International Journal of Obesity (2003) 27, 11001105

& 2003 Nature Publishing Group All rights reserved 0307-0565/03 $25.00
www.nature.com/ijo

PAPER
Is the Canadian childhood obesity epidemic related to
physical inactivity?
MS Tremblay1,2* and JD Willms2
1
College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and 2Canadian Research Institute for
Social Policy, University of New Brunswick, Fredericton, New Brunswick, Canada

OBJECTIVE: This study examined the relation among childrens physical activity, sedentary behaviours, and body mass index
(BMI), while controlling for sex, family structure, and socioeconomic status.
DESIGN: Epidemiological study examining the relations among physical activity participation, sedentary behaviour (video game
use and television (TV)/video watching), and BMI on a nationally representative sample of Canadian children.
SUBJECTS: A representative sample of Canadian children aged 711 (N 7216) from the 1994 National Longitudinal Survey of
Children and Youth was used in the analysis.
MEASUREMENTS: Physical activity and sport participation, sedentary behaviour (video game use and TV/video watching), and
BMI measured by parental report.
RESULTS: Both organized and unorganized sport and physical activity are negatively associated with being overweight
(1024% reduced risk) or obese (2343% reduced risk), while TV watching and video game use are risk factors for being
overweight (1744% increased risk) or obese (1061% increased risk). Physical activity and sedentary behaviour partially
account for the association of high socioeconomic status and two-parent family structure with the likelihood of being
overweight or obese.
CONCLUSION: This study provides evidence supporting the link between physical inactivity and obesity of Canadian children.
International Journal of Obesity (2003) 27, 11001105. doi:10.1038/sj.ijo.0802376
Keywords: body mass index; physical activity; sedentary behaviour; socioeconomic status; television watching

Introduction
There is widespread concern that the prevalences of overweight and obesity are reaching epidemic levels in many
developed and developing countries.1 In Canada, there is
strong evidence that the prevalence of childhood overweight
and obesity is rising rapidly.24 For example, between 1981
and 1996, the prevalence of obesity among Canadian
children aged 713 y tripled from 5 to 15%.2 Since the rate
of change is so great, it is generally believed that environmental factors, not genetic factors, explain the increase in
childhood obesity. It is believed that automated laboursaving devices and inexpensive and ubiquitous access to
calorie-dense food create an environment conducive to
obesity.

*Correspondence: MS Tremblay, College of Kinesiology, University of

Saskatchewan, 105 Gymnasium Place, Saskatoon, Saskatchewan, Canada
S7N 5C2.
E-mail: mark.tremblay@usask.ca
Received 12 September 2002; revised 3 April 2003;
accepted 4 April 2003

Analyses of the 1988 Campbells Survey on the Well-Being

of Canadians suggest that there is a negative relation
between self-reported physical activity and body mass index
(BMI),5 and data from other countries support this relation.1,6 Excessive television (TV) watching and video game
use have been identified as a stimulus for excessive eating
and sedentary behaviour.7 Gortmaker et al8 calculated that
the odds of being overweight were 4.6 times greater for
youth in the United States who watch 45 h of TV per day
compared with those watching 02 h/day. This relation
remained similar after controlling for baseline maternal
overweight, socioeconomic status (SES), household structure, ethnicity, and maternal and child aptitude test scores. It
appears that both physical activity and physical inactivity
may contribute to a positive caloric balance resulting in an
increase in the prevalence of obesity.
To our knowledge, there are no published findings
examining the relations among physical activity, sedentary
behaviour (video game use and TV/video watching),
and BMI on a nationally representative sample of
Canadian children. Furthermore, it is not known how

Physical inactivity and obesity

MS Tremblay and JD Willms

1101
physical activity and inactivity mediate the effect of socioeconomic status and family background on the risk of
overweight and obesity. An assessment of these relations will
assist in understanding the factors that contribute to the
obesity epidemic, and may lend support to certain intervention strategies. Therefore, the purpose of this study was to
examine, on a large representative sample of Canadian
children, the relations among childrens physical activity,
sedentary behaviours, and BMI, while controlling for sex,
family structure, and socioeconomic status.

The outcome measures used in our analysis are dichotomous variables indicating whether or not a child was obese
or overweight. The person most knowledgeable (PMK)
reported the childs height and body mass, and in some cases
(proportion unknown) these were assessed directly. The
limitations of self- and parental-report data for the study
are discussed elsewhere.2,3 Overweight and obesity were
defined using the recently developed international age- and
sex-specific cutoffs presented in Table 1.10
The behavioural characteristics were assessed by parental
response to the following questions:

Methods

Data from the first wave (1994) of the National Longitudinal

Survey of Children and Youth (NLSCY)9 were used to assess
the relations among childrens physical activity (organized
sport, unorganized sports and physical activities), sedentary
behaviours (computer and video game use, and TV/video
watching), and BMI (mass (kg)/height (m2)), while controlling for age, sex, and family background characteristics. The
NLSCY is a nationally representative longitudinal study of
Canadian children. The NLSCY began data collection in
1994 and has been repeated every 2 y. The 1994 NLSCY data
were collected between the fall of 1994 and spring of 1995.
The target population comprised all Canadian children from
newborn to age 11 y (ages 711 y used in these analyses). The
participating households were selected from the sampling
frame of Statistics Canadas Labour Force Survey, which is
representative of Canadas population. The Labour Force
Survey employs a stratified, multistage probability sample
design based on an area frame in which dwellings (residences) are the sampling units.9 Further details of the survey
and sampling procedures are available elsewhere.9 The
responding sample of 13 439 households was drawn from a
household sample of 15 600 (86% response rate). In this
survey, the height and body mass data were gathered
through parental report, which in some cases (proportion
not known) included direct measurement. BMI results were
available for 7216 children aged 711 y from the NLSCY.

Table 1 Published cutoffs for BMI for overweight and obesity by sex between
7 and 11 y of age. The cutoffs are defined to pass through BMI of 25 kg/m2
(overweight) and 30 kg/m2 (obese) at age 18 y
BMI 25 kg/m2

BMI 30 kg/m2

Age (y)a

Males

Females

Males

Females

7.5
8.5
9.5
10.5
11.5

18.2
18.8
19.5
20.2
20.9

18.0
18.7
19.4
20.3
21.2

21.1
22.2
23.4
24.6
25.6

21.0
22.2
23.5
24.8
26.0

Adapted from Cole et al.10

When whole-year age groups (ie 7 7.007.99) are used as in the present
study, it is appropriate to use the mid-point cutoffs (ie 7.5) presented here.

K
K
K

In the last 12 months, outside of school hours, how

often has_______ taken part in any sports which
involved coaching or instruction?
Taken part in unorganized sports or physical
activities?
Taken lessons or instruction in music, dance, art or
other non-sport activities?
Taken part in any clubs, groups or community
programs with leadership, such as Boys and Girls
Clubs, Scouts, Guides or church groups?
Played computer or video games?

Each of the above questions was answered on a five-point

scale: almost never, about once a month, about once a week,
a few times a week, most days. In preliminary analyses, we
found that the critical distinction for the relation between
the activity variables and BMI tended to be between
participation of once a week or less, vs a few times a week
or more. Thus, to simplify the analyses, we collapsed the
categories to create dichotomous variables indicating
whether or not a youth participated at least a few times a
week in each activity. The variable describing video watching
was also coded to indicate whether or not a youth watched
videos at least a few times each week.
Parents were also asked About how many days a week on
average does_______ watch TV or videos at home? and On those
days, how many hours on average does he/she spend watching TV
or videos? Children were then categorized as watching TV on
average less than 2 h/day, between 2 and 3 h/day, and
between 3 and 5 h/day.
Our analyses also included a measure of socioeconomic
status (SES) constructed for the NLSCY. It is a statistical
composite comprising parents level of education, the
prestige of the parents occupations, and family income.11
We identified youth who were in the lowest and highest
quartiles of SES, which were also used in our analyses as
dichotomous variables. Family structure indicates whether
the child was living in a single- vs a two-parent family.
Our first analysis simply examined cross-tabulations of the
relations between obesity, overweight, and activity/inactivity with socioeconomic status and family structure. A oneway analysis of variance F-test was used to assess statistical
significance. Our second analysis fitted three logistic
International Journal of Obesity

Physical inactivity and obesity

MS Tremblay and JD Willms

1102
regression models to assess (a) the relation between obesity
and overweight and activity and inactivity, (b) the relation
between obesity and overweight and SES and family
structure, and (c) the joint relation between obesity and
overweight and activity/inactivity, SES, and family structure.
In all three models, age and sex were included as control
variables, and the sample design weights provided by
Statistics Canada were used to take account of nonresponse
bias and the sample design.

In preliminary analyses, we also examined the effects of a

finer breakdown of TV watching (ie, 01, 12 h, etc), but
because of relatively small sample sizes within these
categories, and because the relative effects associated with
obesity and overweight were small, we found the three
categories (o2, 22.99, and 35 h/day) to be preferable.
There appears to be an important threshold at 2 h/day,
with respect to overweight, and 3 h/day with respect to
obesity.
The results for Model II indicate that children living in
single-parent families were more likely to be obese than
those in two-parent families, while living in a low-SES family
was not a strong risk factor for obesity. Conversely, children
in low-SES families were more likely to be overweight than
children in the middle two quartiles of SES, while living in a
single-parent family was not a strong risk factor for overweight. However, one should note that many single parents
have low household income and low levels of education. In
this sample, 47% of single parents were in the lowest SES
quartile. Living in a high-SES family was negatively associated with both overweight and obesity.
Model III includes both sets of factors. The childs family
background and activity/inactivity are overlapping risk
factors, but only partially. Children who participated in
unorganized sports, and those who watched TV less than 2 h/
day, were less likely to be overweight or obese. These
associations cut across levels of SES. Similarly, differences
in the prevalence of obesity and overweight associated with
SES are only partially attributable to differences in the levels
of childrens activity and inactivity. For both obesity and
overweight, the effects of living in a high-SES family are
equivalent to those associated with regular participation in
unorganized sports activities.
A test for interactions between age and the activity/
inactivity variables indicated that the potential benefits of
unorganized sports increase with age, while the reverse was
found for organized sports.

Results
Table 2 shows the relation between SES and family structure
with obesity and overweight, participation in sport, physical
activity, other organized leisure-time pursuits, and video
game and TV usage. Obesity and overweight are both
significantly related to SES and family structure. Participation in organized sports is more strongly related to SES and
family structure than other forms of activity/inactivity.
Watching TV less than 2 h/day, and more than 3 h/day is
also strongly related to family background, while playing
video games and watching TV 23 h/day are weakly related
to family background. Overall, this analysis shows that SES,
family structure, and activity and inactivity are overlapping
risk factors.12
Table 3 presents the results from three different statistical
models (I, II, III) which describe the relations of obesity and
overweight with childs age and sex, activity/inactivity, and
family background. Model I shows the relations between
obesity and overweight with activity and inactivity, while
controlling for age and sex. Participation in organized or
unorganized sports was negatively associated with obesity,
while watching TV more than 3 h/day was a risk factor.
Playing video games and watching TV more than 2 h/day
were risk factors for overweight, while participating in
unorganized sports was negatively associated with overweight.

Table 2

Relation of obesity, overweight, and activity/inactivity with socioeconomic status and family structure (percentage and ANOVA F)
Socioeconomic status

Obesea
Overweighta
Organized sportsb
Unorganized sportsb
Art, dance, etc.b
Clubsb
Video gamesb
TV, 02 h
TV, 23 h
TV, 35 h
a

Family structure

Lowest quartile

Middle quartiles

Highest quartile

F (2,7212)

Two parent

Single parent

F (1,7213)

12.8
34.5
39.7
70.6
19.3
21.3
54.5
40.2
32.5
27.2

10.7
28.7
62.8
80.6
30.0
30.5
59.6
51.3
32.4
16.3

6.4
22.5
75.6
81.4
49.6
37.9
62.2
62.3
25.8
12.0

24.2**
32.5**
256.0**
36.7**
215.6**
57.0**
10.8**
89.0**
16.5**
75.0**

9.1
27.1
64.6
79.7
35.2
32.2
60.2
54.2
29.8
16.1

13.5
32.3
49.7
74.4
27.6
25.0
55.3
43.9
33.5
22.5

22.1**
32.5**
93.1**
16.6**
25.2**
23.4**
9.9**
41.0**
6.5*
29.0**

Obese and overweight (which includes obese) as defined by Cole et al.10 (see Table 1).
Self-reported participation of a few times a week or more.
*po0.05, **Po0.01.

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Physical inactivity and obesity

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1103
Table 3 Relation of obesity and overweight with childs age and sex, activity/inactivity, and family background (presented as odds ratios (95% confidence intervals)
from logistic regression models)

Child characteristics
Age
Female
Activity/inactivity
Organized sportsa
Unorganized sports

Art, dance, etca

Clubsa
Videoa
TV, 23 hb
TV, 35 hb
(Missing TV data)b

Obesity

Overweight

Model

Model

II

III

II

III

0.63**
(0.590.67)
0.97
(0.811.15)

0.63**
(0.590.67)
1.05
(0.891.22)

0.63**
(0.590.67)
0.96
(0.811.14)

0.81**
(0.780.84)
0.90
(0.801.01)

0.82**
(0.790.85)
0.87**
(0.780.96)

0.81**
(0.780.84)
0.89*
(0.801.00)

0.84
(0.711.00)
0.58**
(0.480.69)
1.04
(0.861.25)
0.98
(0.821.17)
1.13
(0.961.34)
0.98
(0.811.18)
1.51**
(1.221.87)
0.86
(0.431.71)

0.90
(0.801.00)
0.76**
(0.670.87)
0.82**
(0.730.92)
0.99
(0.881.11)
1.17**
(1.04-1.30)
1.19**
(1.051.34)
1.44**
(1.251.67)
1.57*
(1.032.38)

0.77**
(0.650.91)
0.57**
(0.480.69)
0.94
(0.781.12)
0.94
(0.791.13)
1.10
(0.931.30)
1.03
(0.851.25)
1.61**
(1.311.70)
0.86
(0.431.70)

Family background
SESFlowest quartilec
SESFhighest quartilec
Single parentd

1.09
(0.891.33)
0.58**
(0.470.71)
1.40**
(1.141.72)

0.96
(0.781.18)
0.60**
(0.490.74)
1.36**
(1.111.68)

0.97
(0.861.08)
0.77**
(0.670.87)
0.88*
(0.781.00)
1.03
(0.911.15)
1.19**
(1.071.33)
1.15*
(1.021.30)
1.36**
(1.181.58)
1.55*
(1.022.36)

1.26**
(1.101.45)
0.73**
(0.640.82)
1.13
(0.981.31)

1.18*
(1.031.36)
0.76**
(0.670.86)
1.12
(0.961.29)

Reference is participation of once a week or less.

Reference is TV viewing 02 h.
c
Reference is middle two quartiles.
d
Reference is two parents.
*Po0.05,**Po0.01.
b

Discussion
This study is the first to examine the relations among
physical activity, sedentary behaviour, and overweight and
obesity, after controlling for SES and family background, in a
representative sample of Canadian children. The findings
support the intuitive belief that physical activity provides
protection from being overweight or obese, while TV
watching and video game use are risk factors. The results
also suggest that the benefits of participation in unorganized
sport and physical activity increase with age, and are more
important than involvement in organized sport.
The challenge to overcome the growing epidemic of
obesity in Canada is immense. Automated labour-saving
devices and inexpensive and ubiquitous access to caloriedense food create an environment conducive to obesity.
Excessive TV watching and video game use have been

identified as a stimulus for excessive eating and sedentary

behaviour.7 The present study suggests that this behaviour
pattern increases the risk of being overweight or obese,
regardless of SES, and is consistent with the work of
Gortmaker et al.8 From their analysis,8 attributable risk
estimates suggest that more than 60% of overweight
incidence can be linked to excess TV viewing time. This
relation was also reaffirmed for US children aged 816 y13
and Mexican children aged 916 y.14 Researchers in Belgium
observed a significant positive relation between days per
week of TV watching and BMI but in males only, suggesting
that factors contributing to obesity development may be
gender specific.15 Crespo et al16 found that the prevalence of
obesity was lowest among children watching r1 h of TV, and
highest among those watching Z4 h of TV per day. In
contrast to Guillaume et al,15 Crespo et al16 found that TV
International Journal of Obesity

Physical inactivity and obesity

MS Tremblay and JD Willms

1104
watching was positively associated with obesity among girls,
even after controlling for age, race/ethnicity, family income,
weekly physical activity, and energy intake.
Similar to excessive TV watching, the growing use of video
and computer games has likely contributed to the progressive fattening of Canadian children. An inverse relation
between video game playing and daily physical activity has
recently been observed.17 Robinson reported that reducing
childrens TV, video-tape, and video game use may be a
promising, population-based approach to prevent childhood
obesity.18
An interesting observation from these analyses is that art
and dance involvement is negatively associated with being
overweight. This relation, which is evident even after
controlling for SES and other activities included in the
model (see Model III for overweight), suggests that different
forms of leisure engagement may be beneficial. Although
just speculation, it may be that even low-activity forms of
leisure (ie art) may be somewhat protective by preventing
negative behaviours related to typical sedentary living
(eating junk food while watching TV). Alternatively, this
effect may be attributable to self-selection, or other physical
activities not accounted for in the models used. This finding
deserves further investigation.
Ecological data support the findings observed in this study.
Canadian information clearly demonstrates that access to inhome entertainment that promotes sedentary behaviour has
increased.19 For example, between 1986 and 1996 the
number of households with home computers more than
tripled (10.331.6%) and the households with two or more
colour TVs more than doubled (23.851.5%).19 Clearly, the
physical and social environment our children are exposed to
differs significantly from previous generations, and is
conducive to a reduction in energy expenditure. According
to the Health Behaviours of School-Aged Children Survey20
between 1990 and 1998 fewer Canadian students aged 11
15 y exercised two or more times a week outside of school
hours, the percentage of Canadian students who watched TV
four or more hours a day increased, and more Canadian
children reported playing video games 44 h/week than in
most other countries in the survey. In general, Canadians
report about three times as much time spent on passive
leisure compared to active leisure.19 Given the evolving
environment in which Canadian children live, and given the
tendency for obese children to remain obese as adults,21,22
the obesity epidemic in Canada will not likely subside any
time soon unless aggressive public health campaigns against
obesity are implemented.
The relation between overweight and obesity, and morbidity and mortality is well established and has been
reviewed recently.23 Results from the Canadian Heart Health
Survey have shown significant positive relations between
cardiovascular disease risk factors (increased blood pressure,
physical inactivity, diabetes mellitus, and dyslipidaemia) and
BMI.24 The economic cost of obesity has been estimated at
$51.6 billion in direct medical costs in the US in 199525and
International Journal of Obesity

$1.8 billion in Canada in 1997.26 Although it is difficult to

predict exactly how the increase in childhood obesity will
translate into adult health problems,27 it seems likely that
the future economic ramifications will be substantial unless
significant efforts to change physical activity behaviours and
nutrition practices are made.
Despite using a fairly large, nationally representative
sample, there are clear limitations to the findings from
this study. Although large, multipurpose national studies
generally require cursory, parental- or self-reported
measurements of activity and inactivity, caution must be
used when drawing conclusions from these data. Verification
of these findings should be made, even if on a small
sample, using more comprehensive and objective measures
of physical activity/inactivity behaviour. Also, the accuracy
of self- and parental reports of height and weight have
been questioned and discussed.2,3,2830 In general, there
appears to be a tendency for BMIs to be underestimated
as a result of an underestimation of weight and an overestimation of height; so the absolute prevalences listed
here are likely conservative estimates. Finally, the use of BMI
as an indicator of obesity or overweight has been questioned;31 nevertheless, BMI is generally accepted as a valid
indicator of body composition for assessments at the
population level.1,32
Caution must also be used when speculating on causation.
It may be that children who are prone to overweight and
obesity may also be prone to living a more sedentary
lifestyle; that is, obesity and overweight can discourage
children from participating. Other factors such as the
opportunities for recreation and parenting styles may also
be relevant and require further study.
Despite the limitations discussed above, this study provides evidence supporting the link between physical inactivity and obesity of Canadian children. The findings from this
study provide further support for policy initiatives aimed at
increasing physical activity opportunities while decreasing
sedentary behaviour as a means of controlling the childhood
obesity epidemic in Canada. These conclusions are consistent with the recently published guidelines in Canadas
Physical Activity Guide for Children,33 which calls for both an
increase in physical activity time and a reduction in inactive
time. Further work is required to understand how adherence
to these recommendations can be maximized, particularly
for children from single-parent families, and those with
low SES.

Acknowledgements
This project was supported by the Canadian Population
Health Initiative of the Canadian Institute for Health
Information. We would like to thank Human Resources
Development Canada for the use of data from the 1994
National Longitudinal Survey of Children and Youth. The
results presented and the views expressed in this paper are
those of the authors.

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MS Tremblay and JD Willms

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