Reported need for and access to oral health care services during the COVID-19 pandemic in Canada

Background

The COVID-19 pandemic interrupted routine and preventive dental services until precautions could be implemented to limit virus transmission. Access to services for dental emergencies was maintained. The objective of this study was to describe the reported need for, access to, and receipt of oral health care in Canada during the first year of the pandemic.

Data and methods

The 2021 Survey on Access to Health Care and Pharmaceuticals During the Pandemic collected information from Canadians aged 18 years and older. Respondents were asked whether they needed (routine) dental care in the previous 12 months, whether they received that care, whether they experienced any mouth or tooth pain (indicative of a dental emergency), and whether and how COVID-19 affected service access.

Results

Of the 44.5% of Canadians who reported needing dental care in the 12 months before the survey, 5.8% did not receive the care they reportedly needed. Almost 20% of those with a reported need had their appointment cancelled, rescheduled, or delayed because of COVID-19, and this was more common for individuals with unmet dental care needs (46.9%) than it was for those who had received dental care (17.1%). For those requiring more urgent care, 23.3% of Canadians experienced pain in their mouth or teeth in the previous 12 months. Among those with dental pain, 64.2% sought treatment, and the majority (86.4%) received the treatment they needed. One-third (33.2%) avoided care for their dental-related pain because of fear of contracting COVID-19.

Interpretation

During the first year of the pandemic, many Canadians experienced cancelled or delayed dental services or did not receive the oral health care services they reportedly needed. Ongoing monitoring could help determine whether these COVID-19 service interruptions will have lasting effects on Canadians' oral health.

The local restaurant environment in relation to eating out and sugary drink intake among Canadian children and youth

Background

Accessibility of food retail in communities may play a role in shaping the food choices of local residents. However, previous studies have shown mixed results. This study examined associations between the local restaurant environment and the frequency of eating food from restaurants and intake of sugary drinks among Canadian children and youth.

Data and methods

The study cohort consisted of 23,776 participants (aged 1 to 17 years) in the 2019 Canadian Health Survey on Children and Youth who resided in large urban population centres across the Canadian provinces. Measures of geographic access to various restaurant types within walking distance of participants' residential areas came from the 2018 Canadian Food Environment Dataset. Poisson regression models with robust standard errors assessed associations between measures of absolute densities (number per km²) of full-service, fast-food and other restaurants, and the relative density of fast-food restaurants (as a percentage of total restaurants) with the frequency of eating food from fast-food or full-service restaurants and sugary drink intake in the previous seven days.

Results

After adjustment for a range of sociodemographic covariates, there were no consistent associations between absolute and relative measures of restaurant access and the frequency of eating food from restaurants or intake of sugary drinks.

Interpretation

Results reveal no consistent relationships between local restaurant exposures and the frequency of eating food from restaurants or sugary drink intake among Canadian children and youth. Efforts to create environments that foster healthy food choices among young people will remain important but will likely need to target multiple activity spaces beyond the local neighbourhood.

Linkage of the nationally representative Canadian Community Health Survey - Nutrition 2004 to routinely collected mortality records

The Canadian Community Health Survey (CCHS) - Nutrition 2004 (n=35,107; interview dates from January 2004 to January 2005) linked to the Canadian Vital Statistics - Death Database (CVSD) (2011) represents a novel linkage of a population-based, nationally representative nutrition survey with routinely collected mortality records (including date and cause of death). The linkage was done through individual tax data in Canada, and contains longitudinal records for 29,897 Canadians aged 0 years and older-1,753 of whom died-in the 10 provinces of Canada. The median follow-up time was 7.49 years, with 102,953 person-years among males and 114,876 person-years among females (unweighted), and included a special sampling survey weight (for linked data) to account for those who did not agree to share and link their information. The CCHS - Nutrition 2004 linked to CVSD has been used to evaluate associations between lifestyle and sociodemographic characteristics and mortality. Using these data, statistical methods have been developed and tested to control random and systematic measurement errors when evaluating the relationship between different dietary exposures (evaluated using repeated 24-hour dietary recalls) and health outcomes. The linked data are available through Statistics Canada's Research Data Centres.

Development of the Healthy Eating Food Index (HEFI)-2019 measuring adherence to Canada's Food Guide 2019 recommendations on healthy food choices

The release of Canada's Food Guide (CFG) in 2019 by Health Canada prompted the development of indices to measure adherence to these updated dietary recommendations for Canadians. This study describes the development and scoring standards of the Healthy Eating Food Index (HEFI-2019), which is intended to measure alignment of eating patterns with CFG-2019 recommendations on food choices among Canadians aged 2 years and older. Alignment with the intent of each key recommendation in the CFG-2019 was the primary principle guiding the development of the HEFI-2019. Additional considerations included previously published indices, data on Canadians' dietary intakes from the 2015 Canadian Community Health Survey-Nutrition, and expert judgement. The HEFI-2019 includes 10 components: Vegetables and fruits (20 points), Whole-grain foods (5 points), Grain foods ratio (5 points), Protein foods (5 points), Plant-based protein foods (5 points), Beverages (10 points), Fatty acids ratio (5 points), Saturated fats (5 points), Free sugars (10 points), and Sodium (10 points). All components are expressed as ratios (e.g., proportions of total foods, total beverages, or total energy). The HEFI-2019 score has a maximum of 80 points. Potential uses of the HEFI-2019 include research as well as monitoring and surveillance of food choices in population-based surveys. Novelty: The Healthy Eating Food Index-2019 was developed to measure adherence to the 2019 Canada's Food Guide recommendations on healthy food choices. The HEFI-2019 includes 10 components, of which 5 are based on foods, 1 on beverages and 4 on nutrients, for a total of 80 points.

Evaluation of the Healthy Eating Food Index (HEFI)-2019 measuring adherence to Canada's Food Guide 2019 recommendations on healthy food choices

The objective of this study was to evaluate the construct validity and reliability of the Healthy Eating Food Index-2019 (HEFI-2019), which was developed to measure adherence to Canada's Food Guide 2019 (CFG-2019) recommendations on healthy food choices. Dietary intake data from 24-hour dietary recalls in the 2015 Canadian Community Health Survey-Nutrition were used for that purpose. Multidimensionality was examined using principal component analysis. Mean scores were compared among subgroups of the population. The association between scores and energy intake was assessed using Pearson correlations. Cronbach's alpha was calculated to assess reliability. The estimated mean HEFI-2019 score (/80) was 43.1 (95% CI, 42.7 to 43.6) among Canadians aged 2 years and older. The first and 99th percentiles were 22.1 and 62.9 points. The mean HEFI-2019 score for smokers was 7.2 points lower than for non-smokers (95% CI, -8.5 to -5.9). The HEFI-2019 was weakly correlated with energy intake (r = -0.13; 95% CI, -0.20 to -0.06). The principal components analysis revealed at least 4 dimensions. Cronbach's alpha was 0.66 (95% CI, 0.63 to 0.69). Evidence of construct validity and internal consistency support the use of the HEFI-2019 to assess adherence to CFG-2019's recommendations on healthy food choices. Novelty: Examination of the HEFI-2019's psychometric properties is needed prior to implementation. Analyses support the construct validity and internal consistency of the HEFI-2019. Interpretation of the total HEFI-2019 score must be accompanied by its components' scores, considering it assesses multiple dimensions of food choices.

Global, regional, and national consumption of animal-source foods between 1990 and 2018: findings from the Global Dietary Database

Background

Methods

Findings

Interpretation

Funding

Household food insecurity in Canada early in the COVID-19 pandemic

BACKGROUND

Food insecurity linked to insufficient income is an important determinant of health. Whether the COVID-19 pandemic has exacerbated levels of food insecurity in Canada, particularly among vulnerable groups, is unclear. This study estimated the proportion of Canadians reporting experience of household food insecurity six to nine months into the COVID-19 pandemic, and drew comparisons with pre-pandemic levels.

DATA AND METHODS

Data on household food security status during the pandemic came from the population-based cross-sectional Canadian Community Health Survey (CCHS) collected from September to December 2020. Analyses were based on 26,831 respondents aged 12 and older residing in the 10 provinces. The Household Food Security Survey Module was used to categorize respondents' household food security status within the previous 12 months as food secure or marginally, moderately or severely insecure. The percentage of Canadians reporting some experience of household food insecurity was estimated for the overall population and for various sociodemographic groups. T-tests were used to draw comparisons with pre-pandemic rates from the 2017/2018 CCHS.

RESULTS

In fall 2020, 9.6% of Canadians reported having experienced some level of food insecurity in their household in the prior 12 months, which is lower than the estimate of 12.6% from 2017/2018. Overall estimates were also lower in fall 2020 when examined within levels of household food insecurity (i.e., marginal, moderate or severe). The percentage of Canadians reporting experience of household food insecurity was either unchanged or lower than in 2017/2018 among sociodemographic groups vulnerable to experiencing income-related food insecurity, including renters and those with lower levels of education.

INTERPRETATION

During the second wave of the COVID-19 pandemic in fall 2020, about 1 in 10 Canadians aged 12 and older reported experience of food insecurity in their household in the previous 12 months. This proportion was lower compared with 2017/2018, both overall and among several groups at higher risk of food insecurity. Monitoring household food insecurity will continue to be important during the COVID-19 pandemic and throughout the years of recovery ahead.

A food-level substitution analysis assessing the impact of replacing regular-fat dairy with lower fat dairy on saturated fat intake at a population level in Canada

BACKGROUND

The 2019 Canada's Food Guide recommends the consumption of lower fat dairy products to reduce saturated fat (SFA) intakes.

OBJECTIVES

The objective of this study was to assess the impact of such recommendation on SFA intake at a population level in Canada.

METHODS

Analyses were conducted based on dietary intakes from the nationally representative 2015 Canadian Community Health Survey-Nutrition (unweighted n = 20,103). Dietary intake was assessed using 24-h dietary recalls. Food-based substitution modeling analyses were conducted by replacing all regular-fat dairy products reported by an equal amount of a corresponding lower fat dairy product. Regular-fat dairy products included milks ≥2% fat, cheeses >25% fat, and yogurts ≥2% fat. Corresponding lower fat replacement products were 1% fat milks, 10-25% fat cheeses, and <2% fat yogurts. The National Cancer Institute method was used to account for within-person variation in dietary intakes.

RESULTS

Replacing all regular-fat dairy products consumed by Canadians (ages ≥2 y) by a corresponding lower fat product reduced the population's SFA intake from 10.8% of total energy intake (%E; 95% CI: 10.7%, 11.0%) to 10.0%E (95% CI: 9.8%, 10.2%). This reduction was mostly attributable to the milk and cheese substitutions (mean SFA reductions of -0.3%E each). The proportion of the population with an SFA intake <10%E was 34.7% (95% CI: 31.2%, 38.2%) before substitution and 51.5% (95% CI: 47.5%, 55.5%) after substitution.

CONCLUSIONS

This food-based substitution modeling analysis suggests that SFA intakes at a population level are slightly reduced if all regular-fat dairy products consumed by Canadians were replaced by a lower fat dairy product. Approximately half of the population would still consume SFAs in excess of 10%E even if all regular-fat dairy consumed were replaced by lower fat dairy.

Consumption of ultra-processed foods in Canada

BACKGROUND

A larger share of ultra-processed foods and drinks (UPF) in the diet is increasingly linked with poor diet quality, weight gain and elevated risk of diet-related chronic disease. This study used 2015 national-level data, the most recent available, to characterize the intake of UPF among Canadians and to examine changes since 2004.

DATA AND METHODS

The 2004 and 2015 Canadian Community Health Surveys provided 24-hour dietary recall data for Canadians aged 2 or older. All food and drink items were classified according to type of food processing using the NOVA classification. The mean energy contribution of UPF (as a percentage of total daily energy intake) was compared across survey years for the overall population and for eight age-sex groups. The National Cancer Institute's methodology was used to assess the distribution of usual energy contributed by UPF.

RESULTS

On average, UPF contributed 47.8% (95% CI: 47.3% to 48.3%) of total daily energy in 2004 and 45.7% (95% CI: 45.0% to 46.4%) in 2015 among the overall population, and more than half of total daily energy among children and adolescents. Both the mean energy contribution of UPF and their usual energy distribution shifted downward since 2004 for all age-sex groups, except among adults aged 55 or older. The energy contributions of soft drinks, fruit juices and fruit drinks declined, particularly among children and adolescents. Ultra-processed breads contributed more energy in 2015 for nearly all age-sex groups.

DISCUSSION

As in 2004, the overall dietary share of UPF in Canada remained high in 2015, but intakes of some UPF, particularly beverages, declined. The energy contribution of UPF remained highest among children and adolescents, and increased among adults aged 55 or older.

Eating away from home in Canada: impact on dietary intake

BACKGROUND

Public health measures related to the COVID-19 pandemic have upended the way Canadians eat and shop for food. Since the pandemic began, many Canadians have reported consuming food away from home (FAFH) less often. FAFH tends to be less healthful than food prepared at home. Little is known about patterns of Canadians' FAFH consumption before the pandemic. This study used 2015 national-level nutrition data, the most recent available, to characterize patterns of FAFH consumption and selected markers of dietary intake.

DATA AND METHODS

National-level food intake data came from the first 24-hour dietary recall provided by 20,475 respondents aged 1 or older to the 2015 Canadian Community Health Survey-Nutrition. Mean daily intakes of selected food subgroups and nutrients, adjusted for total energy intake, were compared between those who had consumed any food in a restaurant on the previous day and those who had not. Estimates were generated overall and for eight age and sex groups.

RESULTS

In 2015, overall, 21.8% of Canadians had consumed FAFH in a restaurant on the previous day. Eating out was most common among males aged 19 to 54 (27.7%) and least common among young children aged 1 to 5 (8.4%). Compared with Canadians who had not eaten out on the previous day, those who had eaten out had consumed, on that day, fewer servings of whole fruit; whole grains; dark green and orange vegetables; other vegetables (excluding potatoes); milk and fortified soy-based beverages; and legumes, nuts and seeds, on average. Those who had eaten out had consumed, on average, less fibre and total sugar, and more total fat, saturated fat and sodium on that day. There were few differences for meat and poultry, fish and seafood, and protein intake.

DISCUSSION

On the day that Canadians ate out in a restaurant, their dietary intake was generally less favourable than that of Canadians who did not eat out. If Canadians continue to eat at home more and to consume less FAFH, as early pandemic-period reports suggest, then results can be used to gauge the potential dietary implications of these shifts.

NutriQuébec: a unique web-based prospective cohort study to monitor the population's eating and other lifestyle behaviours in the province of Québec

INTRODUCTION

The epidemic of non-communicable diseases including cardiovascular diseases and type 2 diabetes is attributable in large part to unhealthy eating and physical inactivity. In the fall of 2016, the Québec government launched its first-ever Government Health Prevention Policy (Politique gouvernementale de prévention en santé (PGPS)) to influence factors that lead to improved health status and quality of life as well as reduced social inequalities in health in the population of Québec. NutriQuébec is a web-based prospective open cohort study whose primary aim is to provide essential data for the evaluation of the PGPS on the Québec population's eating and other lifestyle behaviours over time.

METHODS AND ANALYSIS

Over a first phase of 3 years, NutriQuébec will enrol 20 000 adults living in the province of Québec in Canada through a multimedia campaign designed to reach different segments of the population, including subgroups with lower socioeconomic status. Participants will be invited to complete on a web platform nine core questionnaires on a yearly basis. Questionnaires will assess several dimensions related to lifestyle, including eating and physical activity behaviours, as well as a large number of personal characteristics and global health status. Temporal trends in eating and lifestyle behaviours will be analysed in relation to the implementation of the PGPS to provide essential data for its evaluation at a population level. Data analyses will use sociodemographic weights to adjust responses of participants to achieve, so far as is possible, representativeness of the adult Québec population.

ETHICS AND DISSEMINATION

Université Laval Research Ethics Board approved the NutriQuébec project. Data analysis, presentations in conferences and publication of manuscripts are scheduled to start in 2020.

TRIAL REGISTRATION NUMBER

NCT04140071.

Comparison of self-reported and accelerometer-measured physical activity among Canadian youth

BACKGROUND

Generally, correlation and agreement between self-reported and accelerometer-measured physical activity are low. The objective of this study is to compare estimates of physical activity from a newly developed Canadian questionnaire with measurements by accelerometer among 12- to 17-year-olds.

DATA AND METHODS

Physical activity was self-reported by domain (transportation, recreation, school, and occupational/household) as part of the new Physical Activity Youth Questionnaire (PAYQ) in the Canadian Health Measures Survey (CHMS; 2014-2017; n = 975) and the Canadian Community Health Survey (CCHS; 2015-2016; n=7,619). The CHMS also collected moderate-to-vigorous physical activity (MVPA) data using the Actical accelerometer. Descriptive statistics and correlation and agreement analyses were used to compare and contrast self-reported and accelerometer-measured physical activity variables. Linear regression was used to assess the association between physical activity and obesity.

RESULTS

The average daily MVPA measured by accelerometry was 49.7 minutes per day. According to the PAYQ, Canadian youth reported an average of 78.2 minutes of physical activity per day from all domains, including recreation (31.3 minutes per day), transportation (15.5 minutes per day), school (25.8 minutes per day), and occupational/household (5.6 minutes per day). According to accelerometer-measured MVPA, 23.1% of youth met the physical activity guideline. The inclusion of all domains of self-reported physical activity resulted in a higher percentage of youth meeting the physical activity guideline (58.6%) than was the case for the recreation domain only (18.5%) or the sum of the recreation and school domains (34.0%). Overall, self-reported and accelerometer-measured physical activity estimates were poorly correlated (R ⟨ 0.2).

DISCUSSION

Population-level estimates of physical activity and the percentage of youth meeting the physical activity guideline were well-aligned between the Actical and the PAYQ; however, large differences were evident at the individual level. Therefore, caution should be exercised in using data from these two methods since their values may not be interchangeable.

Change in vegetable and fruit consumption in Canada between 2004 and 2015

BACKGROUND

Eating plenty of vegetables and fruits on a daily basis is the foundation of a healthy diet. This study investigated patterns in Canadians' vegetable and fruit consumption in 2015 and compared these with 2004 data.

DATA AND METHODS

The 2015 Canadian Community Health Survey (CCHS) - Nutrition and the 2004 CCHS - Nutrition (Cycle 2.2) provided nationally representative 24-hour dietary recall data on Canadians' vegetable and fruit intakes. The frequency of consumption and the average quantity of daily intake for total vegetables, fruits and subgroups were calculated overall and by age and sex group for each survey year. The National Cancer Institute's methodology was used to assess the distribution of usual total vegetable and fruit intake and how it relates to recommendations in the 2007 Canada's Food Guide.

RESULTS

Overall, Canadians reported consuming fewer total servings of vegetables and fruits in 2015 (4.5 average daily servings) than in 2004 (5.3 average daily servings). Lower total fruit intakes were explained by significantly lower intakes of fruit juice across nearly all age and sex groups, resulting in a decline of 0.3 average total daily fruit servings in the overall population. Lower vegetable consumption was largely driven by lower intakes of potatoes and, to a lesser extent, lettuce. Intakes of whole fruits and other vegetables remained largely unchanged. In both years, the majority of Canadians did not usually consume the number of total vegetable and fruit servings recommended for their age and sex group in the 2007 Canada's Food Guide.

DISCUSSION

Canadians reported consuming fewer vegetables and fruits in 2015 compared with 2004. This was largely driven by substantially lower consumption of fruit juice and, to a lesser extent, potatoes. These findings can serve as valuable baseline data to assess any changes in patterns of vegetable and fruit consumption in Canada.

Changes in beverage consumption in Canada

BACKGROUND

Beverage consumption, especially water, is critical to a healthy diet. The 2007 Canada's Food Guide (CFG) makes specific recommendations regarding the intake of water, fruit juice, milk and energy-dense beverages. Earlier comparisons of 2004 and 2015 dietary data show that changing patterns in beverage intake can explain some of the changes in energy and sugar intake observed in the Canadian population. The objective of this study is to describe any changes in beverage consumption between 2004 and 2015, and how these changes relate to existing recommendations in the 2007 CFG.

DATA AND METHODS

Data are from the Canadian Community Health Survey - Nutrition for 2004 and 2015. To estimate any change in the proportion of Canadians consuming a beverage the day before and the quantity consumed, 19 beverage categories were derived using the Bureau of Nutritional Science categories. The CFG classification was used to estimate the relative share of juice intake from total servings of vegetables and fruit, and the intake of milk from milk subcategories. The National Cancer Institute method was used to estimate usual intake.

RESULTS

Water intake was higher in 2015 than in 2004. Consumption of milk, fruit juice, and energy-dense beverages such as fruit drinks and soft drinks was lower in 2015. Changes in water, soft drink and fruit drink consumption mostly reflect changes in the proportion of Canadians consuming these specific beverages the day before reporting, while changes in milk and fruit juice mostly reflect a change in the quantity consumed. In 2015, the majority of the population was consuming more whole vegetables and fruit than juice, which is in line with 2007 CFG recommendations.

DISCUSSION

Beverage consumption patterns in Canada changed between 2004 and 2015. Some of these changes are in line with recommendations from the 2007 CFG, the food guide that was available at the time of the 2015 survey.

Change in total sugars consumption among Canadian children and adults

BACKGROUND

Free sugars are nutrients of public health concern that have been associated with negative health outcomes, including dental caries in children and excess weight gain. Since national-level free sugars data are not currently available for Canadians, total sugars intake was examined to understand sugars intake in the population. The objective of this analysis was to describe and compare total sugars consumption among Canadians in 2004 and 2015.

DATA AND METHODS

Data are from the 2004 and 2015 Canadian Community Health Survey-Nutrition. Separate descriptive analyses of total sugars for children aged 2 to 18 (n=13,919) and adults aged 19 and older (n=31,156) were conducted by year and by misreporting status (under-, plausible and over-reporters), and the top sources of total sugars were identified. Misreporting status was studied to better understand differences in sugars intakes between survey years. T-tests were used to determine significant differences between survey years.

RESULTS

In 2015, the average daily total sugars consumption was 101 grams (24 teaspoons) for children aged 1 to 8, 115 grams (27 teaspoons) for children aged 9 to 18, and 85 grams (20 teaspoons) for adults. Sugary beverages, taken together, were the top source of sugars for all age groups. Total sugars consumption decreased from 2004 to 2015 overall, although not by misreporting status. Total sugars from food alone increased from 2004 to 2015, and total sugars from beverages alone decreased, regardless of age or misreporting status.

DISCUSSION

The overall decrease in total sugars consumption from 2004 to 2015 may be explained by changes in misreporting. Total sugars from food alone increased, while total sugars from beverages alone decreased. This was true for all age groups and for plausible reporters.

Comparison of self-reported and accelerometer-measured physical activity in Canadian adults

BACKGROUND

Self-reported and accelerometer-measured physical activity levels generally exhibit low correlation and agreement. The objective of this study is to compare estimates of physical activity among adults from a newly developed Canadian questionnaire with those obtained objectively by accelerometry.

DATA AND METHODS

Data for 18- to 79-year-olds (N = 2,372) were collected in 2014 and 2015 as part of the Canadian Health Measures Survey (CHMS). Moderate-to-vigorous physical activity (MVPA) was reported on the household questionnaire by domain (transportation, recreation, and occupational or household) as part of the new Physical Activity Adult Questionnaire (PAAQ) and measured objectively using the Actical accelerometer. Correlation and mean difference analyses were used to assess the relationships between measured and reported physical activity variables. Linear regression was used to test the association between measured and reported physical activity and measures of obesity.

RESULTS

On average, Canadian adults reported more physical activity than they accumulated on an accelerometer (49 minutes versus 23 minutes per day). The highest correlation observed was between accelerometer-measured MVPA and the sum of self-reported recreation and transportation activity (R = 0.36, p ⟨ 0.0001). The sum of activity from all domains (recreation + transportation + occupational or household) exhibited a lower correlation with measured variables because the occupational or household domain was negatively correlated with MVPA (R = -0.04). The occupational or household domain was positively correlated with light-intensity physical activity (R = 0.20, p ⟨ 0.0001). Respondents in the least active quintile were more likely than those in the most active quintile to report more activity than was measured by the accelerometer. On average, the most active quintile reported less activity than was measured by the accelerometer.

DISCUSSION

The newly developed Canadian physical activity questionnaire exhibited modest correlation and agreement with accelerometer-measured physical activity among adults. Accelerometers and questionnaires provide complementary information, about different aspects of physical activity (actual movement versus perceived time). Consequently, one should exercise caution in using estimates derived from these methods interchangeably.

Accounting for misreporting when comparing energy intake across time in Canada

BACKGROUND

Estimates of energy intake are lower in 2015 compared with 2004. The difference observed is too large to be explained by a change in energy requirements or physical activity at the population level. Self-reported dietary intake is subject to misreporting and may explain part of this difference. The objectives of this study are to assess how misreporting has changed from 2004 to 2015 and to demonstrate how these changes may affect the interpretation of the national intake data of Canadians.

DATA AND METHODS

Data from the 2004 Canadian Community Health Survey - Nutrition (CCHS - Nutrition) and the 2015 CCHS - Nutrition were used to estimate energy intake and requirements for all participants aged 2 or older. The ratio of energy intake to total energy expenditure requirements (EI:TEE) was used to categorize respondents as under-reporters (EI:TEE ⟨ 0.70), over-reporters (EI:TEE ⟩ 1.42) or plausible reporters (EI:TEE = 0.70 to 1.42). Descriptive analyses by category of respondent were conducted for respondents aged 2 or older who participated in the measured height and weight component. The main caloric sources that contributed to the difference in estimated energy requirements were used to show the impact of misreporting on the analysis.

RESULTS

The prevalence of under-reporters was 7.5% higher in 2015 compared with 2004, while the prevalence of over-reporters was 7.4% lower. There was no change in the prevalence of plausible reporters. Estimated energy intake from participants categorized as plausible reporters showed a difference of 84 kcal from 2004 to 2015, compared with a difference of 250 kcal for the entire sample. Estimated energy intake was lower in 2015 compared with 2004 across all categories of respondents for many foods, including sugar-sweetened beverages and milk, and was higher for only pastries and nuts.

DISCUSSION

Misreporting changes will affect analysis and should, at a minimum, be acknowledged when comparing 2015 with 2004. Using a comparable category of plausible reporters or adjusting for reporting status are options that will allow a better comparison of these two datasets.

Reallocating time between sleep, sedentary and active behaviours: Associations with obesity and health in Canadian adults

BACKGROUND

Moderate-to-vigorous physical activity (MVPA) and sleep are positively associated with adults' health, while the association with sedentary behaviour (SED) is negative. Light-intensity physical activity (LPA) is emerging as an independent predictor of improved cardiovascular health. The health impacts of each of these factors have been examined in isolation, but interest has increased in associations between health and movement behaviours collectively.

DATA AND METHODS

This analysis examines how reallocating time between movement behaviours is associated with obesity and with self-rated general and mental health. Data for 18- to 79-year-olds (n = 10,621) were collected from 2007 through 2015 as part of the Canadian Health Measures Survey. LPA, MVPA, and SED were measured using the Actical accelerometer. Body mass index (BMI) and waist circumference (WC) were directly measured. Sleep and general and mental health were self-reported.

RESULTS

Reallocation of 30 minutes from SED, LPA or sleep to MVPA was associated with a lower BMI and smaller WC, particularly for older and overweight/obese individuals. Time reallocation from SED to LPA was associated with lower BMI and smaller WC in respondents who were aged 50 or older or who were overweight/obese. Time reallocated from SED to any other movement behaviour was associated with decreased odds of reporting poor/fair rather than excellent general health. Time reallocation from SED to LPA or to sleep, but not to MVPA, was associated with decreased odds of reporting poor/fair rather than excellent mental health.

DISCUSSION

These findings confirm previous research indicating a strong association between MVPA and markers of obesity and health, particularly among older and overweight/obese individuals. This study also provides evidence that increasing LPA is an important health promotion message for these two subpopulations.

Overweight and obesity are associated with lower vitamin D status in Canadian children and adolescents

INTRODUCTION

There is evidence that 25-hydroxyvitamin D levels are lower in overweight and obese youth. This study examined the relationship between weight status and 25-hydroxyvitamin D, while controlling for confounders, in Canadian youth.

METHODS

Plasma 25-hydroxyvitamin D from subjects aged 6 to 17 years from the Canadian Health Measures Survey cycles 1 (2007 to 2009) and 2 (2009 to 2011) was used. Sex-specific multiple linear regression and logistic regressions examined the relationship of overweight and obesity (body mass index ≥ 85th percentile) with 25-hydroxyvitamin D levels and the odds of 25-hydroxyvitamin D <40 nmol/L and <50 nmol/L.

RESULTS

The prevalence of risk of vitamin D deficiency (25-hydroxyvitamin D < 30 nmol/L) was 6% (95% confidence interval [CI] 3.26% to 10.12%). Vitamin D inadequacy, estimated by levels <40 nmol/L, was 15% (95% CI 10.34% to 20.39%; 19% [95% CI 13.1 to 25.6] for teenagers). Seventy per cent (95% CI 63.59 to 75.17) had levels >50 nmol/L, consistent with achieving the Recommended Dietary Allowance. In adjusted analyses, overweight/obesity (1/3 of subjects) was independently associated with lower 25-hydroxyvitamin D for both sexes after adjustment for age, race, income, season, vitamin D supplementation and daily milk consumption. For 25-hydroxyvitamin D <40 nmol/L, the overweight/obese odds ratio for males was 2.63 (95% CI 1.34 to 5.18). For 25-hydroxyvitamin D <50 nmol/L, overweight/obese odds ratios were 2.19 (95% CI 1.46 to 3.28) for males and 1.39 (95% CI 1.05 to 1.84) for females.

CONCLUSIONS

This study confirms the inverse association between adiposity and serum concentrations of 25-hydroxyvitamin D in Canadian youth and the independent association of overweight/obesity to 25-hydroxyvitamin D level and vitamin D status after adjustment for other factors.

Physical activity of Canadian children and youth, 2007 to 2015

BACKGROUND

This study describes and compares the percentages of Canadian children and youth who adhere to different operational definitions of the moderate-to-vigorous physical activity (MVPA) recommendation of 60 minutes per day.

DATA AND METHODS

Data for 6- to 17-year-olds (n = 5,608) were collected from 2007 through 2015 as part of the Canadian Health Measures Survey. MVPA was measured using the Actical accelerometer. The MVPA recommendation was operationalized as accumulating 60 minutes of MVPA every day, on most days, and on average.

RESULTS

Data from the most recent cycle of the Canadian Health Measures Survey indicate that 7% of children and youth accumulated at least 60 minutes of MVPA on at least 6 out of 7 days, and 33% achieved a weekly average of at least 60 minutes per day. Boys accumulated more MVPA than did girls, and 6- to 11-year-olds accumulated more MVPA than did 12- to 17-year-olds. Regardless of how adherence to the recommendation is operationalized, MVPA levels among Canadian children and youth did not change over the 9-year period from 2007 to 2015.

INTERPRETATION

The majority of Canadian children do not meet the physical activity recommendation, regardless of the operational definition used. However, the discrepancies between results based on different interpretations of the 60-minutes-per-day recommendation highlight the importance of explicitly reporting how recommendations are operationalized to avoid misinterpreting trends and comparisons.

Outdoor time, physical activity and sedentary time among young children: The 2012-2013 Canadian Health Measures Survey

OBJECTIVES

Previous studies have shown that children who spend more time outdoors are more active and spend less time sedentary, but these studies were limited by the use of small convenience samples. We examined the relationship between outdoor time and measures of physical activity (PA), screen time and sedentary time in a nationally-representative sample of young children.

METHODS

Parental reports of outdoor time were obtained for 594 children aged 3-6 years (47.8% girls) who participated in the 2012-2013 Canadian Health Measures Survey. Participants were asked to wear an Actical accelerometer for seven consecutive days. Outdoor time and screen time were assessed by parent reports. The relationships between outdoor time and measures of PA, screen time and sedentary time were examined with linear regression models. Adherence to PA guidelines was estimated based on a betabinomial distribution, and adherence with the screen time guidelines was assessed through logistic regression models. All analyses were stratified by age group (3-4 and 5-6 year olds) and adjusted for sex, parental education and household income.

RESULTS

Among 5-6 year olds, each additional hour spent outdoors was associated with an additional 10 minutes of moderate-to-vigorous PA (95% CI: 6-14), 27,455 more accelerometer counts/day (95% CI: 11,929-42,980) and an increased likelihood of meeting the PA guidelines (OR = 2.53; 95% CI: 1.68-3.82). No significant relationships were observed among 3-4 year olds.

CONCLUSION

Outdoor time has a large effect on PA among 5-6 year olds at a population level. Future studies should examine the correlates of outdoor time to inform novel PA promotion interventions.

Outdoor time, physical activity, sedentary time, and health indicators at ages 7 to 14: 2012/2013 Canadian Health Measures Survey

BACKGROUND

International data show that the majority of children and youth are not sufficiently active. According to recent research, children who spend more time outdoors accumulate more daily moderate-to-vigorous physical activity and engage in less sedentary behaviour. However, the generalizability of these findings is uncertain, and few studies investigated whether outdoor time is associated with other physical and psychosocial health indicators.

DATA AND METHODS

This study examined associations between outdoor time and measures of physical activity, sedentary time, and physical and psychosocial health in a nationally representative sample of 7-to-14-year-olds (n = 1,159) who participated in the 2012/2013 Canadian Health Measures Survey. Physical activity and sedentary time were measured with Actical accelerometers. Direct measures of height, weight, waist circumference, grip strength, blood pressure, cholesterol, and glycohemoglobin were obtained. The Strengths and Difficulties Questionnaire was used to assess psychosocial health. Relationships between outdoor time and physical health measures were examined with multi-variable linear regression models adjusted for age, sex, parental education, and household income. Logistic regression models controlling for the same variables were used for psychosocial health.

RESULTS

Each additional hour spent outdoors per day was associated with 7.0 more minutes of moderate-to-vigorous physical activity, 762 more steps, and 13 fewer minutes of sedentary time. As well, each hour outdoors was associated with lower odds of negative psychosocial outcomes (specifically, peer relationship problems and total difficulties score). Outdoor time was not associated with any of the measures of physical health.

INTERPRETATION

Children reporting more time outdoors are more active, less sedentary, and less likely to have peer relationship problems, compared with those who spend less time outdoors.

Physical activity and sedentary behaviour of Canadian children aged 3 to 5

BACKGROUND

For preschool children, physical activity is associated with improved measures of health, while sedentary behaviour is associated with less favourable health outcomes. This study updates estimates of physical activity and sedentary behaviour among children aged 3 to 5, based on combined data from two cycles of the Canadian Health Measures Survey (CHMS) in order to calculate adherence to Canadian physical activity and sedentary behaviour guidelines.

DATA AND METHODS

The data are from two independent samples that comprised the 2009-to-2011 (cycle 2) and 2012/2013 (cycle 3) CHMS. Accelerometry and a parent-administered questionnaire were used in both cycles on children aged 3 to 5. Accelerometer data, collected in 60-second epochs in cycle 2 and in 15-second epochs in cycle 3, were combined using an adjustment factor derived in an independent sample. Prevalence of adherence to the physical activity guidelines, according to the accelerometer data, was estimated based on a Betabinomial distribution. Adherence to the screen-time component of the sedentary behaviour guidelines was calculated using parent reports. Results are presented by personal and household-related covariates.

RESULTS

An estimated 73% of 3- to 4-year-olds and 30% of 5-year-olds met their respective physical activity guidelines. Screen-time targets were met by 22% of 3- to 4-year-olds and 76% of 5-year-olds.

INTERPRETATION

Because they rely on a larger sample size and stronger estimation methods, the findings of this study are more robust than previously published estimates. Results reveal room for improvement, particularly 5-year-olds' physical activity and 3- to 4-year-olds' screen time.

Using a Betabinomial distribution to estimate the prevalence of adherence to physical activity guidelines among children and youth

BACKGROUND

Estimates of the prevalence of adherence to physical activity guidelines in the population are generally the result of averaging individual probability of adherence based on the number of days people meet the guidelines and the number of days they are assessed. Given this number of active and inactive days (days assessed minus days active), the conditional probability of meeting the guidelines that has been used in the past is a Beta (1 + active days, 1 + inactive days) distribution assuming the probability p of a day being active is bounded by 0 and 1 and averages 50%. A change in the assumption about the distribution of p is required to better match the discrete nature of the data and to better assess the probability of adherence when the percentage of active days in the population differs from 50%.

DATA AND METHODS

Using accelerometry data from the Canadian Health Measures Survey, the probability of adherence to physical activity guidelines is estimated using a conditional probability given the number of active and inactive days distributed as a Betabinomial(n, a + active days , β + inactive days) assuming that p is randomly distributed as Beta(a, β) where the parameters a and β are estimated by maximum likelihood.

RESULTS

The resulting Betabinomial distribution is discrete. For children aged 6 or older, the probability of meeting physical activity guidelines 7 out of 7 days is similar to published estimates. For pre-schoolers, the Betabinomial distribution yields higher estimates of adherence to the guidelines than the Beta distribution, in line with the probability of being active on any given day.

INTERPRETATION

In estimating the probability of adherence to physical activity guidelines, the Betabinomial distribution has several advantages over the previously used Beta distribution. It is a discrete distribution and maximizes the richness of accelerometer data.

Canadian Pediatric Weight Management Registry (CANPWR): baseline descriptive statistics and comparison to Canadian norms

BACKGROUND

A pilot study was conducted to assess the feasibility of establishing a multi-site CANadian Pediatric Weight management Registry (CANPWR) containing individual, family and weight management program information.

METHODS

Standardized baseline data were collected to characterize CANPWR participants (n = 310) in comparison to a sample of age-matched Canadian children measured in the nationally representative Canadian Health Measures Survey (CHMS; n = 3,788). This study compared demographic, anthropometric, cardiometabolic and lifestyle characteristics of participants (aged 6-17 years) in the CANPWR pilot study with those from the CHMS.

RESULTS

Compared to CHMS respondents, CANPWR participants had higher BMI z-score, waist circumference, blood pressure, total cholesterol, LDL cholesterol, triglycerides and fasting glucose, and lower HDL cholesterol. They reported lower sugared drink consumption, were more likely to be non-white and had parents with lower education.

CONCLUSIONS

The CANPWR cohort represents a group that has biological and behavioral profiles that place them at increased health risk and who differ significantly from typical Canadians of the same age.

Comparison of Physical Activity Adult Questionnaire results with accelerometer data

BACKGROUND

Discrepancies between self-reported and objectively measured physical activity are well-known. For the purpose of validation, this study compares a new self-reported physical activity questionnaire with an existing one and with accelerometer data.

DATA AND METHODS

Data collected at one site of the Canadian Health Measures Survey in 2013 were used for this validation study. The International Physical Activity Questionnaire (IPAQ) was administered to respondents during the household interview, and the new Physical Activity for Adults Questionnaire (PAAQ) was administered during a subsequent visit to a mobile examination centre (MEC). At the MEC, respondents were given an accelerometer to wear for seven days. The analysis pertains to 112 respondents aged 18 to 79 who wore the accelerometer for 10 or more hours on at least four days.

RESULTS

Moderate-to-vigorous physical activity (MVPA) measured by accelerometer had higher correlation with data from the PAAQ (r = 0.44) than with data from the IPAQ (r = 0.20). The differences between accelerometer and PAAQ data were greater based on accelerometer-measured physical activity accumulated in 10-minute bouts (30-minute difference in MVPA) than on all minutes (9-minute difference). The percentages of respondents meeting the Canadian Physical Activity Guidelines were 90% based on self-reported IPAQ minutes, 70% based on all accelerometer MVPA minutes, 29% based on accelerometer MVPA minutes accumulated in 10-minute bouts, and 61% based on self-reported PAAQ minutes.

INTERPRETATION

The PAAQ demonstrated reasonable validity against the accelerometer criterion. Based on correlations and absolute differences between daily minutes of MVPA and the percentages of respondents meeting the Canadian Physical Activity Guidelines, PAAQ results were closer to accelerometer data than were the IPAQ results for the study sample and previous Statistics Canada self-reported questionnaire findings.

Household Food Insecurity Is a Stronger Marker of Adequacy of Nutrient Intakes among Canadian Compared to American Youth and Adults

BACKGROUND

The most recent statistics indicate that the prevalence of food insecurity in the United States is double that in Canada, but the extent to which the nutrition implications of this problem differ between the countries is not known.

OBJECTIVE

This study was undertaken to compare adequacy of nutrient intakes in relation to household food insecurity among youth and adults in Canada and the United States.

METHODS

Data from comparable nationally representative surveys, the 2004 Canadian Community Health Survey and the 2003-2006 NHANES, were used to estimate prevalences of inadequate intakes of vitamins A and C, folate, calcium, magnesium, and zinc among youth and adults in food-secure and food-insecure households. Potential differences in the composition of the populations between the 2 countries were addressed by using standardization, and analyses also accounted for participation in food and nutrition assistance programs in the United States.

RESULTS

Larger gaps in the prevalences of inadequate intakes between those in food-secure and food-insecure households were observed in Canada than in the United States for calcium and magnesium. For calcium, the prevalences of inadequate intakes among those in food-secure and food-insecure households in Canada were 50% and 66%, respectively, compared with 50% and 51%, respectively, in the United States. For magnesium, the prevalences of inadequate intakes in Canada were 39% and 60% among those in food-secure and food-insecure households, respectively, compared with 60% and 61%, respectively, in the United States. These findings were largely unchanged after we accounted for participation in food and nutrition assistance programs in the United States.

CONCLUSIONS

This study suggests that household food insecurity is a stronger marker of nutritional vulnerability in Canada than in the United States. The results highlight the need for research to elucidate the effects of domestic policies affecting factors such as food prices and fortification on the nutritional manifestations of food insecurity.

A comparison of self-reported leisure-time physical activity and measured moderate-to-vigorous physical activity in adolescents and adults

BACKGROUND

Systematic reviews and results of Statistics Canada surveys have shown a discrepancy between self-reported and measured physical activity. This study compares these two methods and examines specific activities to explain the limitations of each method.

DATA AND METHODS

Data are from cycle 1 (2007 to 2009) and cycle 2 (2009 to 2011) of the Canadian Health Measures Survey. The survey involved an interview in the respondent's home and a visit to a mobile examination centre (MEC) for physical measurements. In a questionnaire, respondents were asked about 21 leisure-time physical activities. They were requested to wear an Actical accelerometer for seven days after the MEC visit. The analysis pertains to respondents aged 12 to 79 who wore the accelerometer for 10 or more hours on at least four days (n = 7,158).

RESULTS

Averages of self-reported leisure-time physical activity and moderate-to-vigorous physical activity measured by accelerometer were within a couple of minutes of each other. However, at the individual level, the difference between estimates could exceed 37.5 minutes per day in one direction or the other, and around 40% of the population met physical activity thresholds according to one measurement method, but not according to the other. The disagreement is supported by weak observed correlations.

INTERPRETATION

The lack of a systematic trend in the relationship between the two methods of measuring physical activity precludes the creation of correction factors or being confident in using one method instead of the other. Accelerometers and questionnaires measure different aspects of physical activity.

Physical activity and sedentary behavior during the early years in Canada: a cross-sectional study

BACKGROUND

Physical activity and sedentary behavior habits are established during early childhood, yet only recently has objectively measured data been available on children aged 5 years and younger. This study presents data on the physical activity and sedentary behaviors of Canadian children aged 3-5 years.

METHODS

Data were collected as part of the Canadian Health Measures Survey between 2009 and 2011. A nationally-representative sample (n = 459) of children aged 3-5 years wore Actical accelerometers during their waking hours for 7 consecutive days. Data were collected in 60-sec epochs and respondents with ≥4 valid days were retained for analysis. Parents reported their child's physical activity and screen time habits in a questionnaire.

RESULTS

Eighty-four percent of 3-4 year old children met the physical activity guideline of 180 minutes of total physical activity every day while 18% met the screen time target of <1 hour per day. Fourteen percent of 5 year old children met the physical activity guideline of 60 minutes of daily moderate-to-vigorous physical activity (MVPA) while 81% met the screen time target of <2 hours per day. Children aged 3-4 years accumulated an average of 352 min/d of total physical activity and 66 minutes of MVPA while 5 year old children accumulated an average of 342 min/d of total physical activity and 68 minutes of MVPA. Children were sedentary for approximately half of their waking hours and spent an average of 2 hours per day in front of screens. Only 15% of 3-4 year olds and 5% of 5 year olds are meeting both the physical activity and sedentary behavior guidelines.

CONCLUSIONS

Promoting physical activity while reducing sedentary behavior is important at all stages of life. The findings of the present study indicate that there remains significant room for improvement in these behaviors among young Canadian children.

The association between accelerometer-measured patterns of sedentary time and health risk in children and youth: results from the Canadian Health Measures Survey

BACKGROUND

Self-reported screen time is associated with elevated health risk in children and youth; however, research examining the relationship between accelerometer-measured sedentary time and health risk has reported mixed findings. The purpose of this study was to examine the association between accelerometer-measured patterns of sedentary time and health risk in children and youth.

METHODS

The results are based on 1,608 children and youth aged 6 to 19 years from the Canadian Health Measures Survey (2007-2009). Sedentary time was measured using the Actical accelerometer. Breaks in sedentary time and prolonged bouts of sedentary time lasting 20 to 120 minutes were derived for all days, weekend days and during the after-school period (i.e., after 3 pm on weekdays). Regression analyses were used to examine the association between patterns of sedentary time and body mass index (BMI), waist circumference, blood pressure and non-HDL cholesterol.

RESULTS

Boys accumulated more sedentary time on weekdays after 3 pm and had a higher number of breaks in sedentary time compared to girls. Overweight/obese boys (aged 6-19 years) accumulated more sedentary time after 3 pm on weekdays (282 vs. 259 min, p < .05) and as prolonged bouts lasting at least 80 minutes (171 vs. 133 min, p < .05) compared to boys who were neither overweight nor obese. Prolonged bouts of sedentary time lasting at least 80 minutes accumulated after 3 pm on weekdays were positively associated with BMI and waist circumference in boys aged 11-14 years (p < .006). Each additional 60 min of sedentary time after 3 pm on weekdays was associated with a 1.4 kg·m-2 higher BMI and a 3.4 cm higher waist circumference in 11-14 year old boys. No sedentary pattern variables differed between girls who were not overweight or obese and those who were overweight/obese and none of the sedentary pattern variables were associated with any health markers in girls.

CONCLUSIONS

The findings confirm results of other studies that reported accelerometer-measured sedentary time was not associated with health risk in children and youth. Even when the pattern and timing of sedentary time was examined relative to health markers, few associations emerged and were limited to boys aged 11-14 years.

Nutritional risk among older Canadians

BACKGROUND

Nutritional risk screening is typically done in clinical settings to identify individuals at risk of malnourishment. This article presents the first population-level assessment of nutritional risk based on a large national sample representative of Canadian householders aged 65 or older.

DATA SOURCES AND METHODS

Data from the 2008/2009 Canadian Community Health Survey-Healthy Aging were used to estimate the prevalence of nutritional risk by selected characteristics. Factors associated with nutritional risk were examined with restricted and full logistic models. The distribution of responses on the SCREEN II-AB nutritional risk instrument is reported.

RESULTS

Based on the results of the 2008/2009 survey, 34% of Canadians aged 65 or older were at nutritional risk. Women were more likely than men to be at risk. Among people with depression, 62% were at nutritional risk, compared with 33% of people without depression. Level of disability, poor oral health, and medication use were associated with nutritional risk, as were living alone, low social support, infrequent social participation, and not driving on a regular basis. Lower income and education were also associated with nutritional risk.

INTERPRETATION

Nutritional risk is common among seniors living in private households in Canada. The characteristics of people most likely to be at nutritional risk provide evidence for targeted screening and assessment.

Physical activity, sedentary behaviour and sleep in Canadian children: parent-report versus direct measures and relative associations with health risk

BACKGROUND

The accurate measurement of time devoted to physical activity, sedentary pursuits and sleep is difficult and varies considerably between surveys. This has implications for population surveillance and understanding how these variables relate to health.

METHODS

This sample of children (n = 878) was from the 2007 to 2009 Canadian Health Measures Survey. Moderate- to-vigorous physical activity (MVPA), sedentary behaviour and sleep duration were assessed using both a questionnaire and an accelerometer. This article compared parent-reported and directly measured physical activity, sedentary behaviour and sleep, and examined their associations, alone or in combination, with selected health markers in children aged 6 to 11.

RESULTS

According to parent reports, the children in this study had an average of 105 minutes of MVPA, 2.5 hours of screen time and 9.7 hours of sleep per day; accelerometers recorded 63 minutes of MVPA, 7.6 hours of sedentary time and 10.1 hours of sleep per day. MVPA, measured by parent-report or accelerometry, was significantly associated with body mass index. In a regression model, directly measured MVPA and sleep were significantly associated with body mass index, and directly measured MVPA was significantly associated with waist circumference. Parent-reported screen time approached a significant association with body mass index.

INTERPRETATION

Time estimates and associations with health markers varied between parent-reported and directly measured physical activity, sedentary behaviour and sleep in children. These differences are important to understand before the two measurement techniques can be used interchangeably in research and health surveillance.

Daily patterns of physical activity among Canadians

The 2007 to 2009 Canadian Health Measures Survey (CHMS) collected directly measured physical activity on seven consecutive days for a representative sample of the population aged 6 to 79. Based on the CHMS, half of the active minutes in a day are accumulated between 11:00 a.m. and 5:00 p.m. For children, the most active period is lunch-time (11:00 a.m. to 1:00 p.m.), and for teenagers aged 15 to 19, the after-school period (3:00 p.m. to 5:00 p.m.). Children and youth are more active on weekdays than on weekends. Active children and youth tend to accumulate more minutes of moderate-to-vigorous physical activity after school, whereas active adults do so at lunch time.

Bone health: osteoporosis, calcium and vitamin D

BACKGROUND

Osteoporosis is a bone disease that predisposes to fractures. Sufficient intake of calcium and vitamin D is recommended for prevention and treatment.

DATA AND METHODS

Based on 28,406 respondents aged 50 or older to the 2009 Canadian Community Health Survey (CCHS)--Healthy Aging, the population who reported being diagnosed with osteoporosis is profiled. Analysis of calcium and vitamin D intake is based on 10,879 respondents aged 50 or older to the 2004 CCHS--Nutrition. Frequencies, averages and cross-tabulations were produced to estimate the prevalence of diagnosed osteoporosis, dietary intake of calcium and vitamin D, the use of supplements, and total calcium and vitamin D intake. Associations between a diagnosis of osteoporosis and socio-economic, dietary and lifestyle factors were examined with multiple logistic regression.

RESULTS

In 2009, 19.2% of women and 3.4% of men aged 50 or older reported having been diagnosed with osteoporosis; the 2004 rates were similar. Age, sex and household income were associated with the probability of reporting osteoporosis. In 2004, based on dietary and supplement intake, 45% to 69% of the population aged 50 or older had inadequate intake of calcium, and 54% to 66% had inadequate intake of vitamin D.

INTERPRETATION

A large percentage of people aged 50 or older, particularly women, have osteoporosis. The prevalence of inadequate intake of calcium and vitamin D is relatively high.

Sugar consumption among Canadians of all ages

According to the 2004 Canadian Community Health Survey-Nutrition, Canadians consumed an average of 110 grams (26 teaspoons) of sugar a day, approximately 20% of their total energy intake. While over 30% of this sugar came from vegetables and fruit, 35% came from the "other" foods category, which consists of items such as soft drinks, salad dressings and candy. The top ten sources of sugar accounted for approximately 85% of daily sugar intake. Beverages (milk, fruit juice, fruit drinks and regular soft drinks) represented 44% of the sugar consumed by children and adolescents, and 35% of that consumed by adults. Diabetics' average sugar intake was less than that of non-diabetics, but at 17%, exceeded the recommended 10% cut-off of total daily calories.

Physical activity of Canadian adults: accelerometer results from the 2007 to 2009 Canadian Health Measures Survey

BACKGROUND

Rising obesity rates and declining fitness levels have increased interest in understanding what underlies these trends. This article presents the first directly measured data on physical activity and sedentary behaviour on a nationally representative sample of Canadians aged 20 to 79 years.

DATA AND METHODS

Data are from the 2007 to 2009 Canadian Health Measures Survey (CHMS). Physical activity was measured using accelerometry. Data are presented as time spent in sedentary, light, moderate and vigorous intensity movement as well as steps accumulated per day.

RESULTS

An estimated 15% of Canadian adults accumulate 150 minutes of moderate-to-vigorous physical activity (MVPA) per week; 5% accumulate 150 minutes per week as at least 30 minutes of MVPA on 5 or more days a week. Men are more active than women and MVPA declines with increasing age and adiposity. Canadian adults are sedentary for approximately 9.5 hours per day (69% of waking hours). Men accumulate an average of 9,500 steps per day and women, 8,400 steps per day. The 10,000-steps-per-day target is achieved by 35% of adults.

INTERPRETATION

Before the CHMS, objective measures of physical activity and sedentary behaviour were not available for a representative sample of Canadians. The findings indicate that 85% of adults are not active enough to meet Canada's new physical activity recommendation.

Physical activity of Canadian children and youth: accelerometer results from the 2007 to 2009 Canadian Health Measures Survey

BACKGROUND

Physical activity is an important determinant of health and fitness. This study provides contemporary estimates of the physical activity levels of Canadians aged 6 to 19 years.

DATA AND METHODS

Data are from the 2007 to 2009 Canadian Health Measures Survey. The physical activity of a nationally representative sample was measured using accelerometers. Data are presented as time spent in sedentary, light, moderate and vigorous intensity movement, and in steps accumulated per day.

RESULTS

An estimated 9% of boys and 4% of girls accumulate 60 minutes of moderate-to-vigorous physical activity on at least 6 days a week. Regardless of age group, boys are more active than girls. Canadian children and youth spend 8.6 hours per day-62% of their waking hours-in sedentary pursuits. Daily step counts average 12,100 for boys and 10,300 for girls.

INTERPRETATION

Based on objective and robust measures, physical activity levels of Canadian children and youth are low.

Combining nutrient intake from food/beverages and vitamin/mineral supplements

BACKGROUND

To calculate total intake of a nutrient and estimate inadequate intake for a population, the amounts derived from food/beverages and from vitamin/mineral supplements must be combined. The two methods Statistics Canada has suggested present problems of interpretation.

DATA AND METHODS

Data collected from 34,386 respondents to the 2004 Canadian Community Health Survey-Nutrition were used to compare four methods of combining nutrient intake from food/beverages and vitamin/mineral supplements: adding average intake from supplements to the 24-hour food/beverage recall and estimating the usual distribution in the population (Method 1); estimating usual individual intake from food? beverages and adding intake from supplements (Method 2); and dividing the population into supplement users and non-users and applying Method 1 or Method 2 and combining the estimates based on the percentages of users and non-users (Methods 3 and 4).

RESULTS

Interpretation problems arise with Methods 1 and 2; for example, the percentage of the population with inadequate intake of vitamin C and folate equivalents falls outside the expected minimum-maximum range. These interpretation problems are not observed with Methods 3 and 4.

INTERPRETATION

Interpretation problems that may arise in combining food and supplement intake of a given nutrient are overcome if the population is divided into supplement users and non-users before Method 1 or Method 2 is applied.

Folic acid fortification above mandated levels results in a low prevalence of folate inadequacy among Canadians

BACKGROUND

Understanding folate intakes after folic acid fortification of the food supply will help to establish dietary and supplement recommendations that balance health benefits and risks.

OBJECTIVES

The objectives were to estimate the prevalence of folate inadequacy (POFI) and intakes above the Tolerable Upper Intake Level (UL) among Canadians and to estimate the supplemental dose that, with diet, provides reproductive-aged women with 400 μg folic acid/d to prevent neural tube defects.

DESIGN

Twenty-four-hour recall and supplement (prior 30 d) data from the 2004 Canadian Community Health Survey (n = 35,107) were used to calculate the POFI and intakes above the UL with and without adjustment for fortification overages. POFI was also estimated by risk factors thought to be related to low folate intake. The Software for Intake Distribution Evaluation (SIDE program; Department of Statistics and Center for Agricultural and Rural Development, Iowa State University) was used to estimate usual dietary intakes in all analyses.

RESULTS

Except for women aged >70 y, POFI was <20% after adjustment for fortification overages. For children aged <14 y, POFI approached zero, even when supplement use was excluded. POFI among adults was unaffected by supplement use, except for women aged >70 y. Only 18% of reproductive-aged women consumed 400 μg folic acid/d from diet and supplements. Modeling showed that supplements containing 325-700 μg folic acid would provide adult women with 400 μg/d but not more than the UL. Diabetes was associated with POFI.

CONCLUSIONS

Innovative strategies are needed to ensure that the subgroups of Canadians who could still benefit from improved folate intake are targeted. Consideration should be given to removing folic acid from supplements designed for young children and men.

The effect of supplement use on vitamin C intake

According to results from the 2004 Canadian Community Health Survey-Nutrition, Canadians get an average of 132 milligrams of vitamin C a day from food. About one adult in five has inadequate dietary intake of vitamin C. A third of Canadians take vitamin C supplements, which add 100 milligrams to total average daily intake. Supplement use lowers the overall percentage of adults with inadequate intake by 5 percentage points to 17%. Smokers, people who eat fruit and vegetables infrequently, and members of households with low income and low educational attainment tend to have relatively low vitamin C intake.

Diet composition and obesity among Canadian adults

BACKGROUND

The contribution of specific nutrients to obesity has not been definitively established. The objective of this study was to determine if an association exists between obesity and the relative percentages of fats, carbohydrates, protein and fibre in the diets of Canadians.

DATA AND METHODS

The data are from the 2004 Canadian Community Health Survey--Nutrition. The analysis pertains to 6454 respondents aged 18 or older who provided valid 24-hour dietary recall information and measured height and weight, and whose reported energy intake was considered plausible based on their predicted energy expenditure. Logistic regression models with obesity status as the main outcome were conducted, controlling for potential confounders. All analyses were based on weighted estimates.

RESULTS

When the effect of the control variables was taken into account, total kilocalories consumed increased the odds of obesity in men, and fibre intake decreased the odds. Among women, only total kilocalories consumed was significantly associated with increased odds of obesity.

INTERPRETATION

Higher consumption of kilocalories increased the odds of obesity, but the relative amounts of fats, carbohydrates and protein were generally not significant. The sole exception was an association between higher fibre intake and lower rates of obesity among men.

Diet quality in Canada

BACKGROUND

In addition to recommendations about the consumption of specific foods and nutriens, a measure of overall diet quality is useful. Over the years, a number of countries, but not Canada, have developed indexes to evaluate diet quality.

DATA AND METHODS

The American Healthy Eating Index was adapted to conform to recommendations in Canada's Food Guide. Data from 33,664 respondents to the 2004 Canadian Community Health Survey-Nutrition were used. Usual index scores were calculated with the Software for Intake Distribution Estimation program. Multiple linear regression models were used to examine associations between index scores and various characteristics, particularly the frequency of vegetable and fruit consumption.

RESULTS

For the population aged 2 or older, the average score on the Canadian adaptation of the Healthy Eating Index in 2004 was 58.8 out of a possible 100 points. Children aged 2 to 8 had the highest average scores (65 or more). Average scores tended to fall into early adolescence, stabiilizing around 55 at ages 14 to 30. A gradual upturn thereafter brought the average score to around 60 at age 71 or older. At all ages, women's scores exceeded those of men. The frequency of vegetable and fruit consumption was linked to index scores.

INTERPRETATION

The American Healthy Eating Index can be adapted to Canadian food intake recommendations. Canadian Community Health Survey questions about the frequency of vegetable and fruit consumption can be used as an approximation of diet quality.

Impact of identifying plausible respondents on the under-reporting of energy intake in the Canadian Community Health Survey

BACKGROUND

Under-reporting is common in nutrition surveys. The identification of plausible respondents is a way of measuring the impact of under-reporting on the relationship between energy intake and body mass index (BMI).

DATA AND METHODS

A 24-hour dietary recall from 16,190 respondents aged 12 or older to the Canadian Community Health Survey (CCHS)--Nutrition was used to determine energy and nutrient intake. To identify plausible respondents, a confidence interval was applied to total energy expenditure derived from equations developed by the Institute of Medicine. Estimates of energy and nutrient intake for plausible respondents were compared with estimates for all respondents. Linear regression was used to demonstrate the impact of under-reporting on the relationship between reported energy intake and weight. Logistic regression was used to determine the impact of under-reporting on modelling the characteristics of obese people.

RESULTS

With a confidence interval of 70% to 142% around energy expenditure, 57% of CCHS respondents were identified as "plausible respondents". Nutrient under-reporting varied between 1% and 10%. Analysis based only on plausible respondents re-establishes the theoretical relationship between energy intake and body weight, a relationship that is lost when analysis is based on the full sample.

INTERPRETATION

Identifying plausible respondents is an effective way of measuring the impact of under-reporting food intake. Conclusions based on plausible respondents, rather than on all respondents, are more in line with theoretical expectations, such as a positive association between high energy intake and obesity.

Beverage consumption of Canadian adults

According to results from the 2004 Canadian Community Health Survey-Nutrition, total beverage consumption among adults declined steadily with age. This reflects drops in the percentage of adults consuming most beverages and in the amounts consumed. While water was the beverage consumed most frequently and in the greatest quantity by adults, for many of them, coffee ranked second. Largely as a result of drinking coffee, more than 20% of men and 15% of women aged 31 to 70 exceeded the recommended maximum of 400 milligrams of caffeine per day. About 20% of men aged 19 to 70 consumed more than two alcoholic drinks a day. Owing to declines in the consumption of soft drinks and alcohol, the contribution of beverages to adults' total calorie intake falls at older ages. Regardless of age, men were generally more likely than women to report drinking most beverages, and those who did, drank more. There were, however, a few exceptions, with higher percentages of women than men reporting that they drank water and tea.

Beverage consumption of children and teens

According to results from the 2004 Canadian Community Health Survey--Nutrition, children and teens get about one-fifth of their daily calories from beverages. As they get older, boys and girls drink less milk and fruit juice, and more soft drinks and fruit drinks. By ages 14 to 18, boys' average daily consumption of soft drinks matches their consumption of milk, and exceeds their consumption of fruit juice and fruit drinks. Beverage consumption by children and teens varies little by province, except in Newfoundland and Labrador where it tends to be comparatively high, and in British Columbia where it tends to be low.

Under-reporting of energy intake in the Canadian Community Health Survey

BACKGROUND

Under-reporting of food consumption is a recurrent challenge for nutrition surveys. Past research suggests that under-reporting tends to be most pronounced among overweight and obese people.

DATA AND METHODS

Data from 16,190 respondents to the 2004 Canadian Community Health Survey (CCHS 2.2)-Nutrition were used to estimate underreporting of food intake for the population aged 12 or older in the 10 provinces. Multiple linear regression models were used to assess the impact of different characteristics on underreporting.

RESULTS

Average under-reporting of energy intake was estimated at 10%. Under-reporting was greater among people who were overweight or obese, those who were physically active, adults compared with teenagers, and women compared with men.

INTERPRETATION

Under-reporting of energy intake is not random and varies by key health determinants. Awareness of the characteristics associated with under-reporting is important for users of nutrition data from the CCHS 2.2.

Obesity and the eating habits of the Aboriginal population

OBJECTIVES

This article compares rates of overweight/obesity and obesity and food consumption patterns of off-reserve Aboriginal and non-Aboriginal people aged 19 to 50 in Ontario and the western provinces. DATA SOURCES; The data are from the 2004 Canadian Community Health Survey: Nutrition (cycle 2.2).

ANALYTICAL TECHNIQUES

Cross-sectional analyses were used to estimate the percentages of individuals who were overweight/obese or obese and average nutrient consumption, based on Aboriginal identity and other selected characteristics. Logistic regression was used to determine the independent influence of Aboriginal identity on overweight/obesity and obesity.

MAIN RESULTS

In 2004, the overweight/obesity and obesity rates of off-reserve Aboriginal people aged 19 to 50 were higher than those of the non-Aboriginal population. These overall differences primarily reflected higher rates of overweight/obesity and obesity among Aboriginal women. At ages 19 to 30, these differences can partly be explained by higher calorie intake by Aboriginal women, despite identical energy needs, based on height, weight, age and physical activity. Most of the excess calories are eaten as snacks and come from "other foods".

Canadians' eating habits

OBJECTIVES

This report is an overview of Canadians' eating habits: total calories consumed and the number of servings from the various food groups, as well as the percentage of total calories from fat, protein and carbohydrates.

DATA SOURCES

The data are from the 2004 Canadian Community Health Survey (CCHS) - Nutrition. Published results from the 1970-1972 Nutrition Canada Survey were used for comparisons over time.

ANALYTICAL TECHNIQUES

An initial 24-hour dietary recall was completed by 35,107 people. Asubsample of 10,786 completed a second recall 3 to 10 days later. Data collected in the first interview day were used to estimate, by selected characteristics, average calorie intake and average percentages of calories from fat, protein and carbohydrates. Usual intake of macronutrients was estimated with the Software for Intake Distribution Estimation (SIDE) program, using data from both interview days.

MAIN RESULTS

Although a minimum of five daily servings of vegetables and fruit is recommended, 7 out of 10 children aged 4 to 8 and half of adults did not meet this minimum in 2004. More than a third of 4- to 9-year-olds did not have the recommended two daily servings of milk products. Over a quarter of Canadians aged 31 to 50 obtained more than 35% of their total calories from fat. Snacks account for more calories than breakfast, and about the same number of calories as lunch.