PHYSICAL ACTIVITY PROFILE FOR

St. Mary School

Saskatchewan Population Health and Evaluation Research Unit

Smart Cities, Healthy Kids
smartcitieshealthykids.com

YOUR SCHOOL’S PROFILE
Thank you, St. Mary School, for participating in the Smart Cities, Healthy Kids project.

Smart Cities, Healthy Kids is a three-year project sponsored by the Canadian Institutes of Health Research,

the Heart and Stroke Foundation of Canada, and the Health Research Foundation. We are centred in the Saskatchewan Population Health and Evaluation Research Unit (SPHERU) at the University of Saskatchewan. Our goal is to conduct research that will be of direct benefit to our research participants, partners, and communities in general. We aim to provide information, ideas, and assistance to those who work with children to create innovative health intervention strategies. We are grateful for the opportunity to collect data within the school systems and are happy to provide our results to those who have participated in this study. This report focuses on the results from the Smart Cities, Healthy Kids questionnaire. We will continue to provide updated information from subsequent research phases, as it becomes available. Throughout the report, you will find word bubbles titled “In Their Own Words…” These quotations come directly from comments provided by students through the Smart Cities, Healthy Kids questionnaire, and provide unique insight into the student perspective. Note: Please interpret some results with caution. The data for this profile may or may not be representative of your school due to small sample sizes. In particular, if your school has fewer than 20 participants in this study, your results may not be representative. However, you may still benefit from observing Saskatoon trends, which are reported in most areas for comparison.

Smart Cities, Healthy Kids is pleased to provide this results profile for your school. Sharing information with
the community is made possible through the funding and support of the following organizations: University of Saskatchewan University of Regina City of Saskatoon Saskatchewan Population Health and Evaluation Research Unit Saskatoon Health Region Canadian Institutes of Health Research Heart and Stroke Foundation of Canada Health Research Foundation Saskatchewan Health Research Foundation

The principal investigator for this project is Nazeem Muhajarine, PhD. For more information regarding this profile, the research project associated with it, or a complete list of contributing researchers, visit

smartcitieshealthykids.com

or contact:

Tracy Ridalls Research Manager Saskatchewan Population Health and Evaluation Research Unit (306) 966-2237 tracy.ridalls@usask.ca

TABLE OF CONTENTS
Smart Cities, Healthy Kids: The Project Understanding the Issue: Childhood Obesity Participants from Your School Gender Distribution Grade Distribution Age Distribution Aboriginal Participants Home Neighbourhoods The Home Environment Student Personal Perceptions Body Weight Academic Performance Family and Peer Influences Family Members Friends and Peers Reasons for Inactivity Sedentary Behaviour Screen Time Sources of Physical Activity Gym Class Structured Activity Unstructured Activity The Neighbourhood Factor Park Access Neighbourhood Perceptions Active Transportation Food Consumption and Eating Habits The Food Environment: Our Sister Study References 1 2 3 3 3 3 3 4 4 5 5 5 6 6 6 7 8 8 9 9 9 9 10 10 10 11 12 13 14

SMART CITIES, HEALTHY KIDS: THE PROJECT
The goal of Smart Cities, Healthy Kids is to understand how urban planning and design can be used to encourage children to be more physically active, thus slowing the rise in childhood obesity. Tackling the problem of childhood obesity requires multiple approaches. Many people, from health professionals, funders, policy makers, and researchers, to concerned parents, have identified environmental factors that can either help or hinder children and adults to live more active lifestyles. However, there has been little research into how aspects of the urban built environment in which we all live—such as buildings, roadways, sidewalks, parks, and green spaces-–can encourage children to be physically active. By learning about what is and isn’t working in our current neighbourhoods in Saskatoon, this study will help shape the design of future neighbourhoods, here and elsewhere in Canada.

Research Question 1: How have the specific planning strategies that the City of Saskatoon has used in its neighbourhoods contributed to the “active living potential” of these neighbourhoods?
During the summers of 2009 and 2010, we assessed all 60 of Saskatoon’s residential neighbourhoods using two research surveys: Neighbourhood Active Living Potential (NALP) and Irvine-Minnesota Inventory (IMI). NALP is a 22item survey that examines the activity friendliness, safety, density of destinations and universal accessibility of each neighbourhood. “Activity friendliness” measures how suited the neighbourhood is to human-powered activities such as walking, skateboarding, cycling, and wheelchair use. “Safety” measures physical and social characteristics of the neighbourhood. “Density of destinations” measures destinations within the neighbourhood that people can travel to, such as public parks, sports and recreational centres, bus stops, local events, and shops. IMI consists of 229 neighbourhood features that fall within five domains: attractiveness; diversity of destinations; pedestrian access; safety from crime; and safety from traffic. With these two surveys, observers walked through all 60 of Saskatoon’s residential neighbourhoods and recorded what they encountered. Each neighbourhood’s active living potential was then assessed based on the results. Reports summarizing the results for each neighbourhood can be found at smartcitieshealthykids.com.

Research Question 2: What is the relationship between a neighbourhood’s “active living potential” and the physical activity levels and active transportation of the children between 10 and 13 who live in that neighbourhood?
We recruited 1,610 children to complete two, detailed physical activity questionnaires. The Smart Cities, Healthy Kids questionnaire was used to determine demographic information and self-perceptions related to physical activity. The Modifiable Activity Questionnaire for Adolescents (MAQ-A) was used to gather data on the registered and unregistered physical activities in which the children participate. A sub-group of 465 children was also recruited to wear accelerometers for a week. Accelerometers are small, waist-mounted instruments that measure physical activity directly. This report includes exclusively descriptive information from the Smart Cities, Healthy Kids questionnaire.

Research Question 3: What do children and their parents think about the influence their neighbourhood has on children’s activity levels?
The first two research questions examine the relationship between systematically measured aspects of neighbourhoods and children’s physical activity. Question three recognizes the importance of how children and their parents feel about their neighbourhoods. To find out, we conducted in-depth interviews with 24 families whose children had participated in earlier parts of the study. Each child was lent a digital camera with which to take photographs of places and things that they feel help them to be active or prevent them from being active. These photos were discussed in the interviews with the children, and have been included in presentations of the research findings. In-depth interviews were also conducted with each parent about their perceptions of their neighbourhood environment.

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UNDERSTANDING THE ISSUE: CHILDHOOD OBESITY
Child health concerns in Canada have focused in recent years on rates of obesity and physical inactivity among children. Evidence points to a rising percentage of children that are overweight or obese and experiencing associated health problems. These trends are a cause for concern and indicate a significant childhood obesity and physical inactivity crisis. In fact, if the current trends continue, we will have a generation of children growing up for the first time with poorer health status and lower life expectancy than that of their parents.

What's the Prevalence of Childhood Obesity in Canada?
In 2004, 26% of Canadian children and youth aged 2-17 years were overweight or obese, including 8% who were obese. Overweight and obesity among Canadian 2-5 year olds remained the same between 1979 and 2004 (21%), with obesity reported at 6.3% in 2004. Overweight and obesity doubled among Canadian 6-11 year olds between 1979 and 2004 and obesity tripled among Canadian adolescents aged 12-17 years.1

“Being physically active makes you have a healthier mind/body and makes it easier to live. Without being fit the world would be an unhealthy place.”

What's the Prevalence of Childhood Obesity in Saskatchewan?
In 2007/2008, one-quarter (25%) of youth in Saskatchewan were overweight or obese; this was a 16% increase over 2001. Notably, in the same year, more than half (57%) of youth in Saskatchewan were physically inactive, and the rate of inactivity rose more than 17% since 2001.

“I think physical activity is important for when we're younger so we can be fit and healthy when we're older.”

Canadian Physical Activity Guidelines
For health benefits, children (age 5 to 11) and youth (age 12 to 17) should get at least 60 minutes of moderate to vigorous physical activity (MVPA) daily. This should include vigorousintensity activities (enough to raise your heart rate) at least 3 days per week and activities that strengthen muscle and bone at least 3 days per week. More daily physical activity provides greater health benefits.2 Health and Social Problems associated with Childhood Obesity3
• Type 2 diabetes • Hypertension • Sleep apnea • Impaired balance • Orthopedic problems • Glucose intolerance and insulin resistance • • • • • • Low self-esteem Negative body image Depression Negative stereotyping Teasing and bullying Social marginalization

Quick Fact: Only 7% of Canadian children and youth are meeting the Canadian Physical Activity Guidelines.4

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PARTICIPANTS FROM YOUR SCHOOL
The Smart Cities, Healthy Kids Physical Activity Questionnaire was completed by voluntary participants from grades 5-8 students during spring 2010. Participation rates and demographics varied between schools. There were 1584 total participants that completed the questionnaire. From your school, 9 students participated. The following graphs describe the participants from your school and how they compare to the participants from all schools.

Gender Distribution
The graph below shows the gender distribution of the participants from your school compared to the participants from all schools. Your school had an equal percentage of boys and girls participate in the study. National studies show that more boys than girls tend to participate in school sports.5 Also, girls tend to be more influenced by peer participation than boys.6

Grade Distribution
The graph below shows the grade distribution of the participants from your school compared to the participants from all schools. Your school had a higher percentage of participants in grade 6 than other schools that participated.

Age Distribution
The above graph shows the age distribution of the participants from your school compared to the participants from all schools. Your school had a greater percentage of 13-year-olds than other participating schools.

Aboriginal Participants
The above graph shows the concentration of Aboriginal participants from your school compared to all schools. It is important to acknowledge that the Aboriginal population is more vulnerable, faces additional barriers to physical activity and sport participation than the general population, and is in need of tailored support and engagement strategies.7

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Home Neighbourhoods
The graph to the right shows the distribution of home neighbourhoods for the student participants. With the open school district, most schools had a wide range of home neighbourhoods represented in the student participant sample. This is important to recognize because it provides insight when analyzing topics such as active transportation, distance to park space, and participation in school activities.

The Home Environment
The graphs below show the parent-child living arrangements and number of siblings living in the same household for students from your school compared to students from all schools. The household context has been recognized as an important factor in sport participation rates in adolescents: the parent/guardian arrangement, family income, and other family members’ sports participation levels can all have an impact. 8 This impact can be understood in a number of ways. A child’s home environment can determine, for example, the type of adult modeling behaviour children could emulate, the number of other individuals with whom to engage in physical activity, the level of access to different types of activity (in terms of money, time, or transportation), and the level of support and encouragement provided.

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STUDENT PERSONAL PERCEPTIONS
Although external influences can have a strong impact on physical activity levels in children, so too can internal self-perceptions and self-esteem. Indeed, confidence levels can be important for children when engaging in activities that expose their vulnerability. The physical activity questionnaire included some questions about body weight and academic performance.

“Sometimes I feel embarrassed about doing something wrong in a sport.”

Body Weight
We asked students to indicate how they felt about their own body weight. The graph to the right shows the percentage of students who felt they were over/ underweight by 5 pounds or more and those who felt their weight was okay. A US study found that lower body satisfaction is associated with lower levels of physical activity in adolescents and higher levels of sedentary activity.9 Another Canadian study found similar results in that self-perceptions of body composition and condition, as well as sport skills, were significant determinants of physical activity levels.10 Therefore, efforts aimed at encouraging active participation should stay away from approaches that could also contribute to decreased body satisfaction.

Academic Performance
The graph and chart to the left show how students at your school compare to how students at all schools perceive their academic performance and standing. Academic performance can be connected to physical activity. On one hand, school marks and student perceptions of academic performance have an effect on confidence levels, self-esteem, and perceptions of control over personal outcomes. 11 Each of these can be a factor in student physical activity participation levels. On the other hand, physical activity is shown to have benefits for mental activity in children and youth12 and is positively linked to attention, memory, and executive functions (such as abstract thinking).13 Therefore, physical activity and academic performance can be self-reinforcing: greater physical activity levels can lead to better academic performance and vice versa. However, poor performance in either area could also have a negative impact on the other.

Student Perception of Academic Standing
Grade Range (%) 80 and above 70 to 79 60 to 69 59 and below St. Mary 90% 0% 0% 10% All Schools 74% 14% 6% 6%

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FAMILY AND PEER INFLUENCES
Children’s behaviour can be influenced by the behaviours they observe in people around them. It is important to take into account the type and sources of behaviour modelling to which children are exposed.

Family Members
The physical activity questionnaire asked the students how often they saw any of their family members participate in sports or exercise activities over the previous 30 day period. The graph to the right shows the results from students from your school compared to students from all schools. It is important to note that several students never or rarely observe family members in exercise. National data suggests that few Canadian adults are meeting the Canadian Physical Activity Guidelines for Adults,4 which indicates that few parents are modelling appropriate physical activity levels for their children.

Friends and Peers
Friends can also have a significant influence on children’s participation in physical activity.8 The physical activity questionnaire asked students how many of their closest friends exercise regularly and how often they had seen any of their friends participate in physical activity. The graphs to the right and below show results from your school compared to all schools. An Ontario study found that children are more likely to be active if 3 or more of their close friends are also physically active.14 Further, children report that participating in physical activity with friends increases their enjoyment of the activity.15 However, it is important to note that peer influence can both encourage or discourage participation.

“I could bike to the park with my brother and sister cause they love going to the park, so it would make me and them more active and healthier.”

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REASONS FOR INACTIVITY
If physical activity intervention and obesity prevention strategies for children are to be successful, it is important to understand why children are not meeting recommended physical activity guidelines. The Smart Cities, Healthy Kids questionnaire asked kids what kinds of things most often kept them from being active. The graph below highlights the reasons that students from all schools most identified with.

“I wish I had more time and got around to doing physical activity every day!”

Bad weather

I felt lazy

Too much homework

Family responsibilities

Not enough time

Couldn’t get a ride

Area was not safe

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SEDENTARY BEHAVIOUR
There has been a lot of focus recently in health intervention research on the role of sedentariness in childhood obesity. Children who are sedentary for several hours a day are less likely to meet the physical activity guidelines.16 Sedentary behaviour is associated with “unfavourable body composition, decreased physical fitness, increased risk for metabolic syndrome and cardiovascular disease, decreased self-esteem, behavioural problems and decreased academic achievement.”17 Further, it has been found that health risks associated with sedentary behaviour increase as sedentary time increases.

Sedentary behaviour is time
when teens are doing very little physical movement. Some examples are: • Sitting for long periods • Using motorized transportation (such as a bus or a car) • Watching television • Playing passive video games • Playing on the computer

Canadian Sedentary Behaviour Guidelines for School-Aged Children18
For health benefits, children (age 5 to 11) and youth (age 12 to 17) should minimize the time they spend being sedentary each day. This may be achieved by: 1. Limiting recreational screen time to no more than 2 hours per day; lower levels are associated with additional health benefits. 2. Limiting sedentary (motorized) transport, extended sitting, and time spent indoors throughout the day.

Screen Time
Sedentary behaviour is often associated with some form of screen time. The graph below displays how many hours per day students reported engaging in various forms of screen time, including watching TV or videos/DVDs, playing video games, or using the computer. Research shows that every hour of screen time children and youth accumulate translates into 1/3 of an hour less being physically active.5

“It would be good if parents gave a timing or a limit a day on the computer or on any electronics.”

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SOURCES OF PHYSICAL ACTIVITY

Gym Class
The graph to the left shows how many days per week students report attending gym class. Classroom time devoted to physical and health education curricula is important for the health of children and youth. The importance of this time is two-fold: it can both increase the time children spend being active, and provide them with health literacy that they can apply in their daily lives outside of the classroom.19 A study on the predictors of obesity found that each additional weekday that adolescents participated in physical education decreased their odds of being overweight as an adult by 5%.20

Structured Activity
Children involved in organized sports and physical activity programs have higher overall levels of physical activity21 and are more likely to meet the physical activity guidelines.16 The graph to the right shows how often students engaged in physical activities with a coach over a 30 day period.

“It should be you don’t have to be good at the sport to join.”

Unstructured Activity
Physical activity doesn’t have to be organized and scheduled. Indeed, unstructured forms of active play can help children increase their physical activity while also contributing to social, emotional, and cognitive development.19 The graph to the right shows how often students engaged in physical activities without a coach over a 30 day period.

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THE NEIGHBOURHOOD FACTOR
This Smart Cities, Healthy Kids study has a particular interest in understanding how a child’s neighbourhood impacts their physical activity. Accordingly, the Smart Cities, Healthy Kids questionnaire asked the students some questions about park space and how safe they feel in their home neighbourhood.

“The park should have more street lights to make it less scary.”

Park Access
Children with access to playgrounds, parks, and recreational facilities in their neighbourhoods are more likely to be physically active and less likely to be overweight.22 The graph to the right shows that most children in Saskatoon have adequate access to neighbourhood facilities, which is in line with other Canadian cities.19 However, several studies suggest that park access alone is not a strong determinant of park usage; other factors that influence park use are look of the park (upkeep and condition), presence of amenities (footpaths, wading pools, picnic tables), and safety.23

Neighbourhood Perceptions
Children are more likely to be active outside of school if they perceive their neighbourhood as safe. 24 We asked the participants questions about their perception of safety in their home neighbourhood. The graph below shows the percentage of students who responded feeling “safe,” “pretty safe,” or “very safe.” It is important to note that very few children in Saskatoon felt unsafe in their neighbourhood. However, perhaps more importantly, parents need to perceive that their neighbourhood is safe if they are to allow their children the freedom to engage in independent play and mobility outside. A national survey suggests that 18% of parents agree or strongly agree that safety concerns are an issue in their neighbourhood. 25 Neighbourhood safety concerns commonly cited by parents are harm from strangers, road safety, personal injury, and bullying. 26 Indeed, parental perceptions of neighbourhood safety can have a strong impact on children’s physical activity levels. Research shows that independent mobility in children has drastically reduced over time: in an effort to minimize safety risks to their children, parents have restricted their children’s free time away from adult supervision.27-31 Having to coordinate active outdoor play with parents’ schedules and willingness to supervise may be a hindrance to the amount of unstructured activity children ultimately engage in, which may prove to be more harmful to their wellbeing in the end.

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ACTIVE TRANSPORTATION
With parent and school support, active transportation can be a safe and inexpensive way to increase physical activity levels. Some schools have explored ideas such as “walking school buses,” or policies requiring students be dropped off a safe walking distance from school or discouraging parents who live close by from driving their children to school.19 Research has shown that active transportation is most likely to be adopted if the built environment has strong street connectivity and pedestrian infrastructure, parents perceive the route to school to be safe, and families have “strong social ties with neighbours and emotional satisfaction with their neighbourhood.”32-33 The graph below shows how often students from your school reported walking or biking to school compared with students from all schools.

Quick Fact: On a national level, the most commonly reported barrier to active transportation is the distance between home and school.

Some National Figures:34

24% of parents say their children use only active modes of transportation in trips to and from school. (20% walk, 4% bike) 62% of parents say their children rely on only inactive modes of transportation in trips to and from school. (24% by car, 34% by bus/train, 4% mixed modes) 14% of parents say their children use a combination of active and inactive modes of transportation to and from school.

The two graphs below show the reasons for not walking or biking to school reported by students from your school compared to students from all schools. For comparison, a 2008-2009 National Family Intervention Survey reported reasons given by parents for motorized transportation included inclement weather (21%), convenience and time pressures (18%), driving somewhere else anyway (17%), distance to school is too far (16%), traffic danger (11%) and personal safety issues (11%).35

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FOOD CONSUMPTION AND EATING HABITS
Physical activity alone is not sufficient to mitigate against obesity: proper nutrition must also be considered. There is a direct link between food consumption, nutrition, and overall health outcomes, including obesity. The Smart Cities, Healthy Kids questionnaire included some questions about each student’s food consumption patterns and eating habits. The results from this portion of the questionnaire provide a general impression of children’s food and nutrition health in Saskatoon. Smart Cities, Healthy Kids has launched a sister study to further investigate the role of the food environment on children’s health. (The details of the study can be found on the following page.) Proper nutrition and food consumption habits contribute to better overall health, increase energy, provide stronger muscles and bones, and lower the risk of chronic health problems. 36 Canada’s Food Guide suggests children between ages 9-13 should consume 6 daily servings of fruits and vegetables, 3-4 daily servings of milk or milk alternatives, 6 daily servings of grain products, 1-2 daily servings of meat and meat alternatives, and should limit unsaturated fats.36 Consumption of saturated and trans-fats and sugar-sweetened drinks, along with missing breakfast, are all contributing risk factors associated with childhood obesity. 37-38 The charts below show your students’ self-reported food consumption patterns.

eat fast food? drink pop, fruit drinks, or energy drinks? eat fruit? eat vegetables?

drink milk?

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THE FOOD ENVIRONMENT: OUR SISTER STUDY
PLEASE
CONSIDER ASSISTING OUR RESEARCH AGAIN WHEN WE RETURN TO SCHOOLS IN THE SPRING OF

2012.

Smart Cities, Healthy Kids has received additional funding from the Canadian Institutes of Health Research and the
Saskatchewan Health Research Foundation for a sister study evaluating the impact of the food environment on childhood obesity. The food environment refers to how easily we, and our children, can access nutritious food in the neighbourhoods in which we live. We are interested in where food stores and restaurants are located in Saskatoon and how nutritious the foods they carry are. By incorporating data on body weight of children, we ultimately hope to support the development of improvements to health policy and practice in Saskatoon, and also provide information that would benefit the nutrition and health of children and families.

Question 1a: What is the geographical distribution of food stores and fast food restaurants in Saskatoon and how is this distribution related to neighbourhood demographic and socio-economic profiles?
During the first four months of the study (September-December 2010), Geographic Information Systems (GIS) tools were used to complete maps of fast food restaurants, grocery, convenience, specialty, and all other food stores in all Saskatoon neighbourhoods. This process has already been initiated by Public Health Services (Saskatoon Health Region); parts of the city where food access is limited have already been identified and can be related back to demographic and socio-economic profiles.

Question 1b: What are the differences in food environments, such as location of different types of food stores and food quality, between higher and lower socioeconomic status neighbourhoods in Saskatoon?
The consumer nutrition environments of chain supermarkets, smaller grocery stores, convenience stores and restaurants have been measured using a Canadian adaptation of the Nutrition Environment Measures Survey for Stores (NEMS-S) and the original Nutrition Environment Measures Survey for Restaurants (NEMS-R). Scores will be calculated for each store using availability, quality, and price, and for each restaurant using availability, nutrition information, and price. Using these scores, we will then develop a series of maps showing the distribution of the quality of the food environment within all residential neighbourhoods in Saskatoon. We will also add selected demographic and socio-economic variables to assess the relationship between the food environment and neighbourhood income levels.

Question 2: What is the relationship between the quality of the food environment available, as measured by (NEMS-S) and (NEMS-R), in Saskatoon neighbourhoods, and the dietary intake and body weights of children aged 10-13 years living in those neighbourhoods?
We will recruit approximately 100 children from each of the 20 neighbourhoods that show the most and the least positive food environment characteristics based on the previous study data collection (GIS and NEMS). Children will participate in a food frequency questionnaire (FFQ) for dietary assessment that will be self-administered in class. A research assistant will also measure heights and weights in order to calculate body mass index (BMI) and determine body weight status. The questionnaire includes questions on socio-demographic characteristics, and our analysis will account for things like parental educational level, parental income, proportion of families with no vehicles, and proportion of lone parent families.

Question 3: How should the information collected in this study be shared in order to facilitate change that will improve food environments for Saskatoon, and then in other cities in other regions of the country?
Interviews will be conducted with various governmental, health region, and community-based officials to share preliminary results, ask for feedback, and discuss policy change options to improve the food environment in Saskatoon. The results will be compiled into a document that will be disseminated widely.

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REFERENCES
1. Shields, M. Measured Obesity: Overweight Canadian Children and Adolescents. Nutrition: Findings from the Canadian Community Health Survey: Issue no. 1. Statistics Canada, 2005. 2. Tremblay MS, Warburton DER, Janssen I, Paterson DH, Latimer AE, Rhodes RE, et al. New Canadian physical activity guidelines. Appl Physiol Nutrition Metab. 2011; 36:36-46. 3. Koplan J.P, Liverman CT, Kraak VA. (Eds.). Preventing Childhood Obesity: Health in the Balance. Committee on Prevention of Obesity in Children and Youth. Food and Nutrition Board. Washington, D.C.: The National Academies Press, 2004. 4. Tremblay M, Shields M, Laviolette M, Craig C, Janssen I, Connor Gorber S. Fitness of Canadian children and youth: Results from the 2007-2009 Canadian Health Measures Survey. Health Rep. 2010;21:1-14. 5. Tell Them From Me Survey 2008-2009. Unpublished Data Analysis. From Active Healthy Kids Canada (2011). Don’t Let This Be The Most Physical Activity Our Kids Get After School. The Active Healthy Kids Canada 2011 Report Card on Physical Activity for Children and Youth. Toronto: Active Healthy Kids Canada. Pfaeffli L. In Her Voice: An exploration of young women’s sport and physical activity experiences. Focus group report and recommendations. Ottawa, ON: Canadian Association for the Advancement of Women and Sport and Physical Activity (CAAWS); 2009. Hanna R. Promoting, Developing, and Sustaining Sports, Recreation, and Physical Activity in British Columbia for Aboriginal Youth: First Nations Health Society; 2009. O’Reilly N, Berger I, Hernandez T, Parent M, Seguin B. Urban youth engagement in sport: process, access and participation. Sport Canada Research Initiative 3rd Annual Conference. Ottawa, ON: Canadian Heritage – Sport Canada; 2009. Neumark-Sztainer D, Goeden C, Story M. Associations between Body Satisfaction and Physical Activity in Adolescents: Implications for Programs Aimed at Preventing a Broad Spectrum of Weight-Related Disorders. Eating Disorders. 2004;12:125-137.

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10. Crocker P, Eklund R, Kowalski K. Children’s Physical Activity and Physical Self Perceptions. J Sport Sci. 2000;18:383-394. 11. Ross CE, Broh BA. The Roles of Self-Esteem and the Sense of Personal Control in the Academic Achievement Process. Sociol of Educ. 2000; 73 (4): 270-284. 12. Sibley BA, Etnier JL. The relationship between physical activity and cognition in children: a meta-analysis. Pediatr Exerc Sci. 2003;15:243-256. 13. Shephard RJ. Curricular physical activity and academic performance. Pediatr Exerc Sci. 1997;9:113-126. 14. Leatherdale ST, Manske S, Faulkner G, Arbour K, Bredin C. A multi-level examination of school programs, policies and resources associated with physical activity among elementary school youth in the PLAY-ON study. Int J Behav Nutr Phys Act. 2010;7:6. 15. Canadian Assessment of Physical Literacy 2009. Unpublished Data. From Active Healthy Kids Canada. Healthy Habits Start Earlier Than You Think. The Active Healthy Kids Canada Report Card on Physical Activity for Children and Youth. 2010; Toronto, ON. 16. Canadian Fitness and Lifestyle Research Institute CAN PLAY 2007-2009. Unpublished Data. From Active Healthy Kids Canada. Healthy Habits Start Earlier Than You Think. The Active Healthy Kids Canada Report Card on Physical Activity for Children and Youth. 2010; Toronto, ON. 17. Healy GN, Matthews CE, Dunstan DW, Winkler EA, Owen N. Sedentary time and cardio-metabolic biomarkers in US adults: NHANES 2003-06. Eur Heart J. 2011;32:590-597. 18. The Canadian Society for Exercise Physiology. Sedentary Behaviour Guidelines for Children and Youth. 2011. Available online: www.csep.ca/guidelines. 19. Active Healthy Kids Canada. Healthy Habits Start Earlier Than You Think. The Active Healthy Kids Canada Report Card on Physical Activity for Children and Youth. 2010; Toronto, ON. 20. Menschik D, Ahmed S, Alexander M, Blum R. Adolescent physical activities as predictors of young adult weight. Arch Pediatr Adolesc Med. 2008;162:29-33 21. Spence J, Dutove J, Holt N, Carson V. Uptake and effectiveness of the Children’s Fitness Tax Credit in Canada. International Society for Behavioural Nutrition and Physical Activity (ISBNPA). Lisbon, Portugal; 2009. 22. Veugelers P, Sithole F, Zhang S, Muhajarine N. Neighborhood characteristics in relation to diet, physical activity and overweight of Canadian children. Int J Pediatr Obes. 2008;3:152-159. 23. McCormack GR, Rock M, Toohey AM, Hignell D. Characteristics of urban parks associated with park use and physical activity: a review of qualitative research. Health Place. 2010;16:712-726.

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24. Nichol M, Janssen I, Pickett W. Associations between neighborhood safety, availability of recreational facilities, and adolescent physical activity among Canadian youth. J Phys Act Health. 2010;7:442-450. 25. Canadian Fitness and Lifestyle Research Institute Capacity Survey 2008. Unpublished Data. From Active Healthy Kids Canada. Healthy Habits Start Earlier Than You Think. The Active Healthy Kids Canada Report Card on Physical Activity for Children and Youth. 2010; Toronto, ON. 26. Carver A, Timperio A, Crawford D. Playing it safe: the influence of neighborhood safety on children’s physical activity – a review. Health & Place. 2008;14:217-227. 27. Gill T. Nothing ventured…balancing risks and benefits in the outdoors. Devon, England: English Outdoor Council, 2010. 28. O’Brien M, et al. Children’s independent spatial mobility in the urban public realm. Childhood. 2000;7:257-277. 29. Gaster S. Urban children’s access to their neighborhood: changes over three generations. Environ Behav. 1991;23:70-85. 30. Karsten L. It all used to be better? Different generations on continuity and change in urban children’s daily use of space. Children’s Geographies. 2005;3:275-290. 31. Kinoshita I. Charting generational differences in conceptions and opportunities for play in a Japanese neighborhood. J Intergener Relatsh. 2009;7:53-77. 32. Hume C, Timperio A, Salmon J, Carver A, Giles-Corti B, Crawford D. Walking and cycling to school: predictors of increases among children and adolescents. Am J Prev Med. 2009;36:195-200. 33. Grow H, Saelens B, Kerr J, Durant N, Norman G, Sallis J. Where are youth active? Roles of proximity, active transport, and built environment. Med Sci Sports Exerc. 2008;40:2071-2079. 34. Canadian Fitness and Lifestyle Research Institute. The 2005 Physical Activity and Sport Monitor. Ottawa, Ontario: Canadian Fitness and Lifestyle Research Institute; 2005. Available online: tinyurl.com/68wluqp. 35. 2008-09 Family Intervention Survey. Unpublished data analysis. From Active Healthy Kids Canada (2011). Don’t Let This Be The Most Physical Activity Our Kids Get After School. The Active Healthy Kids Canada 2011 Report Card on Physical Activity for Children and Youth. Toronto: Active Healthy Kids Canada. 36. Health Canada. Eating Well with Canada’s Food Guide. 2009. Available online: www.healthcanada.gc.ca/foodguide. 37. Moreno, LA, Rodriguez, G. Dietary Risk Factors for Development of Childhood Obesity. Curr Opin Clinic Nutrit & Metabo Care. 2007;10:336-341. 38. Ludwig, DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357:505-508.

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