A 50th anniversary celebration of CSEP member contributions to the understanding of exercise physiology: a focus on physical activity and fitness epidemiology

November 17, 2017

The Canadian Society for Exercise Physiology will be celebrating its 50th anniversary in 2017. A signature initiative is a celebration of the contributions of Canadian researchers to exercise physiology over the past 50 years. The objective is to highlight significant Canadian contributors and their contributions to exercise physiology, health and fitness, nutrition and gold standard publications globally as well as provide insights on future research directions in these areas. These achievements have been organized into a series of short historical communiqués on prominent Canadian contributors and will be published on a monthly basis.

A 50th anniversary celebration of CSEP member contributions to the understanding of exercise physiology: a focus on physical activity and fitness epidemiology

Tremblay MS1, Katzmarzyk PT2, Colley RC3, Janssen I4

1HealthyActive living and Obesity Research Group, Children’s Hospital of EasternOntario Research Institute, Ottawa, ON

2Pennington Biomedical Research Center, Baton Rouge, LA, USA

3Health Analysis Division, Statistics Canada, Ottawa, ON

4School of Kinesiology and Health Studies and Department of Public Health Sciences, Queen’s University, Kingston, ON

Background

This brief historical review summarizes the contributions of Canadian Association of Sport Science (CASS) / Canadian Society for Exercise Physiology (CSEP) members and other Canadian researchers to the development and advancement of the field of physical activity and fitness epidemiology over the past 50 years (1967-2017). In the April Edition of the CSEP Communique a complementary review was published that summarized the contributions of CASS/CSEP members to the development of physical activity guidelines (Tremblay et al., 2017a). The present paper will lean on the earlier review to the extent that physical activity and fitness epidemiology is linked with the establishment of accepted guidelines to use as a benchmark.

A literature search was conducted in June of 2017 using a search of key terms in the PubMed database. The following combination of search terms was used in the search: ((physical activity OR exercise OR physical fitness) AND (levels OR prevalence OR monitoring OR surveillance OR epidemiology OR incidence OR cohort OR case-control OR relative risk)). Specific filters were applied based on publication year to determine the number of search results on a per year basis. A second search was then conducted using the same filters, but using the following combination of search terms: ((physical activity OR exercise OR physical fitness) AND (levels OR prevalence OR monitoring OR surveillance OR epidemiology OR incidence OR cohort OR case-control OR relative risk) AND (Canada)). Results are presented in Figure 1. The disproportionate increase in recent decades is reflective of the dramatic increase in publications in these fields of research in recent years. It is also interesting to note that the proportion of the global total that contributed from Canada has increased over time.

1967-1976

As mentioned in the earlier CSEP 50th Anniversary review (Tremblay et al., 2017a), initial work by Bill Orban (creating the 5BX and 10BX programs; Royal Canadian Air Force, 1961; 1962) and Roy Shephard (hosting the International Symposium on Physical Activity and Cardiovascular Health in Toronto in 1966; Shephard, 1967; 2016), helped provide the foundation for what would later become the sub-specialty of physical activity epidemiology. Similarly, the development of the Canadian Home Fitness Test by Don Bailey, Roy Shephard and Bob Mirwald (Bailey et al., 1976), and early fitness surveys (Canadian Association for Health, Physical Education and Recreation, 1966; Howell and MacNab, 1968; Manitoba Department of Education, 1980) contributed to the establishment of normative data for various measures of fitness, facilitating future research in fitness epidemiology.

During these early years, the landmark Trois Rivières Physical Education Study (1970-77; Shephard et al., 1977; 1980; 1982; 1984; Shephard and Trudeau, 2005; Trudeau et al., 1999), led by Hugues Lavallée and Roy Shephard, was initiated. In this study Shephard and colleagues provided a curricular modification to assess the effects of significantly increasing the proportion of curricular time allocated to physical education. The experimental group received one hour of physical education training every day whereas the control group received the normal curriculum of 40 minutes of physical education per week. The intervention lasted for six years (from grade one to six) and both the experimental and control groups were selected from the same schools and exposed to the same teachers (preceding and succeeding years). The authors found an overall improvement in academic attainment in the experimental group despite a curtailment of academic curriculum. Shephard et al. (1977) also demonstrated significant improvements in the maximal oxygen intake, physical working capacity, and muscular strength of children (males and females) in the experimental group compared to the controls. Of tremendous importance was the report by Trudeau et al. (1999) indicating that those children exposed to the intervention program in the early 1970s remained much more active after the intervention when compared to a comparable cohort drawn from the Health Quebec Survey. Their conclusion was that daily physical education at the primary school level can have a long-term positive effect on exercise habits and attitudes.

Between 1970-72, the Nutrition Canada Survey (1973) was completed, and while the focus was on nutrition, several direct measures of anthropometry were collected and this helped bring attention to the importance of the monitoring and surveillance of population indicators of healthy active living and healthy body weights.

1977-1986

Not long after the Nutrition Canada Survey, in 1978-79, the Canada Health Survey was undertaken by Statistics Canada to collect not only measures of anthropometry (height, weight, upper arm length, arm midpoint, arm girth, upper arm skinfold) but also direct measures of blood pressure and cardiorespiratory fitness, the first such national information across all ages. See http://data.library.utoronto.ca/microdata/canada-health-survey-1978-1979 for details.

The Quebec Family Study (1978-2002; Bouchard et al., 1988; Perusse et al., 1988; Perusse et al., 1989) led by Claude Bouchard, was another landmark Canadian study that contributed significantly to our understanding of the genetic epidemiology of obesity, fitness and energy balance related behaviors (physical activity and dietary intake)(Chaput et al., 2014). The Quebec Family Study was a longitudinal investigation with three waves of data collection between 1979 and 2002, and has contributed close to 300 scientific papers to the published literature. Results from this study have highlighted the genetic contributions to physical activity, dietary intake, obesity and physical fitness, and led the field in identifying early genetic markers associated with these phenotypes.

In this decade the first CASS journal, the Canadian Journal of Applied Sports Sciences (1976-1986), was started, and was followed in sequence by the Canadian Journal of Sport Sciences (1987-1992), Canadian Journal of Applied Physiology (1993-2005), and Applied Physiology, Nutrition, and Metabolism (2006-2017). A listing of papers related to physical activity and fitness epidemiology that were published in the CASS/CSEP journals is provided in Appendix A and the temporal pattern seen is Figure 1 is evident again.

The Canadian Fitness and Lifestyle Research Institute (CFLRI) was established in 1980 as a national research organization focused on monitoring the physical activity levels of Canadians and sharing knowledge about the importance of leading healthy, active lifestyles (www.cflri.ca). In 1981 the CFLRI led the landmark Canada Fitness Survey (Canada Fitness Survey, 1983a; 1983b) with leadership from many CASS/CSEP members, notably Claude Bouchard, Gerry Glassford, Tom Stephens and Cora Craig. This nationally representative survey included 23,400 participants aged 7-69 years, and included both a questionnaire on health and lifestyle behaviours, and direct measures of physical fitness, including anthropometry, cardiorespiratory and musculoskeletal fitness (Canada Fitness Survey, 1982). The Canadian Home Fitness Test (Bailey et al., 1976) which over time evolved into the Canadian Standardized Test of Fitness (Fitness Canada, 1986) was used as the battery of tests for the Canada Fitness Survey. These test batteries would be the basis of many theses and physical fitness monitoring and surveillance efforts during this time period.

Through the 1980s Canadian sport scientist and CASS/CSEP member Luc Léger developed and popularized the 20 meter shuttle run test (known by many as the “beep test”; Léger and Lambert, 1982; Léger et al., 1984; 1988; Gadoury and Léger, 1986; Léger and Gadoury, 1989). This test has been adopted, adapted and renamed by researchers and test batteries throughout the world and is the most widespread and popular field test of cardiorespiratory fitness in the world (Tomkinson et al., 2017). Recently Tomkinson et al. (2017) published international norms from the 20 meter shuttle run test based on data from 1,142,026 children and youth representing 50 countries. Using this large global dataset Canadian researchers Justin Lang, Mark Tremblay and Luc Léger and colleagues published additional papers on the global variation in 20 meter shuttle run test performance (Lang et al., 2017a) and a comparison of criterion-referenced standards to assess what proportion of children and youth have healthy fitness levels (Lang et al., 2017b).

1987-1996

In this decade the International Conference on Exercise, Fitness and Health (1988) and International Conference on Physical Activity, Fitness and Health (1992) were hosted in Canada by Claude Bouchard, Roy Shephard, Barry McPherson, Norm Gledhill, Art Salmon, Art Quinney, and several other Canadian researchers (Bouchard et al., 1990; Bouchard et al., 1994). These conferences served to propel forward the global understanding and global research activity related to physical activity, fitness and health.

In 1988 the Campbell’s Survey on the Well-being of Canadians was conducted as a longitudinal follow-up to the Canada Fitness Survey (Stephens and Craig, 1990). This follow-up survey not only produced an update on the fitness of the nation, but established a robust database, along with the Canada Fitness Survey, for future physical activity and fitness epidemiology research.

Beginning in 1991 the CFLRI, in collaboration with ParticipACTION, began releasing “The Research File” (http://www.cflri.ca/art_page/140) as an ongoing series of research summaries featuring synthesized and interpreted scientific information about active lifestyles. The Research File summarizes research findings in the area of physical activity. In 1995 a series of 36 “Progress in Prevention” Bulletins were published by CFLRI (http://www.cflri.ca/pub_page/143) that helped to disseminate their findings in addition to The Research File summaries.

In 1996 the Canadian Physical Activity, Fitness, and Lifestyle Appraisal (CPAFLA) First Edition was published (Canadian Society for Exercise Physiology, 1996) and superseded the Canadian Standardized Test of Fitness (Fitness Canada, 1986) as the recommended battery of tests to assess the physical activity and fitness of Canadians. This new, more health-focused, assessment battery facilitated standardized training of fitness assessors using standardized measures for use by fitness appraisers, personal trainers and exercise physiologists, for individual prescriptions as well as for monitoring and surveillance of groups and populations.

The Health Behaviour in School-aged Children (HBSC) survey is a World Health Organization collaborative cross-national survey that started in 1983/84 with a handful of countries (Aarø et al., 1986). Canada first participated in the third cycle, which was in 1989/90. Canada has participated in every cycle, on a 4 year rotation, since the third cycle, for a total of 7 cycles. The most recent cycle, which was completed in 2013/14, included 47 countries (Freeman et al., 2016; Inchley et al., 2016). The HBSC provides nationally representative data (and in some cases provincially and territorial representative data) on physical activity and sedentary behaviours (e.g., screen time) among 11 to 15 year olds. It has also been used to highlight how the physical activity and sedentary behaviour levels of Canadian youth compare to youth from other countries (Janssen et al., 2005).

In 1996 The U.S. released the Surgeon General’s Report on Physical Activity and Health and Canadians Lawrence Brawley, Oded Bar-Or and Roy Shephard were important contributors and/or reviewers for this landmark document (U.S. Department of Health and Human Services, 1996).

Starting in 1994, a group of cancer epidemiologists at the University of Calgary, under the leadership of Drs. Christine Friedenreich and Kerry Courneya, started investigating the role of physical activity in the prevention and control of cancer (Friedenreich and Rohan, 1994; Friedenreich et al., 2001). They have conducted population-based case-control studies of lifetime physical activity and cancers of the breast, prostate and endometrium. Starting in the year 2002, they also published seminal work on the role of physical activity on individuals living with cancer and cancer survivors (Courneya et al., 2002). This group also conducted the first intervention trial of exercise for breast cancer prevention in Canada, the Alberta Physical Activity and Breast Cancer Prevention (ALPHA) Trial (Courneya et al., 2007). In this trial they found that exercise reduces endogenous estrogens, insulin resistance, adiposity and inflammation.

The National Population Health Survey (NPHS), conducted by Statistics Canada, was a longitudinal survey that started collecting data in 1994. The first three cycles (1994/1995, 1996/1997, and 1998/1999) were both cross-sectional and longitudinal, and the survey became strictly longitudinal in the fourth cycle (2000/2001). The NPHS collected self-reported information about physical activity which was used as an important baseline comparison to data that were collected later in other Statistics Canada surveys.

The National Longitudinal Survey of Children and Youth (NLSCY) was also initiated in 1994 by Statistics Canada and Human Resources and Skills Development Canada (HRSDC), formerly Human Resources Development Canada (HRDC). The NLSCY was a long-term study of Canadian children that followed their development and well-being from birth to adulthood. This survey has been used extensively to examine the inter-relationships between physical activity, sedentary behaviour, obesity, and health. While the NPHS and NLSCY are no longer in operation, they contributed substantially to physical activity epidemiology in Canada, with their nationally representative and longitudinal samples.

1997-2006

In 1997, the Canadian Federal–Provincial–Territorial Ministers responsible for sport, physical activity, and recreation endorsed the development of a national physical activity guide, and set a target to reduce the prevalence of physical inactivity in Canada by 10% by 2003, thus providing momentum and context for the launch of Canada’s first Physical Activity Guide in 1998 (Sharratt and Hearst, 2007). This guide provided a benchmark for assessing the physical activity level of Canadian adults (Health Canada and Canadian Society for Exercise Physiology, 1998), and subsequently older adults (Health Canada and Canadian Society for Exercise Physiology, 1999) and children and youth (Health Canada and Canadian Society for Exercise Physiology, 2002a; 2002b).

Also in 1997 the CFLRI benchmark monitoring officially began and physical activity and sport benchmark indicators were established to monitor progress and hold governments accountable for expenditures related to the outcomes and impacts achieved by the investment of public dollars in support of physical activity and sport. The monitoring program also provided information to guide the development of strategies to increase physical activity levels and sport participation rates. In 2002, the CFLRI began monitoring changes in the levels of these indicators over time. This new monitoring program was designed to help policy makers measure progress in increasing the population levels of physical activity and sport participation, provide information for setting policies and strategies for joint action, and monitor the results of implementation strategies and initiatives within the joint governmental framework (Federal, Provincial and Territorial Fitness and Recreation Committee, 1996). The Physical Activity and Sport Monitors (http://www.cflri.ca/physical-activity-and-sport-monitors-population-studies) have been repeated on a 5 year cycle since 1995 (for Physical Activity) and 2006 (for Sport). In this time period the CFLRI also initiated another important Canadian physical activity epidemiology survey; Canada’s Physical Activity Levels Among Youth (CANPLAY) Survey (http://www.cflri.ca/canplay). The CANPLAY survey examines physical activity levels of children and youth, aged 5 to 19 years objectively using pedometers to measure daily step counts. CANPLAY was the first nation-wide study of its kind, again demonstrating the vision and leadership of Canadian researchers. Since 2005, approximately 3,000 to 10,000 children and youth per year have been randomly selected from across Canada and invited to participate, yielding national, provincial and territorial level data. The tremendous contributions of the CFLRI to physical activity epidemiology has recently been summarized by Craig et al. (2017).

In 1991, the National Task Force on Health Information identified issues with the health information system in Canada which led to the Canadian Institute of Health Information, Statistics Canada, and Health Canada coming together to conceive the Canadian Community Health Survey (CCHS). The CCHS, initiated in 2001, is a large cross-sectional survey (sample approximately 130,000 per two year cycle, with health region level representative samples) that collects information on Canadians aged 12+ years about health status, health care utilization, and health determinants. The CCHS has been collecting self-reported physical activity data since its inception and implemented a new questionnaire module for physical activity and sedentary behaviour in 2015.

The Canadian Health Measures Survey (CHMS), initiated in 2007, is an ongoing survey conducted by Statistics Canada, in collaboration with the Public Health Agency of Canada and Health Canada, that collects health information via a household interview and direct physical measures at a mobile examination centre. Direct measures of physical activity (accelerometry), anthropometry (measured height and weight, skinfolds, waist circumference), and fitness (aerobic, musculoskeletal, flexibility) are collected (Tremblay et al., 2007c).

The nationally-representative physical activity data collected as part of the CCHS and CHMS have played an integral role in our understanding of the physical activity habits of Canadians. These data have been used extensively in several research publications (see next section 2007-2017) as well as important reports aimed at drawing attention to this public health issue (e.g., the Active Healthy Kids Canada/Participaction Report Card, see below).

In 2005, Active Healthy Kids Canada began producing an annual Report Card on the Physical Activity of Children and Youth in Canada (Colley et al., 2012; Tremblay et al., 2014a). These Report Cards (https://www.participaction.com/en-ca/thought-leadership/report-card/archive), synthesize the best available evidence from all sources to inform a series of grades following a published grading scheme, framework and benchmarks (Colley et al., 2012). The Report Cards have been released every year between 2005-2016 and have demonstrated success in influencing policy, practice and research (Tremblay et al., 2014a). The Report Cards have also influenced many other jurisdictions (see next section). In this time period there was a resurgence of interest in revisiting the 1981 Canada Fitness Survey as a baseline from which to develop longitudinal cohorts. In particular, the Canada Fitness Survey Mortality Follow-up Study and the Physical Activity Longitudinal Study (PALS) were developed. The Canada Fitness Survey Mortality Follow-up Study was established by linking the original participant data to the Canadian Mortality Database at Statistics Canada and this study has been used to examine the outcomes of all-cause and cause-specific mortality related to baseline levels of physical activity (Weller and Corey, 1998; Katzmarzyk and Craig, 2006), body weight status or adiposity (Katzmarzyk et al., 2001; Katzmarzyk et al., 2002; Katzmarzyk and Craig, 2006; Mason et al., 2008), musculoskeletal fitness (Katzmarzyk and Craig, 2002), self-rated health (Mason et al., 2007b), sitting (Katzmarzyk et al., 2009) and standing (Katzmarzyk, 2014). PALS (1981, 1988, 2002; Craig et al., 2005; Barnett et al, 2007; Katzmarzyk et al., 2007; Mason et al., 2007a; Brien et al., 2007; Barnett et al., 2008; Mason et al., 2007) was a 20-year follow-up of participants in the 1981 Canada Fitness Survey and 1988 Campbell’s Survey of Wellbeing. The primary aim of PALS was to describe the long-term patterns of physical activity among Canadians, and to also identify predictors of health outcomes associated with physical activity and fitness.

During this time period Canada continued to demonstrate leadership in the area of physical activity epidemiology by planning and hosting the International Conference on Physical Activity and Health Benefits: Dose Response Issues (2000), that was held at Hockley Valley, Ontario and attended by the leading experts around the world. This landmark conference summarized important dose-response issues concerning physical activity and health (Kesäniemi et al., 2001). The conference was led by the same “team” of Canadian scientists and volunteers that organized the 1988 and 1992 international conferences on physical activity, fitness and health (McPherson, 2001). Also during this decade faculty positions dedicated to physical activity epidemiology began to emerge.

For example, Peter Katzmarzyk’s faculty position at York University (1997) was among the first faculty positions that were specifically advertised as “physical activity epidemiology” in Canada. During the 1997-2006 timeframe the development of the first undergraduate and graduate courses and graduate degrees in physical activity epidemiology emerged in Canada.

A key epidemiological paper was published in 2003 that presented evidence from the NLSCY supporting the link between physical inactivity and obesity in Canadian children (Tremblay and Willms, 2003). Another study using data from the NLSCY demonstrated that a high number of physical education hours was predictive of becoming physically active while screen time decreased the odds (Perez, 2003).

2007-2017

In 2007 a special combined supplement of Applied Physiology, Nutrition, and Metabolism and the Canadian Journal of Public Health was published with 14 background papers designed to serve as foundation papers for an update to Canadian Physical Activity Guidelines (Tremblay et al., 2007a). These background papers included comprehensive reviews for all age groups (Janssen et al., 2007; Paterson et al., 2007; Timmons et al., 2007; Warburton et al., 2007), Canadians with a disability (Martin Ginis and Hicks, 2007) Aboriginal peoples (Young and Katzmarzyk, 2007). They also included papers that identified physical activity epidemiology limitations (Katzmarzyk and Tremblay, 2007) and opportunities for more comprehensive surveillance of movement behaviours (Esliger and Tremblay, 2007; Tremblay et al., 2007b). This background work led to the completion of systematic reviews being completed examining relationships between physical activity and health for young children aged 0-4 years (Timmons et al., 2012), children and youth aged 5-17 years (Janssen and LeBlanc, 2010), adults (Warburton et al., 2010) and older adults (Paterson and Warburton, 2010), which in turn led to the development of new Canadian Physical Activity Guidelines (Tremblay et al., 2011a; Tremblay et al, 2012a). The comprehensive development process employed by Canada led to new physical activity guideline development standards (Tremblay et al., 2010a; Tremblay and Haskell, 2012b), that were used to guide the United Kingdom (2011) and the World Health Organization (2010) physical activity guidelines, both using Mark Tremblay as a consultant.

Canada’s leadership in establishing physical activity benchmarks for use in epidemiology was not limited to apparently healthy populations. Canadian researchers developed physical activity guidelines for multiple sclerosis (Latimer-Cheung et al., 2013), Parkinson’s disease (Goodwin et al., 2008), and spinal cord injury (Ginis et al., 2011). Specific guidelines were also developed for pregnancy (Davies et al., 2003) and are currently being updated with leadership by Michelle Mottola and Margie Davenport.

Canada was also the first country to use a comprehensive guideline development process to develop separate and distinct public health guidelines for sedentary behaviour (LeBlanc et al., 2012; Tremblay et al., 2011b; Tremblay et al., 2011c; Tremblay et al., 2012c).

This guideline work was further extended recently to incorporate the full 24-hour period, integrating physical activity, sedentary behaviour and sleep (Carson et al., 2016a; Chaput et al., 2016; Poitras et al., 2016; Saunders et al., 2016; Tremblay et al., 2016a; Tremblay et al., 2016b). These guidelines were further informed by novel compositional analyses using Canadian Health Measures Survey data applied to the time constrained 24-hour period (Carson et al., 2016b), the first such analyses published on a pediatric population. These 24-hour integrated guidelines are the first in the world and are now being replicated in Australia and by the World Health Organization, with several other countries planning to take a similar approach to movement behaviour guidelines. Canadian 24-Hour Movement Guidelines for the Early Years (ages 0-4 years): An Integration of Physical Activity, Sedentary Behaviour, and Sleep will be released in the fall of 2017. The Canadian Society for Exercise Physiology is the copyright owner of the official Canadian Physical Activity/Sedentary Behaviour/24-Hour Guidelines (see http://www.csep.ca/home).

Nationally-representative surveys conducted by Statistics Canada have provided a wealth of information relating to the physical activity habits and fitness of Canadians. Data collected in the 2005 CCHS was used to show that just over half of Canadians aged 12+ years reported that they were at least moderately active during their leisure time (Gilmour, 2007). A comparison to 1996/1997 NPHS data showed that the proportion of Canadians reporting that they were at least moderately active had increased from 43% to 52% (Gilmour, 2007). The physical activity data from the CCHS has been extensively used to examine a range of important topics including (by not limited to): the role of physical activity in healthy aging, physical activity levels in specific ethnic and Aboriginal groups, physical activity levels in people with specific medical conditions, as well as the impact of neighbourhood characteristics on physical activity.

The NLSCY has been used to examine trajectories of participation in organized and unorganized physical activity from childhood to adolescence (Findlay et al., 2009; Findlay et al., 2010; Pabayo et al., 2011) as well as to examine participation characteristics in children with specific medical conditions (Arim et al., 2012).

Using data from the Canada Fitness Survey and the Canadian Health Measures Survey Canadian researchers were able to demonstrate significant and meaningful declines in the fitness of Canadian children and adults between 1981 and 2007-2009 (Craig et al., 2012; Shields et al., 2010; Tremblay et al., 2010b). Direct measures comparisons of the fitness levels of a nationally representative sample across a generation is highly unusual and a sign of the foresight and vision of Canadian researchers and surveillance leaders.

In 2011, for the first time in Canada, nationally-representative directly (or objectively) measured physical activity data were published for children and adults using data from the CHMS (Colley et al., 2010). These data demonstrated that only 7% of school-aged children and youth and 15% of adults were meeting physical activity guidelines (Colley et al., 2011a; Colley et al., 2011b). Since those initial publications, the accelerometer data set has been used extensively to develop analytical approaches (Colley et al., 2012; Wong et al., 2011), describe the nature of physical activity participation in Canadians aged 3 to 79 years (Colley et al., 2013; Garriguet and Colley 2012; Garriguet et al., 2016; Stone et al, 2013), compare direct measures of movement with questionnaire modules (Colley et al., 2012; Copeland et al., 2015; Garriguet et al., 2014; Garriguet et al., 2015), examine the impact of neighbourhood walkability on daily steps (Hajna et al., 2015), examine the impact of outdoor time on physical activity (Larouche et al., 2016a; Larouche et al., 2017), examine the association in physical activity levels between parents and children (Garriguet et al., 2017), and examine associations between movement and health (Carson et al., 2014; Carson et al., 2016; Carson et al., 2017; Colley et al., 2013; Janssen et al., 2013; Larouche et al., 2014; Larouche et al., 2016b; Rao et al., 2016). In collaboration with external Canadian experts (Mark Tremblay, Ian Janssen, Valerie Carson), two research analysts in the Health Analysis Division of Statistics Canada (Rachel Colley, Didier Garriguet) have played an important role in developing analytical procedures and publications using the accelerometer-measured data in the CHMS.

In the last decade the HBSC has continued to be used to provide nationally representative descriptive statistics on physical activity and other movement behaviours in Canadian youth in grades 6-10. Most recently, findings from the HBSC demonstrate that only 3% of Canadian youth meet the recommendations contained within Canada’s new 24-hour integrated guidelines (Janssen et al., 2017). More youth met recommendations for sleep duration (66%) than for moderate-to-vigorous physical activity (35%) and screen time (8%). A recent emphasis of the HBSC has been to examine how features of the built environment relate to a variety of physical activity and sedentary behaviours. This includes researching examining how connectivity of streets (Mecredy et al., 2011), crime and perceptions of safety (Janssen, 2014), and green space correlate with physical activity (Janssen and Rosu, 2015).

Between September 2011 and December 2013 data were collected in 12 countries with diverse geography, climate, inequality and Human Development Indices on >7,000 9-11 year-old children for the International Study of Childhood Obesity, Lifestyle, and the Environment (ISCOLE)(Katzmarzyk et al., 2013). The overall ISCOLE study was led by Peter Katzmarzyk and the Canadian site was led by Mark Tremblay and Jean-Philippe Chaput. This unique study, with participating countries from very high, high, middle and low income countries was heavily influenced by Canadian researchers and the study to date has led to >70 peer-reviewed publications.

Exercise is Medicine® (EIM) was launched in 2007 by the American College of Sports Medicine. In 2002, under the leadership of CSEP, Exercise is Medicine® Canada was initiated. The primary goal of Exercise is Medicine® Canada (EIMC) is to increase the number of health care professionals who assess, counsel, and prescribe physical activity in their patients. EIMC programs are based on epidemiological evidence demonstrating that physical activity reduces the risk of several chronic disease and premature mortality. EIMC therefore provides a bridge between epidemiological evidence and clinical practice.

The COMPASS study is another large Canadian Study designed to contribute to physical activity epidemiology in Canada. This nine-year study (started in 2012-13) funded by the Canadian Institutes of Health Research (CIHR) and Health Canada examines health behaviours of students annually in grades 9-12. It is being conducted by researchers at the University of Waterloo in collaboration with researchers at the University of Alberta, the University of British Columbia, and the University of Toronto. COMPASS tracks changes made to the school’s health policies and programs over time and each year participating schools receive a detailed feedback report, including evidence-based recommendations for health policy and program improvement. Details are available on the COMPASS website at https://uwaterloo.ca/compass-system/compass-system-projects/compass-study.

In 2013, CSEP launched the Physical Activity Training for Health (PATH) which was the result of an overhaul and update of the 2003 CPAFLA. The intent of this product was to provide an evidence-based resource for exercise professionals (CSEP Certified Personal Trainers and CSEP Certified Exercise Physiologists). New validated questionnaire modules were included in PATH to estimate physical activity levels and to identify people who are meeting the current physical activity guideline (Fowles et al., 2017).

The success of the Canadian Report Cards on the Physical Activity of Children and Youth (Tremblay et al., 2014a) had an influence internationally. As awareness of the Report Card process and success increased, enquiries from countries around the world to replicate the process in their country began to arrive. To accommodate and exploit this reality, in 2014 Canada hosted a Global Summit on the Physical Activity of Children (Tremblay, 2014) where 15 countries including Canada simultaneously released country Report Cards using a harmonized process and yielding what was called the Global Matrix of grades (Tremblay et al., 2014b). In 2016 the Global Matrix 2.0 was released with 38 participating countries (Tremblay et al., 2016c). This process not only serves to consolidate physical activity epidemiology information within jurisdictions, but also serves to stimulate research and build capacity for research within participating countries. It is interesting to note that there have been changes in the Canadian grades over the 12 years of doing the Report Card (Barnes and Tremblay, 2016).

With the use of direct measures of physical activity and sedentary behavior using accelerometry becoming routine for population surveillance, Canadian researchers Roy Shephard and Catrine Tudor-Locke recently published a book specifically looking at the contributions of accelerometry to epidemiology, exercise science and rehabilitation (Shephard and Tudor-Locke, 2016).

Canadian researchers Mark Tremblay, Travis Saunders and Joel Barnes were responsible for the creation of the Sedentary Behaviour Research Network (SBRN, www.sedentarybehaviour.org) in response to the growing research in the field of sedentary physiology. SBRN has over 1100 members from around the world and has produced two influential papers (SBRN, 2012; Tremblay et al., 2017b) designed to assist sedentary behavior epidemiological research by standardizing definitions for key terms used in sedentary behavior research. Coincidently, the first prospective cohort study to describe in detail the association between excessive sitting and mortality was based on analyses of the Canada Fitness Survey Mortality Follow-up Study (Katzmarzyk et al., 2009).

2018 and Beyond

Statistics Canada is committed to the continued inclusion of physical activity and sedentary behaviour in its annual CCHS questionnaire module.

Statistics Canada is committed to the continued measurement of physical activity and sedentary behaviour in every 2 year cycle of the CHMS using both questionnaire modules and accelerometry. Future cycles may examine 24-hour movement patterns, including sleep, using accelerometry.

·The Canadian Health Survey on Children and Youth (CHSCY) is currently under development by Statistics Canada, Health Canada, and the Public Health Agency of Canada. This new survey is designed to collect data on the health and well-being of Canadian children and youth aged 1 to 17 years. The survey will provide detailed information at the national and provincial/territorial levels. The survey will include many measures to help understand many physical and mental health issues currently facing Canadian children and youth. The survey is currently at the pilot stage of development. A pedometer measure of physical activity was included in the pilot phase of the survey.

·The HBSC is a flagship project of the Division of Childhood and Adolescents of the Public Health Agency of Canada and the Agency continues to support this survey.Data collection for the 2017/18 cycle will begin within the next 6 months.

Report Cards on the Physical Activity of Children and Youth will continue to be published by ParticipACTION every second year.

New 24-Hour Movement Guidelines for the Early Years will be released later in 2017 and similar guidelines for adults and older adults are planned in the years ahead.

Summary

In summary, for the past 50 years CASS/CSEP and other Canadian scientists have been influential in the development and advancement of the field of physical activity and fitness epidemiology in Canada and internationally. This subspecialty research area now provides important monitoring, surveillance, assessment and guidance on physical activity and public health.

Disclaimer

We apologize if we have missed other important events, papers or researchers who have contributed in a significant fashion to the development of the physical activity and fitness epidemiology movement in Canada, it was a challenge to contain the length of this article!

References

Aarø, L.E., Wold, B., Kannas, L., Rimpelä, M. Health behaviour in school-children. A WHO cross-national survey. Health Promo. Int. 1(1):17-33, 1986.

Arim, R.G., Findlay, L.C., Kohen, D.E. Participation in physical activity for children with neurodevelopmental disorders. Int. J. Pediatr. 2012:460384, 2012.

Bailey, D., Shephard, R.J., Mirwald, R. Validation of a self-administered test of cardio-respiratory fitness. Can. J. Appl. Sport Sci. 1:67-78, 1976.

Barnes, J., Tremblay, M.S. Changes in indicators of child and youth physical activity in Canada, 2005-2016. Can. J. Public Health 107(6):e586-e589, 2016.

Barnett, T.A., Gauvin, L., Craig, C.L., Katzmarzyk, P.T. Modifying effects of sex, age, and education on 22-Year trajectory of leisure-time energy expenditure in a Canadian cohort. J. Phys Act Health 4:153-166, 2007.

Barnett, T.A., Gauvin, L., Craig, C.L., Katzmarzyk, P.T. Distinct trajectories of leisure time physical activity in adults and predictors of trajectory class membership: a 22 year cohort study. Int J Behav Nutr Phys Act 5:57 (E-Pub), 2008.

Bouchard, C., Pérusse, L., Leblanc, C., Tremblay, A., Thériault, G. Inheritance of the amount and distribution of human body fat. Int. J. Obes. 12:205–15, 1988.

Bouchard, C., Shephard, R.J., Stephens, T., Sutton, J.R., and McPherson, B.D. (Editors). Exercise, fitness, and health: a consensus of current knowledge. Human Kinetics, Champaign, Ill., 1990.

Brien, S., Katzmarzyk, P.T., Craig, C.L., Gauvin, L. Physical activity, cardiorespiratory fitness and body mass index as predictors of substantial weight gain and obesity: The Canadian Physical Activity Longitudinal Study. Can. J. Public Health 98:121-124, 2007.

Canada Health Survey. The Health of Canadians: Report of the Canada Health Survey (Statistics Canada, Catalogue 82-538) Ottawa: Health and Welfare Canada/Statistics Canada, 1981.

Canada Fitness Survey. Canada’s Fitness: Preliminary findings of the 1981 survey. Ottawa, Canada Fitness Survey, 1982.

Canada Fitness Survey. A User’s Guide to CFS Findings. Ottawa: Canada Fitness Survey, 1983a.

Canada Fitness Survey. Fitness and lifestyle in Canada. Ottawa: Canada Fitness Survey, 1983b.

Canadian Association for Health, Physical Education and Recreation. The CAHPER Fitness-Performance Test Manual for boys and girls 7 to 17 years of age. CAHPER, 1966.

Canadian Society for Exercise Physiology (CSEP). The Canadian Physical Activity, Fitness and Lifestyle Approach (CPAFLA) First Edition. Ottawa, Canada: Canadian Society for Exercise Physiology, 1996.

Carson, V., Wong, S.L., Winkler, E., Healy, G.N., Colley, R.C., Tremblay, M.S. Patterns of Sedentary Time and Cardiometabolic Risk among Canadian Adults. Prev. Med. 65:23-27, 2014.

Carson, V., Tremblay, M.S., Chaput, J-P., Chastin, S.F.M. 2016b. Associations between sleep duration, sedentary time, physical activity, and health indicators among Canadian children and youth using compositional analyses. Appl. Physiol. Nutr. Metab. 41(6 suppl.3):S294-S302, 2016a.

Carson, V., Hunter, S., Kuzik, N., Gray. C.E., Poitras, V.J., Chaput, et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth: an update. Appl. Physiol. Nutr. Metab. 41(6 suppl.3):S240-S265, 2016b.

Carson, V., Chaput, J.P., Janssen, I., Tremblay, M.S. Health associations with meeting new 24-hour movement guidelines for Canadian children and youth. Prev.Med. 95:7-13, 2017.

Chaput, J.-P., Gray, C.E., Poitras, V.J., Carson, V., Gruber, R., Olds, T., et al. Systematic review of the relationships between sleep duration and health indicators in school-aged children and youth. Appl. Physiol. Nutr. Metab. 41:S266-S282, 2016.

Chaput, J.-P., Perusse, L., Despres, J.-P., Tremblay, A., Bouchard, C. Findings from the Quebec Family Study on the etiology of obesity: Genetics and environmental highlights. Curr. Obes. Rep. 4(3):54-66, 2014.

Colley, R.C., Brownrigg, M., Tremblay, M.S. The Active Healthy Kids Canada Report Card on Physical Activity for Children and Youth. Health Promot. Pract. 13(3):320–330, 2012.

Colley, R.C., Connor Gorber, S., Tremblay, M.S. Quality control and data reduction procedures for accelerometry-derived measures of physical activity. Health Rep. 20(4):63-69, 2010.

Colley, R.C., Garriguet, D., Adamo, K.B., Carson, V., Janssen, I., Timmons, B.W., Tremblay, M.S. Physical activity and sedentary behaviour during the early years in Canada: a cross-sectional study. Int. J. Behav. Nutr. Phys. Act. 10:54, 2013.

Colley, R.C., Garriguet D., Janssen I., Craig C.L., Clarke J., Tremblay M.S. Physical activity of Canadian adults: Accelerometer results from the 2007-2009 Canadian Health Measures Survey. Health Rep. 22(1): 7-14, 2011a.

Colley, R.C., Garriguet D., Janssen I., Craig C.L., Clarke J., Tremblay M.S. Physical activity of Canadian adults: Accelerometer results from the 2007-2009 Canadian Health Measures Survey. Health Rep. 22(1):15-23, 2011b.

Colley, R.C., Garriguet, D., Janssen, I., Wong, S.L., Saunders, T.J., Carson, V., Tremblay, M.S. The association between accelerometer-measured patterns of sedentary time and health risk in children and youth: a cross-sectional study. BMC Public Health.13: 200, 2013.

Colley, R.C., Janssen, I., Tremblay, M.S. Daily step count target to measures adherence to physical activity guidelines in children. Med. Sci. Sports. Exerc. 44(5):977-982, 2012.

Colley, R.C., Wong, S.L., Garriguet, D., Janssen, I., Connor Gorber, S., Tremblay, M.S. Physical activity, sedentary behaviour and sleep in Canadian children: A comparison between parent-report and accelerometry measures and their relative association with health outcomes. Health Rep. 23(2):1-9, 2012.

Copeland, J.L., Clarke, J., Dogra, S. Objectively measured and self-reported sedentary time in older Canadians. Prev. Med. Rep. 2:90-95, 2015.

Courneya, K.S., Friedenreich, C.M., Sela, R.A., Quinney, H.A., Rhodes, R.E. Correlates of adherence and contamination in a randomized controlled trial of exercise in cancer survivors: an application of the theory of planned behavior and the five factor model of personality. Ann. Behav. Med. 24(4):257-268, 2002.

Courneya, K.S., Segal, R.J., Mackey, J.R., Gelmon, K., Reid, R.D., Friedenreich, C.M., Ladha, A.B., Proulx, C., Vallance, J.K., Lane, K., Yasui, Y., McKenzie, D.C. Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J. Clin. Oncol. 25(28):4396-4404, 2007.

Craig CL, Shields M, LeBlanc AG, Tremblay MS. Trends in aerobic fitness among Canadian children and adults 1981 to 2007-2009: what can we conclude? Applied Physiology, Nutrition and Metabolism 37:511-519, 2012.

Craig, C.L., Cameron, C.A., Bauman, A. Utility of surveillance research to inform physical activity policy: an exemplar from Canada. J. Phys. Act. Health 14:229-239, 2017.

Craig, C.L., Gauvin, L., Cragg, S., Katzmarzyk, P.T., Stephens, T.M., Russell, S.J., Potvin, L., Keast, M., Bentz, L. Towards a social epidemiological perspective on physical activity and health: The aims, design, and methods of the Physical Activity Longitudinal Study (PALS). J. Phys. Act. Health 3:272-284, 2005.

Davies, G.A.L., Wolfe, L.A., Mottola, M.F., MacKinnon, C. Joint SOGC/CSEP Clinical Practice Guideline: Exercise in Pregnancy and the Postpartum Period. Can. J. Appl. Physiol. 28(3):329-341, 2003.

Esliger D.W., Tremblay, M.S. Physical activity and inactivity profiling: the next generation. Appl. Physiol. Nutr. Metab. 32(suppl.2E):S195-S207, 2007.

Federal, Provincial and Territorial Fitness and Recreation Committee. Physical Inactivity: A Framework for Action. Ottawa, ON: Health Canada, 1996.

Findlay, L.C., Garner, R.E., Kohen, D.E. Patterns of children’s participation in unorganized physical activity. Res. Q. Exerc. Sport. 81(2):133-142, 2010.

Findlay, L.C., Garner, R.E., Kohen, D.E. Children’s organization physical activity patterns from childhood into adolescence. J. Phys. Act. Health. 6(6):708-715, 2009.

Fitness Canada. Canadian Standardized Test of Fitness (CSTF) Operations Manual. Third Edition. Ottawa: Fitness and Amateur Sport, Government of Canada, 1986.

Fowles, J.R., O’Brien, M.W., Wojcik, W.R., d’Entremont, L., Shields, C.A. A pilot study: Validity and reliability of the CSEP-PATH PASB-Q and a new leisure time physical activity questionnaire to assess physical activity and sedentary behaviours. Appl. Physiol. Nutr. Metab. 42(6):677-680, 2017.

Freeman, J., King, M., Pickett, W. Editors. Health Behaviour in School-aged Children in Canada: Focus on Relationships. Public Health Agency of Canada, 2016.

Friedenreich, C.M., Rohan, T.E. Recreational physical activity and risk of benign proliferative epithelial disorders of the breast in women. Eur. J. Cancer Prev. 3(6):465-471, 1994.

Friedenreich, C.M., Bryant, H.E., Courneya, K.S. Case-control study of lifetime physical activity and breast cancer risk. Am. J. Epidemiol. 15;154(4):336-347, 2001.

Gadoury, C., Léger, L. Validité de l’épreuve de course navette de 20 m avec paliers de 1 minute et du Physitest canadien à 2 marches pour prédire le des adultes. Revue STAPS 7(13): 57-68, 1986.

Goodwin VA, et al. The effectiveness of exercise interventions for people with Parkinson’s Disease: a systematic review and meta-analysis. Movement Disorders 23(5):631-640, 2008.

Garriguet, D., Carson, V., Colley, R.C., Janssen, I., Timmons, T.W., Tremblay, M.S. Physical activity and sedentary behaviour of Canadian children aged 3 to 5. Health Rep. 27(9):14-23, 2016.

Garriguet, D., Colley, R.C. When are Canadians most (and least) active? Health Rep. 23(2):1-7, 2012.

Garriguet, D., Colley, R.C. A comparison of self-reported leisure-time physical activity and measured moderate to vigorous physical activity in adolescents and adults. Health Rep. 25(7):3-11, 2014.

Garriguet D., Tremblay, S., Colley, R.C. Comparison of physical activity adult questionnaire with accelerometer data. Health Rep. 26(7):11-17, 2015.

Gilmour, H. Physically active Canadians. Health Rep. 18(3):45-65, 2007.

Ginis, K.A. Martin, Hicks, A.L., Latimer, A.E., Warburton, D.E.R., Bourne, C., et al. The development of evidence-informed physical activity guidelines for adults with spinal cord injury. Spinal Cord 49:1088-96, 2011.

Hajna, S., Ross, N.A., Joseph, L., Harper, S., Dasgupta, K. Neighbourhood walkability, daily steps and utilitarian walking in Canadian adults. BMJ Open 5(11):e008964, 2015.

Health Canada and the Canadian Society for Exercise Physiology. Canada’s physical activity guide for healthy active living. Cat. no. H39-429/1998-1E. Health Canada. Ottawa, ON., Canada, 1998.

Health Canada and the Canadian Society for Exercise Physiology. 1999. Canada’s physical activity guide for older adults. Cat. no. H39-429/1999-1E. Health Canada. Ottawa, ON., Canada.

Health Canada and the Canadian Society for Exercise Physiology. Canada’s physical activity guide for youth. Cat. no. H39-611/2002-1E. Minister of Public Works and Government Services Canada. Ottawa, ON., Canada, 2002a.

Health Canada and the Canadian Society for Exercise Physiology. Canada’s physical activity guide for children. Cat. no. H39-611/2002-2E. Minister of Public Works and Government Services Canada. Ottawa, ON., Canada, 2002b.

Inchley, J., Currie, D., Young, T., Samdal, O., Torsheim, T., Augustson, L., Mathison, F., Aleman-Diaz, A., Molcho, M., Weber, M., Barnekow, V. Editors. Growing up unequal. HBSC 2016 study (2013/2014 survey). World Health Organization, 2016.

Janssen, I., Katzmarzyk, P.T., Boyce, W.F., Vereecken, C., Mulvihill, C., Roberts, C., Currie, C., Pickett, W. Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obes. Rev. 6(2):123-132, 2005.

Janssen, I. Physical activity guidelines for children and youth. Appl. Physiol. Nutr. Metab. 32(Suppl. 2E):S109-S121, 2007.

Janssen, I., LeBlanc, A.G. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int. J. Behav. Nutr. Phys. Act. 7:40, 2010.

Janssen, I., Wong, S.L., Colley, R.S., Tremblay, M.S. The fractionalization of physical activity throughout the week is associated with the cardiometabolic health of children and youth. BMC Public Health 13:554, 2013.

Janssen, I. Crime and perceptions of safety in the home neighborhood are independently associated with physical activity among 11-15 year olds. Prev. Med. 66:113-117, 2014.

Janssen, I., Rosu, A. Undeveloped green space and free-time physical activity in 11 to 13-year-old children. Int. J. Behav. Nutr. Phys. Act. 12:26, 2015.

Janssen, I., Roberts, K.C., Thompson, W. Adherence to the 24-Hour Movement Guidelines among 10 to 17-year-old Canadians. Health Promo. Chronic Dis. Prev. Can. 2017; in press.

Katzmarzyk, P.T. Standing and mortality in a prospective cohort of Canadian adults. Med. Sci. Sports Exerc. 46:940-946, 2014.

Katzmarzyk, P.T., Craig, C.L. Musculoskeletal fitness and risk of mortality. Med. Sci. Sports Exerc. 34:740-744, 2002.

Katzmarzyk, P.T., Craig, C.L.. Independent effects of waist circumference and physical activity on risk of all-cause mortality in Canadian women. Appl. Physiol. Nutr. Metabol. 31:271-276, 2006.

Katzmarzyk, P.T., Craig, C.L., Bouchard, C. Underweight, overweight and obesity: Relationships with mortality in the 13-year follow-up of the Canada Fitness Survey. J. Clin. Epidemiol. 54:916-920, 2001.

Katzmarzyk, P.T., Craig, C.L., Bouchard, C. Adiposity, adipose tissue distribution and mortality. Int. J. Obes. Relat. Metabol. Disord. 26:1054-1059, 2002.

Katzmarzyk, P.T., Craig, C.L., Gauvin, L. Adiposity, physical fitness and incident diabetes: The Physical Activity Longitudinal Study. Diabetologia 50:538-544, 2007.

Katzmarzyk, P.T., Tremblay, M.S. Limitations of Canada’s physical activity data: implications for monitoring trends. Appl. Physiol. Nutr. Metab. 32(suppl.2E):S185-S194, 2007.

Katzmarzyk, P.T., Barreira, T.V., Broyles, S.T., Chamagne, C.M., Chaput, J.P., Fogelholm, M., et al. The international study of childhood obesity, lifestyle and the environment (ISCOLE): design and methods. BMC Public Health 13:900, 2013.

Katzmarzyk, P.T., Church, T.S., Craig, C.L., Bouchard, C Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med. Sci. Sports Exerc. 41:998-1005, 2009.

Katzmarzyk, P.T., Craig, C.L., Gauvin, L. Adiposity, physical fitness and incident diabetes: The Physical Activity Longitudinal Study. Diabetologia 50:538-544, 2007.

Kesäniemi, Y.A., Danforth, E., Jensen, M.D., Kopelman, P.G., Lefebvre, P., Reeder, B.A. Dose-response issues concerning physical activity and health: an evidence-based symposium. Med. Sci. Sports Exerc. 33:S351–S358, 2001.

Lang, J.J., Tremblay, M.S., Leger, L., Olds, T., Tomkinson, G.R. International variability in 20 m shuttle run performance in children and youth: who are the fittest from a 50-country comparison? A systematic literature review with pooling of aggregate results. Br. J. Sports Med. 2017a. (on-line ahead of print), DOI: 10.1136/bjsports-2016-096224.

Lang, J., Tremblay, M.S., Ortega, F., Ruiz, J., Tomkinson, G. Review of criterion-referenced standards for cardiorespiratory fitness: What proportion of 1 142 026 international children and youth are apparently healthy? Br. J. Sports Med. 2017b. (on-line ahead of print), doi: 10.1136/bjsports-2016-096955.

Larouche, R., Faulkner, G., Fortier, M., Tremblay, M.S. Active transportation and adolescents’ health: the Canadian Health Measures Survey. Am. J. Prev. Med. 46(5):507-515, 2014.

Larouche, R., Garriguet D., Gunnell, K.E., Goldfield, G.S., Tremblay, M.S. Outdoor time, physical activity, sedentary time, and health indicators at ages 7 to 14: 2012/2013 Canadian Health Measures Survey. Health Rep. 27(9):3-13, 2016a.

Larouche, R., Faulkner, G., Tremblay, M.S. Active travel and adults’ health: The 2007-to-2011 Canadian Health Measures Surveys. Health Rep. 27(4):10-18, 2016b.

Larouche, R., Garriguet, D., Tremblay, M.S. Outdoor time, physical activity and sedentary time among young children: The 2012-2013 Canadian Health Measures Survey. Can. J. Public. Health 107(6):e500-e506, 2017.

Latimer-Cheung, A.E., Martin Ginis, K., Hicks, A.L., Motl, R.W., Pilutti, L.A., Duggan, M., Wheeler, G., Persad, R., Smith, K.M. Development of evidence-informed Physical Activity Guidelines for Adults With Multiple Sclerosis. Arch. Phys. Med. Rehab. 94:1829-1836, 2013.

LeBlanc, A.G., Spence, J., Carson, V., Spence, J.C., Connor Gorber, S., Dillman, C., et al. Systematic review of the relationship between sedentary behaviour and health indicators in the early years (aged 0–4 years). Appl. Physiol. Nutr. Metab. 37:753–772, 2012.

Léger, L., Lambert, J. A maximal multistage 20-m shuttle run test to predict. Eur. J. Appl. Physiol. 49:1-12, 1982.

Léger, L., Lambert, J., Goulet, A., Rowan, C., Dinelle, Y. Capacité aérobie des Québécois de 6 à 17 ans – Test navette de 20 mètres avec paliers de 1 minute. Can. J. Appl. Spt. Sci. 9(2):64-69, 1984.

Léger, L.A., Mercier, D., Gadoury, C., Lambert, J. The multistage 20 m shuttle run test for aerobic fitness. J. Sports Sci. 6:93-101, 1988.

Léger, L., Gadoury, C. Validity of the 20 m shuttle run test with 1 min stages to predict in adults. Can. J. Sport Sci. 14(1):21-26, 1989.

Manitoba Department of Education. Manitoba Physical Fitness Performance Test Manual and Fitness Objectives for Manitoba Youth 5-18 years of age. Canadian Association for Health, Physical Education and Recreation, 1980.

Martin Ginis, K.A., Hicks, A.L. Considerations for the development of physical activity guide for Canadians with physical disabilities. Appl. Physiol. Nutr. Metab. 32(Suppl. 2E):S135–S147, 2007.

Martin Ginis, K.A., Hicks, A.L., Latimer, A.E., Warburton, D.E.R., Bourne, C., et al. The development of evidence-informed physical activity guidelines for adults with spinal cord injury. Spinal Cord 49:1088-1096, 2011.

Mason, C., Brien, S., Craig, C.L., Gauvin L, Katzmarzyk, P.T. Musculoskeletal fitness and weight gain in Canada. Med. Sci. Sports Exerc. 39:38-43, 2007a.

Mason, C., Katzmarzyk, P.T., Craig, C.L., Gauvin, L. Mortality and self-rated health in Canada. J. Phys. Act. Health 4:423-433, 2007b.

Mason, C., Craig, C.L., Katzmarzyk, P.T. Influence of central and extremity circumferences on all-cause mortality in men and women. Obesity 16:2690-2695, 2008.

Mason, C., Craig, C.L., Gauvin, L., Katzmarzyk, P.T. Opposing effects of waist and extremity circumferences on the risk of incident diabetes. Can. J. Diabetes 33:85-91, 2009.

McPherson, B.D. Preface. Med. Sci. Sports Exerc. 33 (6 Suppl.): S345-6, 2001.

Mecredy, G., Pickett, W., Janssen, I. Street connectivity is negatively associated with physical activity in Canadian youth. Int. J. Environ. Res. Public Health 8(8):3333-3350, 2011.

Nutrition Canada. Nutrition – A National Priority (Catalogue H58-36) Ottawa: Department of National Health and Welfare, 1973.

Pabayo, R., Gauvin, L., Barnett, T.A. Longitudinal changes in active transportation to school in Canadian youth aged 6 through 16 years. Pediatrics 128(2):e404-e413, 2011.

Paterson, D.H., Jones, G.R., Rice, C.L. Ageing and physical activity: evidence to develop exercise recommendations for older adults. Appl. Physiol. Nutr. Metab. 32(Suppl. 2E):S69-S108, 2007.

Paterson, D.H., Warburton, D.E.R. Physical activity and functional limitations in older adults: a systematic review related to Canada’s Physical Activity Guidelines. Int. J. Behav. Nutr. Phys. Act. 7: 38, 2010.

Perez, C.E. Children who become active. Health Rep. 14(Suppl):17-28, 2003.

Pérusse, L., Tremblay, A., Leblanc, C., Cloninger, C.R., Reich, T., Rice, J., Bouchard, C. Familial resemblance in energy intake: contribution of genetic and environmental factors. Am. J. Clin. Nutr. 47:629–35, 1988.

Pérusse, L., Tremblay, A., Leblanc, C., Bouchard, C. Genetic and environmental influences on level of habitual physical activity and exercise participation. Am. J. Epidemiol. 129:1012–22. 1989.

Poitras, V.J., Gray, C.E., Borghese, M.M., Carson, V., Chaput, J-P., Janssen, I., et al. Systematic review of the relationships between objectively measured physical activity and health indicators in school-aged children and youth. Appl. Physiol. Nutr. Metab. 41(6 suppl.3):S197-S239, 2016.

Rao, D.P., Orpana, H., Krewski, D. Physical activity and non-movement behaviours: their independent and combined associations with metabolic syndrome. Int. J. Behav. Nutr. Phys. Act. 13:26, 2016.

Royal Canadian Air Force. 5BX Plan for Physical Fitness. Queen’s Printer, 1961.

Royal Canadian Air Force. XBX Plan for Physical Fitness. Queen’s Printer, 1962.

Saunders, T.J., Gray, C.E., Poitras, V.J., Chaput, J-P., Janssen, I., Katzmarzyk, P.T., et al. Combinations of physical activity, sedentary behaviour and sleep: relationships with health indicators in school-aged children and youth. Appl. Physiol. Nutr. Metab. 41(6 suppl.3):S283-S293, 2016.

Sedentary Behaviour Research Network. Letter to the Editor: Standardized use of the terms “sedentary” and “sedentary behaviours”. Appl. Physiol. Nutr. Metab. 37(3):540-542, 2012.

Sharratt, M.T., Hearst, W.E. Canada’s physical activity guides: background, process, and development. Appl. Physiol. Nutr. Metab. 32(Suppl. 2E):S9–S15, 2007.

Shephard, R.J. Guest Editor. Proceedings of the International Symposium on Physical Activity and Cardiovascular Health. Can. Med. Assoc. J. 96:695-915, 1967.

Shephard, R.J. The first fifty years: A personal perspective on the history of Canadian Exercise Physiology. CSEP Communique, September, 2013.

Shephard, R.J., Lavallee, H., Rajic, M., Jequier, J.C., Beaucage, C., LaBarre, R. Influence of added activity classes upon the working capacity of Quebec school children. In H. Lavallee and R.J. Shephard (Eds.) Frontiers of Activity and Child Health (pp. 237-245). Quebec City: Editions du Pelican, 1977.

Shephard, R., Jequier, J., Lavallee, H., LaBarre, R., Rajic, M. Habitual physical activity: Effects of sex, milieu, season, and required activity. J. Sports Med. Phys. Fitness 20:55-66, 1980.

Shephard, R.J., Volle, M., Lavallee, H., LaBarre, R., Jequier, J.C., Rajic, M. Curricular time for physical education? A controlled experiment in French Canada asks how much curricular time should be spent on physical education. J. Physical Ed. Rec. Dance 53:19-20, 28, 1982.

Shephard, R.J., Volle, M., Lavallee, H., LaBarre, R., Jequier, J.C., Rajic, M. Required physical activity and academic grades- a controlled study. In J. Ilmarinen and I. Valimaki (Eds.) Proceedings of the 10th Pediatric Work Physiology Symposium, Joutsa, Finland, 1981 (pp. 58-63). Berlin: Springer-Verlag, 1984.

Shephard, R.J., Trudeau, F. Lessons learned from the Trois-Rivières Physical Education Study: a retrospective. Pediatr. Exerc. Sci. 17:112-123, 2005.

Shephard, R.J., Tudor-Locke, C. (Eds.), The Objective Monitoring of Physical Activity: Contributions of Accelerometry to Epidemiology, Exercise Science and Rehabilitation. Springer Series on Epidemiology and Public Health, Springer International Publishing, Switzerland, 2016.

Shields, M., Tremblay, M.S., Laviolette, M., Craig, C.L., Janssen, I., Connor Gorber, S. Fitness of Canadian adults: Results from the 2007-2009 Canadian Health Measures Survey. Health Rep. 21(1):21-36, 2010.

Stephens, T., Craig, C.L. The Well-Being of Canadians: Highlights of the 1988 Campbell’s Survey. Ottawa: Canadian Fitness and Lifestyle Research Institute, 1990.

Stone, M.R., Faulkner, G.E., Buliung, R.N. How active are children in Toronto? A comparison with accelerometry data from the Canadian Health Measures Survey. Chronic. Dis. Inj. Can. 33(2):61-68, 2013.

Timmons, B.W., Naylor, P.-J., and Pfeiffer, K.A. Physical activity for pre-school children — how much and how? Appl. Physiol. Nutr. Metab. 32(Suppl. 2E):S122-S134, 2007.

Timmons, B.W., LeBlanc, A.G., Carson, V., Connor Gorber, S., Dillman, C., Janssen, I., et al. Systematic review of physical activity and health in the early years (aged 0-4 years). Appl. Physiol. Nutr. Metab. 37:773-792, 2012.

Tomkinson, G., Lang, J., Tremblay, M.S., Dale, M., LeBlanc, A., Belanger, K., Ortega, F., Léger, L. International normative 20 m shuttle run values from 1,142,026 children and youth representing 50 countries. Br. J. Sports Med. 2017. (on-line ahead of print), doi:10.1136/bjsports-2016-095987.

Tremblay, M.S., Willms J.D. Is the Canadian childhood obesity epidemic related to physical inactivity? Int. J. Obes. Relat. Metab. Disord. 27(9):1100-1105, 2003.

Tremblay, M.S., Shephard, R.J., Brawley, L.R. Research that informs Canada’s Physical Activity Guides: an introduction. Appl. Physiol. Nutr. Metab. 32(suppl.2E):S1-S8, 2007a.

Tremblay, M.S., Esliger, D.W., Tremblay, A., Colley, R.C. Incidental movement, lifestyle-embedded activity and sleep: new frontiers in physical activity assessment. Appl. Physiol. Nutr. Metab. 32(suppl.2E):S208-S217, 2007b.

Tremblay, M.S., Wolfson, M., Connor Gorber, S. Canadian Health Measures Survey: Background, Rationale and Overview. Health Rep. 18(Suppl.):7-20, 2007c.

Tremblay, M.S., Kho, M.E., Tricco, A.C., Duggan, M. Process description and evaluation of Canadian physical activity guidelines development. Int. J. Behav. Nutr. Phys. Act. 7:42, 2010a.

Tremblay, M.S., Shields, M., Laviolette, M., Craig, C.l., Janssen, I., Connor Gorber, S. Fitness of Canadian children and youth: Results from the 2007-2009 Canadian Health Measures Survey. Health Rep. 21(1):7-20, 2010b.

Tremblay, M.S., Warburton, D.E.R., Janssen, I., Paterson, D.H., Latimer, A.E., Rhodes, R.E., et al. New Canadian Physical Activity Guidelines. Appl. Physiol. Nutr. Metab. 36(1):36-46, 2011a.

Tremblay, M.S., LeBlanc, A.G., Kho, M.E., Saunders, T.J., Larouche, R., Colley, R.C., et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int. J. Behav. Nutr. Phys. Act. 8:98, 2011b.

Tremblay, M.S., LeBlanc, A.G., Janssen, I., Kho, M.E., Hicks, A., Murumets, K., et al. Canadian Sedentary Behaviour Guidelines for School-aged Children and Youth. Appl. Physiol. Nutr. Metab. 36(1):59-64, 2011c.

Tremblay, M.S., LeBlanc, A.G., Carson, V., Choquette, L., Connor Gorber, S., Dillman, C., et al. Canadian Physical Activity Guidelines for the Early Years (aged 0-4 years). Appl. Physiol. Nutr. Metab. 37:345-356, 2012a.

Tremblay, M.S. Haskell, W.L. From science to physical activity guidelines. In C. Bouchard, S.N. Blair and W.L. Haskell (Eds.), Physical Activity and Health, 2nd Edition. Human Kinetics Publishers. p. 359-378, 2012b.

Tremblay, M.S., LeBlanc, A.G., Carson, V., Choquette, L., Connor Gorber, S., Dillman, C., et al. Canadian Sedentary Behaviour Guidelines for the Early Years (aged 0-4 years). Appl. Physiol. Nutr. Metab. 37:370-380, 2012c.

Tremblay, M.S. 2014 Global Summit on the Physical Activity of Children. J. Phys. Act. Health 11(suppl.1):S1-S2, 2014.

Tremblay, M.S., Barnes, J.D., Cowie Bonne, J. Impact of the Active Healthy Kids Canada Report Card: A 10-year analysis. J. Phys. Act. Health. 11(suppl.1):S3–S20, 2014a.

Tremblay, M.S., et al. Physical activity of children: A global matrix of grades comparing 15 countries related to the physical activity of children. J. Phys. Act. Health 11(suppl.1):S113-S125, 2014b.

Tremblay, M.S., Carson, V., Chaput, J-P. Introduction to the Canadian 24-Hour Movement Guidelines for Children and Youth: An Integration of Physical Activity, Sedentary Behaviour, and Sleep. Appl. Physiol. Nutr. Metab. 41(6 suppl.3):iii-iv, 2016a.

Tremblay, M.S., Carson, V., Chaput, J-P., Connor Gorber, S., Dinh, T., Duggan, M., et al. Canadian 24-hour Movement Guidelines for Children and Youth: An Integration of Physical Activity, Sedentary Behaviour, and Sleep. Appl. Physiol. Nutr. Metab. 41(6 suppl.3):S311-S327, 2016b.

Tremblay, M.S., et al. Global Matrix 2.0: Report Card Grades on the Physical Activity of Children and Youth comparing 38 countries. J. Phys. Act. Health 13(Suppl 2):S343-S366, 2016c.

Tremblay, M.S., Duggan, M., Adams, R., Bouchard, C., Shephard, R.J. A 50th anniversary celebration of CSEP member contributions to the understanding of exercise physiology: physical activity guidelines. CSEP Communiqué, April, 2017a.

Tremblay, M.S., et al. Sedentary Behavior Research Network (SBRN) – Terminology Consensus Project Process and Outcome. Int. J. Behav. Nutr. Phys. Act. 14:75, 2017b.

Trudeau, F., Laurencelle, L., Tremblay, J. Rajic, M., Shephard, R.J. Daily primary school physical education: effects on physical activity during adult life. Med. Sci. Sports Exerc. 31:111-117, 1999.

United Kingdom. Start Active, Stay Active. A report on physical activity for health from the four home countries’ Chief Medical Officers. Department of Health, London, U.K., 2011.

U.S. Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Ga. pp. 9–60, 1996.

Warburton, D., Katzmarzyk, P.T., Rhodes, R.E., and Shephard, R.J. Evidence-informed physical activity guidelines for Canadian adults. Appl. Physiol. Nutr. Metab. 32(Suppl. 2E):S16-S68, 2007.

Warburton, D.E.R., Charlesworth, S., Ivey, A., Nettlefold, L., Bredin, S.S.D. A systematic review of the evidence for Canada’s Physical Activity Guidelines for Adults. Int. J. Behav. Nutr. Phys. Act. 7(1): 39, 2010.

Weller, I., Corey, P. The impact of excluding non-leisure energy expenditure on the relation between physical activity and mortality in women. Epidemiology 9(6):632-635, 1998.

Wong, S.L., Colley, R.C., Connor Gorber, S., Tremblay, M.S. Sedentary activity Actical accelerometer thresholds for adults. J. Phys. Act. Health 8:587-591, 2011.

World Health Organization. Global recommendations on physical activity for health. Geneva: World Health Organization, 2010.

Young, T.K., Katzmarzyk, P.T. Physical activity in Aboriginal people of Canada. Appl. Physiol. Nutr. Metab. 32(Suppl. 2E):S148-S160, 2007.