly 102 when it came to higher intensity activities. However, when one considers the Step Test results and the negative attitudes toward participation in VPA held by many of the obese males, it could be possible that they overestimated the time they spent doing specific activities. For example, they may indicate that they play soccer twice a week for one hour each time but they may actually only be playing soccer for 15 minutes of that hour. The proportion of non-obese males and non-obese females classified as "sufficiently active" was similar to that reported for all Canadian children aged 10-14 years (Stephens and Craig, 1990). It is possible that the "activity level" of the children in this study, particularly that of the obese children, may have been underestimated. The "activity level" of the children was determined from their energy expenditure data and, in order to calculate energy expenditure, the time spent in specific activities was multiplied by the METS values for each activity. Recently, Sallis et al. (1991) found that the use of adult energy cost values underestimates energy expenditure in children with the bias being much larger in younger children. They estimated the underestimation to be about 40% in pre-school children and about 20% in children 10 years of age. However, Sallis et al. (1991) also state that there is no direct evidence that age-adjusted energy cost values provide more valid estimates of energy expenditure for children than standard adult values when using physical activity measures commonly used in epidemiological 103 studies. Thus, although the use of adult METS values in this study may underestimate the children's energy expenditure, both the OC and the NOC should be similarly affected. In addition, other errors associated with the physical activity questionnaire may have overestimated their energy expenditure, but again, both the OC and the NOC should have been similarly affected. Also, the energy expenditure of the OC may have been further underestimated because of the effect of body weight. In other words, an obese child that expends 2 kcal/kg/day of energy will expend more total energy than a non-obese child because of the obese child's extra weight. The results of the Step Test in this study strongly suggest that the OC have a lower level of fitness than the NOC with the obese females appearing to be the least fit. Specifically, the OC appear to be less fit because not one of the OC was able to complete the third stage of the test. However, there may be various reasons why the OC did not complete this stage. A participant may voluntarily quit the test at any time and for any reason. They may say they are fatigued, dizzy or feeling sick or they may just lack the motivation to continue. The technician administering the test may also stop a participant from advancing to the next stage of the test if the participant's heart rate is above an age specific rate or if they are unable to step at the required pace. In addition, the technician may stop a participant from stepping if they appear to be pale, excessively 104 fatigued or uncomfortable. Although it would undoubtedly be valuable to have this information, the simple fact that none of the OC wanted to, or were able to, complete the third stage of the Step Test strongly suggests an important and significant difference between OC and NOC with respect to physical activity. Either the OC are indeed less fit than the NOC or they at least have a lower level of exercise tolerance which may be due to psychological factors, physical factors or a combination of both. On the other hand, it may be argued that it is not fair to compare the OC and NOC's results from the Step Test because it is a bias test in favor of the NOC. That is, a weight-bearing, graded exercise test is more difficult for OC, compared to NOC, because of the OC's excess weight. The results may have been different had the fitness test been conducted using a bicycle ergometer. Other studies have shown that physical activities are more strenuous for OC than for their healthy non-obese peers (Ylitalo, 1981) and OC have also been shown to become breathless more easily during graded exercise (Farebrother, 1979). With the OC and NOC being different with respect to activity level, and possibly fitness level, it was interesting to assess if they also had different attitudes and goals with respect to physical activity. Overall, the OC were less likely to view participation in vigorous physical activity as easy, fun and not 105 painful but these differences were largely due to the differences seen between the obese males and non-obese males. In fact, similar to the findings of Romanella et al. (1991) the obese females' attitudes towards participation in vigorous physical activity were not significantly different from the non-obese females with the majority of females viewing VPA as fun, not painful, pleasant and beneficial. It is difficult to postulate why the obese males seem to be the least likely to view VPA as easy, fun and not painful. It may be that they evaluate participation in VPA from a competitive perspective whereby if they are not able to win or be the best in an activity they are less likely to view it as easy and fun. Considering the previous energy expenditure results which found almost 80% of the obese males to be "sufficiently active", although they appear to be less fit, it seems as though the obese males may be participating in physical activity even though they are not enjoying it and may even find it painful. Overall, it appears that the relationship between the attitudes and behaviours of OC, with respect to physical activity, is complex and warrants further investigation. In addition, the obese males indicated the lowest level of support or encouragement to participate in physical activity with only 36% feeling supported by their close friends and only 54% feeling supported by their parents. Thus, although the obese males actual participation in physical activity does not yet 106 appear to be negatively affected by these negative attitudes and lack of support it is likely that these factors will eventually have an undesirable effect in the long-term. In contrast, the obese females seem to have fairly positive attitudes and feel supported by their family and peers but are still not as active or as fit as their non-obese counterparts. This difference may be related to the barriers to being more active that were perceived by the children. Similar to Canadians in general (Stephens and Craig, 1990), the most frequently identified barrier to being more physically active was a lack of time due to work or school. In particular, over half of the obese females identified this as an important barrier and this was significantly more than their non-obese counterparts. It seems unlikely that obese females have more homework than non-obese females but it may be that the obese females prefer to spend their time studying as opposed to exercising and they conveniently use this as an excuse. Perhaps they feel more confident and experience more success in school than they do when they participate in physical activity. These are possible explanations that need to be further investigated. The OC and NOC appear to spend their non-physical leisure time in a similar manner as the average time spent visiting friends, visiting relatives, reading, doing hobbies or crafts and attending cultural events was similar between the two groups. 107 However, in sharp contrast to the findings of Dietz and Gortmaker (1985) the obese females watched significantly less television than the non-obese females. In addition, all the children in this study watched quite a bit less television when compared to other studies. Specifically, a 1985 Nielsen Report found that children aged 6-11 years watched an average of 16 hours of television each week and the population average for Canadians is reported to be 24 hours/week (Statistics Canada, 1988). In comparison, the OC in this study watched television an average of 7.5 hours/week while the NOC watched an average of 9.6 hours/week. These low numbers may be partially due to the fact that the highest rating allowed on the questionnaire was 15 or more hours/week and this was recorded as 15 hours for the purpose of calculating an average. In addition, the time the children spent playing video games was not considered and this may take up a greater portion of children's leisure time than watching television. Another possible reason for the low averages is that the questionnaires were completed by the children in a very casual atmosphere in their homes with their parents present; the children were allowed to interact with their parents and have them assist in completing the questionnaire and it is possible that the parents underestimated the time their children spent watching television. Although Dietz and Gortmaker (1985) reported a very strong connection between obesity and television viewing time this relationship may be much more complex. It has been suggested that metabolic rate is decreased when watching 108 specific types of shows on television (Klesges et al., 1993) but it has also been shown that metabolic rate increases when children are playing video games (Segal and Dietz, 1991). It has also been postulated that children who watch more television eat differently from children who watch less television. Thus, it seems that future investigations in this area need to assess both the quantity and the type of television shows being viewed while also taking into account other factors that may be contributing to the obesity such as diet and exercise habits; as well, males and females need to be assessed separately. Similar to other studies, the results of this study do not provide any evidence to suggest that the OC were any different from the NOC with respect to their psychological well-being. Specifically, 18.5% of the obese males and 13.6% of the non-obese males were classified as depressed which is slightly higher than the incidence of depression in the general pediatric population which is estimated to be 6-10% (Kazdin,1988). On the other hand, 13.6% of all the OC were classified as depressed and this was much lower than the 32% found by Wallace et al (1993). However, the population group studied by Wallace et al. (1993) and the tool they used to assess depression were both different from this study. Specifically, the obese children studied by Wallace et al. (1993) were all referred by a local physician or their parents to a hospital-based weight management program and they used the Childhood Depression Inventory (Kovacs, 1987). 109 These differences may be important factors contributing to the high incidence of depression that they found. The results of the Bradburn Balance Scale were similar to those reported by both Stephens and Craig (1990) for 10-14 year olds and to that found in the Canada Fitness Survey (1983). Both of the instruments used in the Campbell's Survey to assess emotional well-being appear to be designed with the adolescent or the adult in mind as the references that cite validity and reliablity data for these two tests do not provide any such data for 10-12 year olds (Bradburn, 1969; Radloff and Locke, 1986). Although this does not necessarily mean these tests are not suitable for 10-12 year old children, there are tests designed specifically for children that may be more appropriate such as Battle's Culture-Free Self-Esteem Inventory, the Piers-Harris Children's Self-Concept Scale and the Childhood Depression Inventory. However, these tests require more time to complete and therefore may not be suitable for large scale epidemiological studies. Previous studies (Garn, 1986; Dietz et al. 1985) have found childhood obesity to be more prevalent in higher socioeconomic families. In this study, greater proportions of the obese children and the non-obese children were from families with incomes over $25,000 with the greatest proportion coming from families with incomes between $35,000 and $54,000. This data suggests that, regardless of obesity status, a greater proportion of the children came from the higher income groups. The actual 110 prevalence of obesity for specific income groups was not tested. It was not suprising to find that almost all of the obese females were concerned with looking better or losing weight as a goal to be achieved during their spare time. In addition, compared to non-obese females, significantly more of the obese females thought that participation in VPA would or does help them to lose and/or control their weight and more of the obese females stated that they watched what they ate in order to lose weight. These findings suggest that these obese females were preoccupied and dissatisfied with their appearance and/or their weight while the same cannot be said of the obese males, non-obese males or non-obese females. Similar to the findings of other studies, the results of this study revealed that the OC and the NOC were very similar when it came to general eating habits. The only significant difference found was that obese females were much less likely to eat breakfast than non-obese females. The tendency of obese people to skip meals, particularly breakfast, has been reported by others (Story and Alton, 1991; Lloyd and Wolff, 1976). Other factors that have been postulated to be more common in obese individuals such as increased consumption of sugar and fat and increased number of meals eaten out were not found to be any different between the OC and the NOC. In fact both groups of children ate out less than once a week and the majority of OC and 111 NOC were attempting to limit their fat intake. Although the guestionnaire used to assess the dietary habits of the children has never been used before and it provides only a general picture of eating habits, it may actually be more useful than a detailed nutritional analysis. Obesity treatment programs appear to be changing the emphasis to promotion of general healthy eating habits as opposed to counting calories. Furthermore, assessing the specific nutritional intakes of OC and NOC is only useful if accurate measures of energy requirements and energy expenditure are made, and these types of measurements are not practical for large scale epidemiological studies. It was interesting to note that while the obese females were more concerned with dieting to lose weight, the obese males were more concerned with dieting to maintain their weight. This finding suggests that the obese males view their obesity status differently from the obese females. That is, the obese males appear to be more concerned with not gaining any more weight while the females are more concerned with losing weight. This may be related to the idea that males may be more likely to attach positive feelings to being heavy (ie. feeling masculine and strong) whereas females are more likely to attach negative feelings to being heavy (ie. feeling unattractive and less desirable). 112 The database used in this study provided a unique opportunity to assess familial factors that may be associated with childhood obesity. Unfortunately, due to missing data, the sample size decreased substantially for this part of the analysis, with the obese sample becoming particularly small (22 children). This small sample size may have been one reason why the differences often found between the OC and their parents did not reach significance even though the differences appeared to be similar to those observed for the NOC and their parents. As a result, the findings in this section should be viewed with some caution. Similar to other studies (Gam and Clark, 1976; Darwish et al., 1985), the OC in this study were more likely to have obese parents than the NOC. This tendency for obese parents to have obese children may be useful information for targeting prevention strategies. With respect to their patterns of leisure activity, the POC and the PNOC were generally less active than their respective children. Similarly, compared to their respective children, greater proportions of the parents were classified as sedentary although this difference was only significant for the PNOC and their NOC. In other words, the OC were similar to their parents when it came to energy expenditure whereas the NOC expended significantly more energy than their parents. A report on this same database found a general decline in the active population with age (Stephens and Craig, 1990). It is difficult to interpret these results as one indicator of 113 activity level (patterns of leisure activity) found significant differences between the parents and their respective children while another indicator (energy expenditure) found that OC were not significantly different from their parents while the NOC were. These results are further complicated by the fact that, according to their patterns of leisure activity, the POC were actually significantly more active than the PNOC but according to their energy expenditure data, similar proportions of the PNOC and the POC were classified as sedentary. Possible explanations for these inconsistent results include the small sample size for the OC and the reliability and validity of the instrument used to assess activity level. However, the entire questionnaire used in the Campbell's Survey on Wellbeing in Canada was pilot tested and good levels of test-retest reliability over three weeks for survey data items of major interest, such as participation in various activities, were found (Stephens and Craig, 1990). It should be noted that children were not used in this pilot test and therefore the questionnaire may have acceptable levels of reliability for adults but not necessarily for children. The POC and the PNOC had similar eating habits and both groups of parents tended to have less desirable eating habits than their respective children with significant differences being found only for the NOC and their parents. These differences in eating patterns are similar to the age related differences reported by Stephens and Craig (1990). Compared to their NOC, significantly 114 more of the PNOC were concerned with dieting to lose or maintain their weight. Conversely, and not surprisingly, similar proportions of the OC and their parents were dieting to lose or maintain their weight. The proportion of PNOC and POC classified as having a positive well-being and the proportion classified as being depressed were both similar to that reported for all adults aged 25-44 (Stephens and Craig, 1990) and similar to that found in the Canada Fitness Survey (1983). It was not surprising that the POC and the PNOC spent significantly less time visiting friends than their respective children. There was no consistent trend found with respect to parent's television viewing habits and their childrens' as the PNOC watched significantly less television than their children while the POC and their OC watched a similar amount of television. With respect to the goals of their spare time, barriers to participation in physical activity and the goals of vigorous physical activity, the POC and the PNOC were fairly similar but they differed from their respective children in several areas. In general, these differences were similar to the age related differences reported by Stephens and Craig (1990). For example, the parents were more concerned with relaxing and feeling better 115 mentally during their spare time while the children were more concerned with having fun, competing, challenging their abilities and taking risks. Similarly, with respect to the contribution of VPA to the achievement of specific goals, the POC and the PNOC responded similarly but both groups of parents responded differently from their children on several of the goals. Most of these differences were only significant when comparing the PNOC with their NOC. However, compared to their NOC significantly more of the PNOC cited "a lack of time due to work or school" as an important barrier to being more physicaly active while similar proportions of the POC and their OC cited this as an important barrier. Thus, the most active group, the NOC, were the least likely to cite this particular barrier while the more inactive groups, the parents and the OC (especially obese females), were the most likely to cite this barrier. The attitudes of the POC with respect to VPA were only significantly different from their OC in two areas and they were not significantly different from the PNOC. On the other hand, the attitudes of the PNOC were significantly different from their NOC in five of the six areas assessed. Overall, the OC (in particular, the obese males) tended to have less positive attitudes toward VPA but most of these attitudes were similar to their parents. In contrast, the NOC tended to have positive attitudes toward VPA and these were very different from their parents. Similar to the relationship observed for the NOC and 116 their parents, Stephens and Craig (1990) noted that positive attitudes toward VPA generally declined with age. These results strongly suggest that, compared to NOC, OC (particularly males) are more likely to have negative attiudes towards VPA and these attitudes are more likely to be similar to those of their parents. Unfortunately, the data does not provide insight as to whether these differences in attitudes are a cause or a result of the obesity or if they are perhaps related to more complex familial factors. Thus, in general, the POC were not different from the PNOC with respect to their eating habits, activity levels, and goals and attitudes toward physical activity. However, in many of these areas the parents differed from their children and the NOC and their parents were more likely to differ than the OC and their parents. As mentioned earlier, this may be partially due to the smaller sample size for the obese children since the differences between the OC and their parents were often very similar to that observed for the NOC and their parents. In addition, in most cases, the parents tended to have less desirable habits and attitudes which may, in time, influence the habits and attitudes of their children. In some areas, it appears that the OC have already adopted the less desirable habits of their parents while the NOC have not done the same. It is also interesting to note that even though a greater proportion of the POC were obese, the POC and the PNOC rarely differed in their responses. Thus, it 117 seems that the differences they had with their children were more related to age than to parental obesity status. (V) CONCLUSIONS AND RECOMMENDATIONS The most important finding from this study was the significant increase in pediatric obesity in Canada between 1981 and 1988. This is a trend that needs to be addressed in the near future as a great deal of time and expense has been devoted to adult obesity while comparatively little has been devoted to childhood obesity. The results of this study also provide evidence that OC and NOC are significantly different with respect to various physical factors, lifestyle behaviours and attitudes towards participation in vigorous physical activity. In particular, the finding that OC are less fit (or have a lower exercise tolerance) than NOC could have implications for school based physical education programs as well as obesity treatment programs. Longitudinal, prospective studies are needed in this area to provide insight as to whether this difference in fitness level (or exercise tolerance) is a cause or a consequence of the obesity. In addition, future studies should ensure that the test being used to assess the fitness level of OC and NOC is unbiased. The results of this study suggest that the relationship between attitudes and behaviours with regards to physical activity may be 118 quite complex. The finding that obese males had the least positive attitudes towards participation in vigorous physical activity and they felt the least amount of support from their parents and friends to participate in vigorous physical activity was surprising since they were a fairly active group. Further investigations are undoubtedly needed in order to understand this complex relationship between attitudes and behaviours. It was also surprising to find that obese females watch significantly less television than non-obese females while there was no difference between obese and non-obese males. As these results are in sharp contrast to those of many others, further and more detailed studies are warranted in this area. Another important finding from this study was that the obese females appeared to be very concerned with their weight. The results further suggested that the obese females may be trying to lose weight by the unhealthy and undesirable habit of skipping breakfast. These findings could have valuable implications for designing both prevention and treatment programs. Many significant differences were found between parents and their children with regards to lifestyle habits, and goals and attitudes towards physical activity. While it is important to note that the majority of these differences were consistant with the age-related differences reported by others, it is also 119 important to note that, compared to the non-obese children, the obese children were more likely to have habits, goals and attitudes similar to their parents. The small sample size and multitude of factors analyzed make it difficult to draw any firm conclusions in this area but the results certainly warrant further studies in this area. Overall, the results of this study emphasize the need for more research in this area. In particular, there is a need to develop a better understanding of the eating habits and activity patterns of the "becoming obese" child and to understand the motivations behind these behaviours. Longitudinal, prospective studies are necessary in order to unravel these complex relationships as factors associated with the onset of obesity may be very different from those associated with the maintenance of obesity. Furthermore, since children are not merely "small adults", the instruments used in subsequent studies should be designed specifically for the age group being assessed. 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In a typical week, how many hours do you spend doing the following activities? watching television reading crafts or hobbies done mainly on your own visiting with relatives visiting with friends attending cultural events {such as musical performances or plays) organizing or coaching physical activity or sport programs as a volunteer involvement with religious groups or church activity involvement in service or fraternal organizations such as hospital auxiliary, Rotary or Shriners involvement with social or entertainment groups such as a card club or a cooking club other group activities (please specify): activity: activity: 0 • D • • • • • • D • • . • r 1-2 • • • • • • • • D a • a lours per 3-4 a a a • a a • a a a a a week 5-9 a D • a a a • a a a a • 10-14 a • • a • D • a a a a • 15 or more a • a a • • a a a a a a Spare time provides a chance to reach many different goals. How important is it to you to reach each of these goals in your spare time? just relaxing, forgetting about your cares getting together with other people having fun earning money getting outdoors competing, winning feeling independent feeling better mentally feeling better physically improving/maintaining physical fitness challenging your abilities, learning new things looking better, controlling your weight taking risks, seeking adventure very important D • D D D D • • • • • D • D D • D • • D • • • • • • D • • • • • • • D • • • • • D • • • • D • • • • • • • • • not at all mportant • • • • • • D • • • • • • 136 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 ^ 3 3 3 3 3. Which o, ,he t o l l i n g best describes your experience „ i ,h tobacco? , C / l e c * a „ ,»a, „ * j I have never smoked : [~] years ago I stopped smoking cigarettes: r-j recently Q over a year ago «•#•• I stopped smoking a pipe, cigar • recently or cigarillos: r—i LJ over a year ago I currently smoke: Q cigarettes occasionally D less than 1/2 pack daily • about a pack daily • U 2 or more packs daily U a pipe, cigars or cigarillos 4 . Does your spouse (or mate) currently smoke cigarette,, a pipe, cigars or cigarillos? does not smoke: Q currently smokes: Q cigarettes • a pipe, cigars, cigarillos don't have a spouse (or mate): • 5. How many close relatives do you have -- people that can call on for help? close relatives you can talk to about private matters, and 6. How many close friends do you have that vou feel reaiiv ^ « *~ , L private matters, and can call on for help? * " P e ° P ' e t h a t y 0 U C a n t a l k to a b o u t close friends 7. Does your spouse (or mate) exercise regularly? • yes • no C I don't have one 8- Of your other relatives and friends, how many I i-J relatives I i ,-jfriends • none exercise regularly 137 exercise regularly? PHYSICAL ACTIVITY IN YOUR SPARE TIME 9- The following activities refer to physical activities that are not related to work. Have you done any of the following physical activities in the past 12 months? Please indicate whether you have done each activity listed below. Then for those activities which you have done, please complete the number of times done each month, and the average time spent on each occasion (not counting travel time, changing etc.). walking for exercise bicycling jogging or running home exercises exercise class, aerobics No Yes • • • • L> • DH • Q~ • CM Number of times each month Jan Feb Mar AprMayJune JulyAugSep I , I , I , I , I . I I . l . l . 1 . 1 , 1 , 1 . 1 . 1 Average time per occasion Oct Nov Dec hrs min _J L-JI I J L J L-IL J J U J U L J ice skating cross-country skiing downhill skiing Ice hockey swimming No Yes • D"*M • O • L> • D* J 1 , 1 , 1 . 1 , 1 . F M . 1 . 1 . 1 . 1 . l . i l . l A M J J A S O N J < l l h i l l ^ III I • I -I I.. I—I -J * l . l . D hrs min —J U L J — J i »i • i —J U L _ I J L J L J U L _ I gardening, yard work golf tennis weight training baseball, Softball No Yes J n r>#*. . n n-#>1 . n m * i . n r~H^ i . n rH*" i . F M i \ . I . I • 1 r 1 l . l . 1 . 1 • A M J J A S O N * D hrs min — I U L J I U L J ^ J U L J I i n • ' U popular or social dance No Yes J F M A M J J A S O N D hrs min • C H * I . I . I 11 L J I \ I . I . I I - I • < I U U_J ballet, modern or jazz dance Q Q « ^ i i . i . 11 . i . i square or folk dance D • " § * * » ' • ' ' • - • - • - • bowling • E J H ^ I I L Jl • I • I I L J l i . i . i i . i . i _L J U L _ J J U l -I I U U _ J Please refer to the Physical Activity Reference Card and list any other activities that you have done in the past 12 months. F -M A M J J A S O N D hrs min 1 . 1 . 1 . I I . 1 . 1 . 11 1 1 1 I I 1 1 11 1 . 1 . 1 . 11 . 1 . 1 . 11 U l U l U l U U - J 138 10. In the past year, did you stop doing any physical activity in your spare time (not including any activity stopped because of a change in season)? • No D Yes: What was it? What was the main reason for stopping? Any other activity? What was the main reason for stopping? 1 1 . Have you done some physical activity at least once a week during the past 3 months? Q No [ j " Yes: Which exercise or sport activity contributed most to your fitness during the past 3 months? b. Was this activity... (Check all that apply.) U scheduled at specific times D directed by an instructor or supervisor • competitive, with organized tournaments, leagues or races • casual, freely scheduled with little or no direction from a n instructor * aX^st^^^ir ^  ^  breathin9 Wh6n *» did « * U a little faster than normal • a lot faster but talking was possible LJ so fast that talking was impossible U unchanged d onTe a ' w i i r W b " n d0i"° S O m e • * « « * * * your spare l i m e a, ,eas, L 1 less than 3 months Q 4-6 months LJ 6 months to just under 1 year LJ 1-2 years LJ 3-4 years LJ 5-7 years ^ m o r e than 7 years (since before 1981) 12- s c ^ r vz^irdurino ,he ,as*iz momhs -* *> « » - » . U much more physically active U a little more physically active U a little less physically active • much less physically active • about the same - I have always been active U about the same - I have never been active 139 13 14 15 16 17 18 . Compared to other people your age when you were 15 years old, would yo much more active D D D D D j say you were... much less active . Compared to the way other people your age spend their spare time much more active • O • • • would you say you are... much less active . With whom do you usually do your physical activities in your spare time?{Choose one.) |"~l no one D co-workers | I friends n classmates at school [~l immediate family Q others Where do you usually do your physical activities in your spare time? (Choose one.) LJ home • commercial facility or private club • park • outside using no special facility • recreational facility • school, college or university facility • work • other .Are there any exercise or sports activities you would like to start • No Q Yes: First choice: Second choice: How important are the following in preventing you from be in the next year? ing more physically active? very important lack of time due to work or school Q • lack of time due to family obligations Q Q lack of time due to other interests O CZI lack of energy, too tired • lack of athletic ability O lack of programs, leaders or accessible facilities Q lack of a partner O lack of support from family or friends Q lack of babysitting services CI cost n lack of self-discipline or willpower [~\ self-conscious, ill at ease D long-term illness, disability or injury Q fear of injury [ [ ] • • a • a a • a a a a • • • • • • • • • • • • • • not • • • • • • • • • • • • • • at all important • • • • • • • • • • • • .• • 140 OPINIONS ABOUT VIGOROUS PHYSICAL ACTIVITY For the next few questions, regular participation in vigorous physical activity means doing some activity in your spare time: • 3 or more times each week, • for 20 minutes or more each time, and • at a level which causes your breathing to be a lot faster, but at which talking is still possible 19.How do you feel about participating regularly in vigorous physical activity? Do you think it is. boring beneficial unpleasant convenient painful easy • D D • • • • • • • D • • • • • • • • n • • • • • • • • • • fun harmful pleasant inconvenient not painful difficult 20.All things considered, how much choice do you have over whether you participate regularly in vigorous physical activity? completely • • • • • t 0 ° m a n y c o n s t r a i n t s my choice imposed on me 21 .How much do the following people encourage you to participate regularly in vigorous physical activity? spouse, boyfriend, girlfriend parents son, daughter other family members most of your close friends your employer your doctor doesn't apply don't have one • • D • • • • encourages me, very supportive • • • • • D • • • • • • D • • • • • • ( • • • • • • • discourages me, very negative • • • • • • 141 22. How much does (or would) participation in vigorous physical ac (Please answer whether or not you are now active in your spare a great deal relax, forget about your cares d get together with other people d have fun d earn money d get outdoors d compete, win d feel independent d feel better mentally d feel better physically d challenge your abilities, learn new things d look better d control / lose weight d take risks, seek adventure d improve/maintain overall physical fitness r~] improve/maintain cardiovascular fitness [H improve/maintain muscular strength and r—j endurance *—' improve/maintain flexibility d d d d d d d d d d d d d d d d d d livity help you > time.) d d d d d d d D d d d d d d d d d d d d d d d d d d d d d d d d d 23. Would you agree or disagree that, if you wanted to, you could easily participate physical activity 3 or more times a week for at Jeast 20 minutes at a time? strongly agree d d d d d strongly disagree 24. In the coming year, how often do you intend to participate regularly in d never d 'ess than once a week d 1-2 times per week f~l 3 times per week d 4-5 times per week d 6 or more times a week to.... not at all d d d d d d d d d d d d d d d d d in vigorous vigorous physical activity? 142 NUTRITION 25. In answering the following questions, think about your typical eating pattern. For each food listed, please give the number of servings eaten on a typical day and then the average number of days each week that you eat this type of food. Servings are defined on the reference card. For a combination dish, such as pizza, casserole or soup, please try to break it down into individual ingredients. For example, one slice of pizza includes bread, cheese and perhaps meat. never or less How often do you have ... red meat (beef, pork, lamb, liver, etc.) processed meats (bacon, hot dogs, cold cuts, etc.) chicken, turkey, other poultry fish eggs dried beans, dried peas, nuts vegetable juice yellow vegetables (carrots, squash, sweet potato, etc.) green vegetables (broccoli, green beans, cabbage, spinach, etc.) potato other vegetables including tomatoes oranges, grapefruit, lemons orange, grapefruit, or lemon juice other fruit (apples, bananas, peaches, etc.) other fruit juice milk (whole or evaporated) milk (2%, skim, buttermilk) milk products (puddings, yogurt, ice cream) cheese and cheese products (whole) cheese and cheese products (low fat) bread, muffins, cereals etc. made from whole grains bread, muffins, cereals etc. made with refined white flour rice, pasta (macaroni, spaghetti, etc.) margarine, vegetable oils, salad dressings, butter sweets (soft drinks, cookies, cakes, pie, sweet cereals, jams, jellies, candy, donuts, etc.) sugar added at the table salt added at the table salty snacks (potato chips, pretzels, etc.) tea, coffee alcohol (beer or wine or liquor) other han once a week • • • • • D never <1 a week • • • • • • • • • never <1 a week • • • ' • q • • • • never <1 a week • • • • • • • servings per day L_J L_l l_l L_l LJ L_l servings per day L_J L_l I_J L_l L_l L_I L_l LJ LJ servings per day LJ L_J LJ l_J LJ l_J LJ L_J LJ servings per day !_J LJ l_J l_J 1_J L_I L_J days per week LJ LJ l_J l_J l_J LJ days per week L_I l_J l_J l_J LJ l_I l_J LJ LJ days per week l_l l_l LJ LJ l_l L_J L_l l_l LJ days per week l_l LJ L_l L_l LJ l_J LJ 143 26 27 28 29 How often do you eat the following store-bought foods? frozen meals frozen vegetables canned vegetables frozen desserts and pastries fresh baked goods canned soup How many days per week do you.. never or less than once a eat small amounts all day rather than any regular meals replace 1 or 2 regular meals by eating small eat 3 regular meals eat breakfast (not just coffee or eat at a restaurant, take-out, or tea) snack bar Compared to about 6 or 7 years ago, that is in same amount of: red meat poul t ry f ish fruit and vegetables fats and fried foods sugar and sweet foods salt and salty food store-bought, prepared foods total calories meals on a regular basis whole grain cereals low-fat dairy products alcohol (beer or wine or liquor) At what weight do you look your same as before • • D • • D • • • • • • • best? | amounts 1981 i i week • • • • • • serving S per day LJ L_l l_J LJ L_J l_J days per week LJ LJ LJ LJ LJ days per weel-LJ l_I L_l l_J l_J L_J , have you been consuming more, less, or the more • .• • • • .• • • • • • D • • • • lbs less • • • • • • • • • • • • • • D When did you make this change? less than 12 more than 12 months ago months ago sss#s-SWftlsS:-S88p&«-•KSSogKS-SWftgiS'" «&$&*' swssjgS^ iKsslSs-SKKsfi&SX-•wswj;::-."^ syiK^:::-:^ ~-y.o--* • • D D • • • • • • • • • • • or i , , i kg • • • • • • • • • • • • • 144 3 9 3 3 3 3 3 3 5 f 30. Do you watch what you eat, for health reasons? • ND • Yes Do you take dietary measures to... (Check all that apply.) lose weight p i maintain weight p"| prevent specific health problems • control heart disease P ] control high blood pressure control diabetes control food allergies another reason: • • • D 31 .Are you on a diet prescribed for you by a doctor or dietitian? D No Q yes 32. How often do you... eat second helpings avoid sugar and sweet foods avoid salt and salty foods choose broiling, roasting, etc. over frying use artificial sweeteners instead of sugar trim visible fat off meat remove skin from chicken choose diet food and drinks over regular induce vomiting, take laxatives to lose weight take appetite suppressants choose foods high in calcium very often • • • u • • • • • • • • • • • • • • • • • • D • • • • • • • • D • • • • • • • • • • D • 145 YOUR HEALTH AND WELL-BEING 33 34 35 36 . How important is each of the following to your health? i adequate rest and sleep good diet maintaining proper weight participation in social and cultural activities control of stress regular physical activity such as exercise, sports or games a smoke-free environment very mportant • • • • • • • • • • • • • • • • • • • • • • • • • • • • not at all important • • • • • • • . Here is a list of how people feel at different times. During the'pastfew weeks, how often have you felt .... on top of the world very lonely or remote from other people particularly excited or interested in something depressed or very unhappy pleased about having accomplished something bored proud because someone complimented you on something you had done so restless you couldn't sit long in a chair that things were going your way upset because someone criticized you stressed often • • • • • • • • • • • . Are you limited in the type or amount of work you can do (or school you illness, injury or handicap? (Check all that apply.) • no |~1 yes, because of a temporary illness l~l yes, because of a long-term illness l~~l yes, because of a temporary injury f l yes, because of a permanent injury or handicap . Are you limited in the amount of leisure-time physical activity injury or handicap? (Check all that apply.) • no l~~l yes, because of a temporary illness l~l yes, because of a long-term illness |~~1 yes, because of a temporary injury |"~1 yes, because of a permanent injury or handicap you can can sometime • • • • • • • • • • • 3S never • • • • • • • • • • • attend) because of do because of illness, 1 l\C 37. Did your mother or your father ever have . . heart disease high blood pressure diabetes, non-insulin-dependent diabetes, insulin-dependent a stroke cancer overweight problem 38. Do you presently have... anemia skin allergies hay fever or other allergies asthma arthritis or rheumatism lower back problems cancer diabetes, non-insulin-dependent diabetes, insulin-dependent cerebral palsy emphysema or chronic bronchitis any emotional disorders epilepsy high blood pressure heart or circulation problems paralysis of the arms paralysis of the legs kidney problems stomach or intestinal ulcer thyroid trouble or goiter recurring migraine headaches missing arm(s) or hand(s) missing leg(s) or foot (feet) 39.Do you have any other long-term illness or n no [ [ ] yes: Wh^t i c '*9 • yes • • • • • • • Mothe no • • • • • • • r don't know • • • • • • • no • • • • • • • • • • • • • • • • • • a • • D a Father yes no D D n n n • • • • • • • • • for how yes many years? • 1: Q: • .: • *,:& D*^ [ > . : : * • • :;:.:* D^> D ^ -D™&-D - ^ D r ^ • *.*-> • •:,-:::::•• • **> • «:^ D,^ ..... rv„, U ™P n-i::.-Q - # D « ^ • *4* impairment not listed above? L_I 1 l_l 1 don't know • • • • • • • Any nthprs? „ ., 147 40. The next question asks about trouble you have doing certain activities even when using a special aid. Report only those problems which you expect to last 6 months or more. Do you have any trouble... hearing what is said in a normal conversation with one other person? hearing what is said in a group conversation with at least three other people? reading ordinary newsprint, with glasses if normally worn? seeing clearly the face of someone from 12 feet (4 metres), with glasses if normally worn? speaking and being understood? walking 400 yards (400 metres) without resting? walking up and down a flight of stairs? carrying an object of 10 pounds for 30 feet (5 kg for 10 metres)? moving from one room to another? standing for long periods of time, that is for more than 20 minutes? when standing, bending down and picking up an object from the floor? dressing and undressing yourself? getting in and out of bed? cutting your own toenails? using your fingers to grasp and handle? reaching in any direction? cuting your own food? 4 1 . In the past 12 months, have you suffered an injury as a result of doing sports or exercise? CH no Q yes: Most recent injury: What activity? For how long did this injury prevent you from . . . working or studying: i , i days o_r i , i weeks or i , i months exercising: i , idavs or i , i weeks or i , imonths 42. During the last 12 months... ...did you see or talk to a doctor about your health? D no CD yes: how many times? i • i times ...did you see or talk to any other kind of health professional? D no CI yes: how many times? i__i_J times ...how many nights did you spend a in hospital, a nursing home or a convalescent home? L J none o_[ i • i nights have trouble n n-• • • • • • • • • • • • • • • no trouble • • • • • • D • • D • • • • • • • • 148 43. During the past two weeks... ...how many days did you stay in bed all or most of the day because of illness, injury or some other health problem? • none or i • i days How many of these days were work or school days? • none o_r i i i days ... not counting days in bed, how many days did your health keep you from your normal activities? • none o_i i • i days How many of these days were work or school days? f~l none Q I I • i days 44. Below is a list of how you might have felt or behaved. Please way in the past week. During the past week... I was bothered by things that don't usually bother me. I did not feel like eating; my appetite was poor. I felt that I could not shake off the blues even with help from my family or friends I felt that I was just as good as other people. I had trouble keeping my mind on what I was doing. I felt depressed. I felt that everything I did was an effort. I felt hopeful about the future. I thought my life had been a failure. I felt fearful. My sleep was restless. I was happy. I talked less than usual. I felt lonely. People were unfriendly. I enjoyed life. I had crying spells. I felt sad. I felt that people disliked me. I could not get "going". indicate how often you have felt this less than 1-2 3-4 5-7 one day days days days • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • D D • • • • • • • • • • • • • • • • • • • • • • • • • • • 45. What do you consider to be your ideal weight from the point of view of health? I • • I lbs or i , . i kg 46. In general, how would you describe your state of health? I~l very good D poor • good • very poor • average 149 ABOUT YOU 47. Are you ... • male? Q female? 48. What is your date of birth? i i i day i .i.,,, i month \ • i year 49.Where were you born? 1 1 Newfoundland f~l Nova Scotia 1 1 New Brunswick f~1 Prince Edward Island Q Quebec |~1 Ontario • • • • • • 50. What language did you first learn at home? f~l English [~l French f~l German 51 .What is your marital status? i—1 married (including a common-law L- ' relationship) f~l widowed f~l divorced • • • • • Manitoba Saskatchewan Alberta British Columbia Northwest Territories Yukon Italian Ukrainian other separated single (never married) 52. How would you describe yourself? (Check all that apply.) [~] student full-time f~l student part-time r~l homemaker full-time I I homemaker part-time other: • n • • employed full-time employed part-time TPtirprl" ^inrp unemployed or on strike: since 53. What is the highest level of education you have reached? If you are a student, please indicate your current level of education. |"1 elementary or less f*1 some secondary school l~] secondary diploma a • • some post-secondary community college or CEGEP diploma one or more university degrees 150 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 > > 54. About how many years have you lived in this province? i—i—i years 55. About how many years have you lived in this city? i—i—i years 56. About how many years have you lived in this neighbourhood? i—i—i years 57. What are the highest levels of education your father and your mother reached? Father's education: • elementary or less some secondary school secondary diploma • some post-secondary • post-secondary diploma or certificate • one or more university degrees 58.Where were your father and mother born? Eather; • Newfoundland • Nova Scotia New Brunswick • Prince Edward Island Q Quebec • Ontario • Manitoba • Saskatchewan D Alberta British Coloumbia • Northwest Territories • Yukon • outside of Canada Mother's education-elementary or less some secondary school secondary diploma • some post-secondary • post-secondary diploma or certificate • one or more university degrees Mother: • Newfoundland • Nova Scotia C I New Brunswick • Prince Edward Island • Quebec • Ontario • Manitoba • Saskatchewan • Alberta • British Coloumbia • Northwest Territories • Yukon • outside of Canada 151 59. What kind of work do you do? Please provide as much detail as possible (e.g. posting invoices, selling shoes), am not *—' working b. For whom do you work? Please indicate what kind of business, industry or service this is (e.g. retail shoe store, paper box manufacturing, board of education, government department, self-employed carpentry). c How many people are you in charge of at work (including those directly and indirectly under your supervision)? D none D 11 to 49 • 1 • 50 to 99 O 2 to 4 • 100 or more • 5 to 10 d. How many hours per week do you normally work at your job? i i i hours e. Do you have any of the following at or near your place of work? LJ pleasant places to walk, jog or wheel • showers or change rooms O playing fields or open spaces for ball games, etc. organized recreational sport teams LJ organized fitness classes LJ other physical activities f. At work, do you have... I~l programs to improve health, physical fitness or nutrition l~l a total ban on smoking • smoking restricted to designated areas g. At work, how much time do you spend.... almost all about 3/4 about 1/2 about 1/4 almost none sitting • • • • • standing D D D D D walking, wheeling [H j~1 |~] fH [~] walking up and down stairs (~l f~l 1~1 f~l Q lifting or carrying heavy Q Q Q Q Q objects h. Comparing your present physical activity level at work with 6 or 7 years ago, that is in 1981, would you say you're... much more active IZI CD D C EH much less active 1R? 60.Before taxes, approximately what were your total personal and total household incomes last year? Total personal income: " • less than $10,000 • • • • • • $10,000 $15,000 $20,000 $25,000 $35,000 $14,000 $19,000 $24,000 $34,000 $54,000 Total household innomfi: • less than $10,000 • $10,000 ' • $15,000 • $20,000 • $25,000 • $35,000 $14,000 $19,000 $24,000 $34,000 $54,000 $55,000 and over • $55,000 and over INFORMATION FOR FUTURE FOLLOW-UP Would you please give the names of two relatives or friends outside this household with whom you keep in touch? (We are hoping to repeat this survey in 5 years. We ask this in case we should want to reach you and you are no longer living at this address.) Name Address Relationship Name Address Relationship Would you please give your provincial health insurance number? (We are asking for this number so that we may have access to health records in future. The number will be used only for this purpose and will be kept strictly confidential.) Health Plan Number: This completes the questionnaire portion of the survey. Thank you for participating. 153 PHYSICAL MEASUREMENTS Signed Consent Q no-stop Q yes-proceed Station 1 Weight Height Skinfolds I I I ' l kg l i ' i — I cm Triceps Subscapular Biceps Iliac crest Medial calf o_r i—i—i—i—i estimated • 0 r I—i—I—i—i estimated 1st i I i I • lbs • in . • kg CD cm i l i I i I i l i l i l i I L_L I • ' I ' I ' • ' L Girths Upper arm Chest Abdomen Gluteal Thigh Station 2 PAR-Q heart trouble frequent pain in heart and chest? spells of severe dizziness? blood pressure medication prescribed by doctor bone or joint problem other reason (please specify) J J 2nd i i i i i i i i ? i i i i ? i i i i ? i i i i ? i 3rd 1 1 1 1 1 i i i ? i i i i ? i i i i ? i i i i ? i unable refusal to obtain • • • • • • • D D • • • • • • • Screening for Children limited for health reasons under doctor's care other reason (please specify) • • refusal D • • • D unable to obtain D • • • n 154 Observat ion With the exception of pregnancy, these conditions are to be observed not asked. Conditions- Not Screened Out Bl indness \Z\ Deafness C3 Limb problem f j Conditions- Screened Out of Fitness Tests Pregnancy Q Fever • Persistent cough Q Muscular co-ordinat ion or i—• orthopedic problem 1—1 Impairment from alcohol [~1 Other Resting Heart Rate and Blood Pressure Cuff size Resting heart rate Systol ic Diasto l ic D4 D5 d child I I I I l_l l__l l _ l L_J • adult If > 100 rest 5 min If > 150 rest 5 min If > 100 rest 5 min • large ' ' • ' I I I I I I I I L_1_L o v e r , „ ( „ „ ! unable to l imi t refusal o b t a i n • • • • • • • • • • • Canadian Aerobic Fitness Test Tempera tu re i • i Starting Stage I _ I I Exercise Heart Rates D refusal 1st bout ' ' ' ' 2nd bout L_J l_J 3rd bout I I I 1 If the exercise was interrupted or discont inued, specify reason 4th bout I I I I 5th bout I I I I S ta t ion 3 Muscular Strength and Endurance Grip Strength Right hand Left hand P u s h - u p s Si t -ups I I i I 1st I I I I ' I ' ' 2nd I I I I l i l l refusal unable to obtain • • • • refusal screened out • • • • screened out • • • • F l e x i b i l i t y T runk f lex ion 1st i i i i 2nd I I I refusal screened out • • • 155 

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