Adult & Senior Needs Assessment Report

Adult & Senior Needs Assessment Report Phase Two: Anthropometric Measures & Questionnaires Five Hills Health Region Prepared by: Tara Schellenberg, BSc, MSc Epidemiologist 2006-2007

Executive Summary Introduction: Accurate information is essential to the delivery of successful programming. However, health data from federal/provincial governments is not always reflective of each health region because of variation in resident make-up between regions. Using federal statistics consisting of data primarily from large cities may be less useful to a health region consisting primarily of small cities and rural communities. The purpose of the needs assessment was to determine the general health and service needs of residents of the Five Hills Health Region (FHHR) in order to deliver and improve health care and services. This phase of the needs assessment collected a range of anthropometric measures, as well as data from supporting questionnaires. Methods: Respondents of the phase one questionnaires, volunteered to take part in the second phase which was to collect anthropometric measures. The measures collected were: age, sex, height, weight, % body fat, BMI, strength, endurance and flexibility. Short questionnaires were also given on the topics of nutrition, physical activity (PA), disability and leisure-time activity. Descriptive analyses (e.g., frequency distributions, cross tabs) were preformed using selected variables (e.g., sex, BMI, age). Results: 92 residents were measured (Adults =54%, Seniors =46%, mean age=60 yrs, Male=27%, Female=73%). Some findings were: 30% of participants were obese (BMI 30+); 70% of participants had unhealthy waist circumferences and body fat percentages; 48% of participants are not participating in enough PA; 21% of participants need to improve their body strength; 50% of participants need to improve their endurance; 34% of participants need to improve their flexibility; 9% of participants do not eat breakfast; 21% of participants are sedentary; 80% of participants minimal or no disability. Discussion: The specificity of these findings will allow the FHHR to develop policies to better serve the residents of their health region. In all surveys there are issues that arise, in the future the methodological issues arising from the needs assessment will be monitored and addresses as appropriate. 2

Table of Contents 1.0 Introduction 4 2.0 Methodology 5 2.1 Questionnaires 5 2.2 Surveying 5 2.3 Sample size and error 6 2.4 Response rate 6 2.5 Limitations and biases 6 3.0 Results 7 3.1 Demographics 7 3.2 Anthropometric measures 10 3.3 Questionnaires 22 3.4 Interpretive Analysis 27 4.0 Discussion, Conclusions and Recommendations 30 4.1 Methods 30 4.2 Results 30 5.0 References 33 6.0 Acknowledgements 35 7.0 Appendices 36 7.1: Physical Activity Questionnaire 37 7.2: Nutrition Questionnaire 38 7.3: Godin Leisure-time Questionnaire 40 7.4: Oswestry Disability Questionnaire 41 7.5: Physical Activity Readiness Questionnaire 44 7.6: Canadian Guidelines for body weight classification in adults 46 7.7: Health Benefits Zones for Body Composition and Musculoskeletal fitness 48 7.8: Percent Body Fat Guidelines 48 7.9: Healthy Musculoskeletal Fitness Norms for Males and Females 49 7.10: Physical Activity Guide 51 Page 3

1.0 Introduction The Five Hills Health Region (FHHR) has a population of 53,921 (2006). Adults between the ages of 20 and 64, constitute 57.5% (30,984) of the total FHHR population and seniors (65 years and over) make up 18.6% (10010). These two groups make up the majority of the FHHR population. Adults and seniors have similar needs in many areas of health but their needs can differ, which is most often related to aging and to the significant changes that occur in the senior years. The purpose of a Needs Assessment is to get a better idea what the specific needs of a certain part of the population are related to particular areas of interest. In this case, the needs of the adults and seniors of the Five Hills Health Region related to pain, physical activity, and nutrition. Accurate information is essential to the delivery of successful programming. However, health data from federal/provincial governments is not always reflective of each health region because of variation in resident make-up between regions. Using federal statistics consisting of data primarily from large cities may not be useful to the health region consisting of small cities and rural communities. The purpose of this assessment was to determine the general health and service needs of adult and senior residents of the Five Hills Health Region. 4

2.0 Methodology The participants that completed the Needs Assessment questionnaires in the first phase of this study, were also asked if they would like to volunteer for the anthropometric phase (phase 2) of the assessment. 2.1 Questionnaires: The questionnaires used, contained topics such as: Nutrition, Physical activity, Leisure- Time Activity (Godin) and Disability (Oswestry), as well as the PAR-Q (physical activity readiness questionnaire) prior to getting measured (see appendices 7.1 7.5). The questionnaires were given to both adults and seniors before they had their anthropometric measures taken. Questions were created using the FHHR 2006 Adult & Senior Needs Assessment Questionnaire use in phase 1, and the Godin-leisure time and Oswestry Disability questionnaires. 2.2 Surveying & Measuring: Survey participants were selected from the FHHR using the Reverse phone directory after the names had been deleted and the phone numbers randomized for each area, i.e. Rural and Urban. (See phase 1). Participants that completed the phase 1 questionnaire were asked if they would volunteer for phase 2. Those that volunteered were contacted in March and April, 2007 to set up appointments to have anthropometric measures taken. Appointments were every Saturday in May 2007 (4 dates) from 09:00 to 18:00. People who did not have an appointment were allowed to drop-in during the appointment hours. Clinics were held in Moose Jaw at the Public health Office in the W.G. Davies building. Participants had their blood pressure taken. Their height and weight were measured, from which BMI (body mass index) was calculated. Percent body fat was calculated using an electrical impedance scale and central adiposity was measured using waist circumference. Body strength was measured using grip strength (hand dynamometer). Endurance was measured by max push-ups and number of curl ups in one minute. Flexibility was measured using the sit and reach test (flexometer). (see The Canadian Physical Activity, Fitness and Lifestyle Approach, manual 3 rd ed. for details) 1 Questionnaires were completed by hand then the responses and the anthropometric measures were entered into Excel and SPSS for data cleaning and analysis. Error rates were calculated for each question due to the varied response rate per question. 5

2.3 Sample Size and Error: The sample sizes needed were calculated using a sample size calculator (Win Episcope 2.0). For a 50% prevalence at 95% confidence and 5% error, a sample of 140 was needed. 2.4 Response Rate: There were 380 volunteers, 144 booked appointments and 79 (54.9%) came to their appointment and 15 dropped in. 94 people came to clinic, which is 24.7% of all the volunteers, but complete data was only available for 92 (24.2%). 2.5 Limitations and Biases: There was a non-responder (selection) bias of 75.8% (residents who volunteered but failed to show up to clinics). Non-responders were both urban and rural as well as adults and seniors. Non-responders usually have differences (most often significant) in their health needs. The non-responders of this phase of the study are not true non-responders because they did complete the first phase of the study. Selection bias was also introduced because only those residents that had a current phone number present in the reverse directory were contacted initially. Those residents with no telephone, use cell phones exclusively, have an unlisted number or lived in a healthcare facility without private phones were unable to be selected because they had no phone or their number was inaccessible. Females were over-sampled because there was no gender-specific selection methods used in the first phase of the study. Not all the questions had the same response rate. Some questions had a response rate that was lower and this increased the level of error. There was a potential for recall bias because participants were asked to recall behaviors the happened in an average week. Seniors or adults living in palliative care or that are mentally handicapped were not interviewed. Phone interviews for the first phase were conducted during the week in the evenings during the Fall, which may have created a selection bias. And clinics were only available on Saturdays in May 2007. 6

3.0 Results Note: Error and confidence limits requests can be sent to FHHR Epidemiologist 3.1 Demographics

Moose Jaw was designated as urban and the rest of the Five Hills Health Region (FHHR) was considered rural. 3.1.1. Adults/Seniors & Urban/Rural & Gender (N=92) Percent N Adults 54.3% 50 Seniors 45.7% 42 Urban 60.9% 56 Rural 39.1% 36 Males 27.2% 25 Females 72.8 % 67 The average age of adults (20+ yrs) for the covered population of FHHR is 50 years. 2 3.1.2: FHHR adult (20+ yrs) population average (50 yrs) FHHR study average (60 yrs) 8

3.1.3: Percentage of Adults and Seniors by Age Group for the Anthropometric Measured Population Percentage 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 50-54 45-49 40-44 35-39 30-34 25-29 20-29 85-89 80-84 75-79 70-74 65-69 60-64 55-59 95+ 90-94 Age Group 3.1.4 FHHR Population Distribution of Adult & Seniors Needs Assessment vs. SK Covered Population, 2006 20.0% 18.0% 16.0% 14.0% Percentage 12.0% 10.0% 8.0% 6.0% 4.0% FHHR Needs Assessment SK Covered POP (FHHR) FHHR Anthro Pop 2.0% 0.0% 95+ 90-94 85-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-29 Age Group 9

3.2 Anthropometric Measurements

Anthropometric measures are physical traits such as height, weight as well as indicators of physical attributes like grip strength is a measurement of overall body strength. 3.2.1 Self reported height is typically over estimated and weight is usually under reported. People think they are tall and lighter than they are. 3,4 The average height of participants was 166 cm (5 5 ), 162 cm (5 4 ) for women and 175 cm (5 9 ) for men. The average weight of participants was 75.6 kg (166 lbs), 71.6 kg (158 lbs) for women and 86.9 kg (191 lbs) for men. BMI: Height and weight measurements are used to calculate body mass index (BMI). BMI is an indirect measure of body fat. The average BMI score of participants was 27.5 (median score was 26.8), 27.2 (median score was 26.4) for women and 28.4 (median score was 28.2) for men. These scores are all in the overweight category which puts the average participant at an increased risk of developing health problem (see appendix 7.6). 5 Because BMI is a score, median values may be more appropriate. 11

3.2.2 Weight Distribution 25 20 Frequency 15 10 5 0 Mean = 75.646 Std. Dev. = 16.926 N = 90 40.0 60.0 80.0 100.0 120.0 Weight (kg) 3.2.3 Measured Height (cm) and Weight (kg) 130 120 110 100 Weight (kg) 90 80 70 60 50 40 30 100 110 120 130 140 150 160 170 180 190 200 Height (cm) 12

3.2.4 BMI Distribution 14 12 10 Frequency 8 6 4 2 0 15.0 20.0 25.0 30.0 35.0 40.0 Mean = 27.514 Std. Dev. = 5.1485 N = 90 BMI score In the study participants, 30% are obese which puts them at high to extremely high risk of developing health problems. Over a third (34.4%) of participants are at increased risk of developing health problems and only a third (33.3%) of participants are at the least risk. Some of these health problems are type 2 diabetes, hypertension and some cancers (see appendix 7.6). 5 3.2.5 BMI status (N=90) Percentage N Risk of developing health problems Underweight * * Increased Normal weight 33.3% 30 Least Overweight 34.4% 31 Increased Obese 30.0% 27 High to extremely high * Cell size less than 5 Waist Circumference: Waist circumference is an indicator of central adiposity accumulation. The average waist circumference of participants was 94.7 cm (37.5 ), 90.7 cm (36.3 ) for women and 104.4 cm (41.8 ) for men. 70% of participants are at an increased risk of developing type 2 diabetes, coronary heart disease and/or hypertension, whether male of female. (see appendix 7.6). 5 13

3.2.6 Waist Circumference Distribution 14 12 10 Frequency 8 6 4 2 0 60.0 70.0 80.0 90.0 100.0 110.0 120.0 130.0 Mean = 94.371 Std. Dev. = 15.7782 N = 90 Waist Circum (cm) Body Composition: BMI and waist circumference can be used together to derive a body composition composite score. Each score is assigned a classification which is described in Appendix 7.7. 1 3.2.7 Body Composition Score (BMI & Waist circumference) (N=91) Classification Percentage Excellent 22.0% Very Good 24.2% Good * Fair 25.3% Needs Improvement 28.6% * Cell size less than 5 Over half (53.9%) of participants need to improve ( fair and needs improvement ratings) their body composition because these classifications of body composition carry some to considerable health risks. The average fitness score of participants was 1.86 (median score was 1.0); 1.88 (median score was 1.0) for women and 1.79 (median score was 1.0) for men. Because body composition is a score, median values may be more appropriate. These scores are all in the fair category which puts the average participant at an increased risk of developing health problem (see appendix 7.7). 1 14

3.2.8 Distribution (percentage) of Body Composition Composite Scores 35% 30% 25% Percentage (%) 20% 15% 10% 5% 0% Needs improvement Fair Good Very good Excellent 0 1 2 3 4 Score & Classification 3.2.9 BMI, waist circumference, % body fat & Blood pressure status Acceptable Unhealthy (at risk) Body mass index (N=90) 33.3% 66.7% Waist circumference (N=90) 30.0% 70.0% Percent Body Fat (N=89) 29.2% 70.8% Blood pressure (N=92) 67.7% 32.6% Body Fat & Blood Pressure: Percent body fat composition was calculated using an electrical impedance scale, which a participant merely stands on. The average percent body fat of participants was 33.8%, 36.0% for women and 27.9% for men. The average body fat for both men and women is unhealthy (obese). 70% of participants are considered to have an unhealthy body fat percentage (obese) and are at an increased risk of developing health problems. (see appendix 7.6 and 7.8). 5, 6 The average systolic blood pressure of participants was 133 mmhg, 131 mmhg for women and 139 mmhg for men. The average diastolic blood pressure of participants was 77 mmhg, 76 mmhg for women and 81 mmhg for men. 33% of participants are considered to have an unhealthy blood pressure level and are at an increased risk of developing health problems. 7 15

3.2.10 Percent Body Fat Distribution 40 30 Frequency 20 10 0 0.0 10.0 20.0 30.0 40.0 50.0 60.0 Mean = 33.82 Std. Dev. = 9.3548 N = 89 % Body Fat 3.2.11 Distribution of Percent Body Fat 8 7 6 Male % Body Fat cutoff = 25% Female % Body Fat cutoff = 32% male female 5 Number 4 3 2 1 0 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Percent body fat (%) 16

3.2.12 Measured Blood Pressure (mmhg) 190 180 170 160 150 Systolic cutoff = 140 Systolic 140 130 120 110 100 90 Diastolic cutoff = 90 80 30 40 50 60 70 80 90 100 110 120 Diastolic 17

Physical Tests: The participants with high blood pressure were advised not to take part in the endurance tests. The participants that took part in the physical tests for strength, endurance and flexibility had varied results. Having results in the categories of fair to needs improvement indicate that participants will have corresponding health risks (some to considerable respectively). 35.5% of participants needed to improve their body strength, 55.6% of participants needed to improve their flexibility and 53.6% and 60.6% of participants needed to improve their endurance (curl-up & push up tests respectively). The composite scores indicate that 48.4% of participants have a musculoskeletal fitness level that puts them at some to considerable health risk. For all these tests, the older the person the lower the cuts-offs, to achieve a rank of excellent to needs improvement. 3.2.13 Strength (grip), Endurance (push ups & curl ups), Flexibility (sit & reach) and Fitness Composite Measures (see appendix 7.7) 1 Excellent Very Good Fair Needs Improvement good Grip strength (N=90) 37.8% 18.9% 7.8% 14.4% 21.1% Push ups (N=66) * 18.2% 16.7% 10.6% 50.0% Curl ups (N=69) 27.5% 10.1% 8.7% * 49.3% Sit & Reach (N=79) 11.4% 15.2% 12.7% 24.1% 34.2% Fitness Comp score (N=91) 6.6% 25.3% 19.8% 29.7% 18.7% * Cell size less than 5 3.2.14 Maximum Grip Strength Distribution 25 20 Frequency 15 10 5 0 20 40 60 80 100 Grip strength max sum (kg) 120 140 Mean = 63.29 Std. Dev. = 23.329 N = 90 18

Grip strength was calculated using a hand dynamometer. The average kilograms (kg) of pressure exerted by participants was 63.3 kg; 56 kg for women and 84.5 kg for men. The average grip strength for women was in the category of fair to excellent depending on age. For men, the average was in the fair to good categories, also depending on age. (see appendix 7.9) 1 Push ups and curl ups were used to calculate endurance. The average number of push ups that participants maxed out at was 8; 8 for women and 8 for men. The average number of push ups to max for women was in the needs improvement to good categories, depending on age. For men, the average was in the needs improvement to fair categories, also depending on age. (see appendix 7.9) 1 3.2.15 Maximum Push Ups Distribution 40 30 Frequency 20 10 0 0 10 20 30 40 50 Mean = 7.86 Std. Dev. = 10.324 N = 66 Max. Push ups The average number of curl ups in one minute that participants reached was 11; 11 for women and 12 for men. The average number of curl ups for one minute for women was in the category of needs improvement to good, depending on age. For men, the average was in the needs improvement to good categories, also depending on age. (see appendix 7.9) 1 19

3.2.16 Maximum Curl Ups (in one minute) Distribution 40 30 Frequency 20 10 0 0 5 10 15 20 25 Mean = 11 Std. Dev. = 11.207 N = 69 # of Curl up (1min) The average number of centimeters (cm) that participants reached was 24.9; 27.2 for women and 17.3 for men. The average reach for women was in the needs improvement to good categories, depending on age. For men, the average was in the needs improvement to fair categories, also depending on age. (see appendix 7.9) 1 3.2.17 Maximum Sit & Reach (Flexibility) Distribution 15 Frequency 10 5 0 0 10 20 30 Sit & Reach 40 50 Mean = 24.85 Std. Dev. = 10.281 N = 79 20

Musculoskeletal Fitness composite Score: The average fitness score of participants was 1.7 (median score was 2.0); 1.9 (median score was 2.0) for women and 1.1 (median score was 1.0) for men. Because the fitness composite is a score, median values may be more appropriate. The score for women is in the good category which gives the average female participant many health benefits but the score for men is in the fair category which puts the average male at an increased health risk. (see appendix 7.7 & 7.9) 1 3.2.18 Distribution (percentage) of Musculoskeletal Fitness Composite Scores 35% 30% 25% Percentage (%) 20% 15% 10% 5% 0% Needs improvement Fair Good Very good Excellent 0 1 2 3 4 Score & Classification 21

3.3 Questionnaires

There were four supplementary questionnaires give to the participants before they were measured. These questionnaires covered physical activity, nutrition, leisure-time activity and disability. Physical Activity Questionnaire: The physical activity questionnaire (see appendix 7.1) was used to collect information on frequency and intensity of physical activity in participants. Almost all the participants (98.9%) said they were doing some type of physical activity. Most participants (95.6%) indicated they did physical activity 3 to 7 days a week on average. Most participants (95.6%) also indicated they did at least 15 minutes of physical activity. Many participants (87.0%) did light to moderate intensity physical activity. Based on this information and the guideline set forth by the Public Health Agency of Canada and the Canadian Society of Exercise Physiology in the physical activity guide 8 (see appendix 7.10), 47.8% of participants were not doing enough physical activity. 3.3.1 Average days a week, time participated and intensity level while partaking in physical activity Days/wk (N=91) Percentage Minutes (N=91) Percentage Intensity (N=92) Percentage Two * 1-14 * Minimal * Three 24.2% 15-29 15.4% Light 28.3% Four 12.1% 30-44 20.9% Moderate 58.7% Five 15.4% 45-59 20.9% Vigorous 9.8% Six 13.2% 60+ 38.5% Maximum * Seven 30.8% * Cell size less than 5 Nutrition Questionnaire: The nutrition questionnaire (see appendix 7.2) was used to collect information on meal make up, factors affecting nutrition and key factor affecting what people choose to eat in participants. Over three quarters (78.3% & 76.1%) of participants are not eating all four food groups at lunch and supper respectively. And 44.6% of participants are not eating the recommended number of food groups ( 3 ) for breakfast. Less than 10% of participants do not eat at these meals. 3.3.2 Meal make up (N=92) Breakfast Lunch Supper Not eating recommended number of food groups 44.6% 78.3% 76.1% Eating recommended number of food groups 46.7% 19.6% 21.7% Not eating at this meal 8.7% * * 3 out of the 4 food groups recommended all 4 food groups recommended * Cell size less than 5 23

Less than half (34.8%, 43.5% & 46.7%) of participants are not eating the recommended number of food groups ( 2 ) for a snack. Less than half (33.7%, 43.5% & 48.9%) of participants are not eating a snack at these times. 3.3.3 Snack make up (N=92) Morning Afternoon Evening Not eating recommended number of food groups 43.5% 34.8% 46.7% Eating recommended number of food groups 13.0% 16.3% 19.6% Not eating at this snack 43.5% 48.9% 33.7% 2 out of the 4 food groups recommended Eating habits was the top barrier (59.2%) to eating as healthy as the participants would like. Prep time (42.5%), work demands (36.1%) and lack of time (32.9%) were also issues to eating better. Many participants feel they have adequate dietary knowledge and nutritious choices to choose from and it is not a barrier for them (86.5% and 91.8%). 3.3.4 Limitations to eating as healthy as one would like Yes No Lack of dietary/nutrition knowledge (N=74) 13.5% 86.5% Lack of interest/motivation (N=74) 27.0% 73.0% Lack of time (N=73) 32.9% 65.8% Work demands (i.e. shift work, traveling, etc.) (N=72) 36.1% 62.5% Season (N=73) 27.4% 69.9% Cost (N=74) 16.3% 78.4% Eating Habits (N=74) 59.5% 39.2% Preparation Time of food (N=73) 42.5% 56.2% No one to eat with (N=72) 12.5% 86.1% Few nutritious choices (at work, home, etc.) (N=73) 8.2% 91.8% Don t know how to cook/don t want to cook (N=71) * 93.0% * Cell size less than 5 The number one factor considered when choosing what foods to eat (N=90) was food likes and dislikes (46.7%), nutritious value of food (30.0%) and medical condition (11.1%). Almost half of the participants choose their food based on their food preferences (likes/dislikes). Godin Leisure-time Exercise Questionnaire: The Godin Leisure-Time Exercise questionnaire 9 (see appendix 7.3) was used to collect information on weekly frequency of strenuous, moderate, and mild leisure-time activity of at least 15 minutes and to produce a single score (exercise METS per week). The average score (METS) for participants was 35.6 (median score was 31.5), 33.9 (median was 31.0) for women and 40.1 (median was 33.0) for men. 24

The average METS for women was considered not sufficiently physically active. For men, the average was considered sufficiently physically active. 3.3.5: Godin Score Distribution 20 15 Frequency 10 5 0 0 50 100 150 200 Mean = 35.55 Std. Dev. = 26.545 N = 92 Godin leisure-time score (METS) Less than half (46.7%) of participants are sufficiently active ( 38 METS for men and 35 METS for women. 10 Just over 20% (20.7%) of participants were considered sedentary. 3.3.6: Leisure time activity categories Males (N=25) Females (N=67) Total (N=92) Sufficiently active 48.0% 46.3% 46.7% Not sufficiently active 32.0% 32.8% 32.6% Sedentary ( 15 METS) 20.0% 20.9% 20.7% Oswestry Disability Questionnaire: The Oswestry Disability questionnaire 11, 12, 13 (see appendix 7.4) was used to collect information on how leg and or back pain affects everyday life. The average score for participants was 12.0% (median score was 8.0%), 10.4% (median was 6.7%) for women and 16.4% (median was 12.0%) for men. The average scores for women and men was considered to represent minimal disability, the patients can cope with most living activities. 25

3.3.7: Oswestry Score Distribution 40 30 Frequency 20 10 0 Mean = 12.015 Std. Dev. = 14.2323 N = 91 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 Oswestry score (%) Over 80% (80.2%) of participants were considered minimally disabled, some people had no disability (35.6% of minimally disabled participants had a score of 0%). 3.3.8: Oswestry Disability categories Males (N=24) Females (N=67) Total (N=91) Minimal disability 70.8% 83.6% 80.2% Moderate disability * 13.4% 13.2% Severe disability * * 5.5% Crippled * * * Bed-bound * * * * Cell size less than 5 26

3.4 Interpretive Analysis Note: Other interpretive analysis requests can be sent to FHHR Epidemiologist

BMI & Waist Circumference: There is evidence that BMI ( 25) and waist circumference ( 88 cm in females; 102 cm in males) can increase the risk of developing health problems. (see appendix 7.6) 5 3.4.1: BMI vs. Waist Circumference in Men and Women 140 130 120 Waist Circumference (cm) 110 100 90 80 70 Male WC cutoff = 102 men women Female WC cutoff = 88 60 50 BMI cutoff =25 40 15 20 25 30 35 40 BMI Score 3.4.2: Waist circumference and BMI together as related to health risk (N=89) Health Risk Classification: Health Risk Level (%): Number Least risk 28% 25 Increased risk 7% 6 High risk 35% 31 Very High risk 30 % 27 In total 72% of those measured, are at least at an increased risk of health problems such as developing type 2 diabetes, coronary heart disease and/or hypertension. 30% are at a very high risk of the same health problems. (see appendix 7.6) 5 28

Body Composition and Musculoskeletal Fitness Composite Scores: Scores in the fair and needs improvement classifications carry some to considerable health risks. Having good to excellent scores will provide health benefits for those participants. (see appendix 7.7) 1 3.4.3 Distribution (percentage) of Body Composition and Fitness Composite Scores 35% 30% Fitness score Body comp. score 25% Percentage (%) 20% 15% 10% 5% 0% Needs improvement Fair Good Very good Excellent 0 1 2 3 4 Score & Classification 3.4.4 Body comp. and fitness score together as related to health risk and benefits (N=90) Health Risk Classification: Percent (%): Number Considerable benefits (very good & excellent) 22.2% 20 Increased benefits (good) 26.7% 24 Increased risk (fair) 32.2% 29 Considerable risk (needs improvement) 18.9 % 17 Over half (51.1%) of participants were found to have increased health risks related to their body composition and fitness level. 29

4.0 Discussion, Conclusions & Recommendations 4.1 Methodology: There were limitations and biases that arose, which happen when conduction research of any kind. Some of these issues can be corrected in the analysis but most cannot and all that can be done is to report them and try to correct them for future research. Non-responder bias was an issue. This could be reduced in the future by collecting measurements in the volunteer s home or offering incentives; but incentives or going to individual s homes can also introduce other issues. The non-responders in this phase of the study were not true non-responders because they did complete the phase one questionnaire and they volunteered to do the second phase. Selection bias was also an issue. Only residents with a listed phone number were contacted for phase one and then could volunteer for phase two. This could be reduced with use of a complete list of all non-business phone numbers. Females were oversampled (selection bias) and this could be corrected by asking for the person in the household with the next birthday who meets the enrollment criteria. Interviews were conducted in the fall and on weekday evenings for phase one and then clinics were only available in May on Saturdays in Moose Jaw, which also introduced selection bias. Calling and having clinics at different times in the year, evenings and days as well as weekdays and weekends would allow for the collection of participants with different schedules. Having clinics in different locations would have also aided in collection of data from participants, especially those in rural areas. There was a potential for recall bias, because participants were asked to recall behaviors over an average week. Many people recall whet they did most recently, which may have not been an average week. Limitations of the study were also present. Clinics were only possible in May, on Saturdays and in Moose Jaw. Having more clinics, in different locations and on different days may have allowed for more people to get measured. Time constraints and associated expenses, negated the possibility of dispersed clinics. All these proposed methods for correcting or decreasing the occurrence of the issues that arose in this assessment, all have issues of their own and might not correct the original issue or could potentially create other issues. There is no exact or perfect answer in research. 4.2 Results: Demographics: There was almost a 50/50 split in adults and senior volunteers, which is not representative of the actual 75/25 split for adults and seniors in the FHHR. Males and female split 30

should have been closer to 50/50 but was approximately 25/75 (males/females). Adults age 20-29 and 40-44 were under represented adults 50-54 and seniors 65-79 were over represented. The urban/rural split was fairly representative of the FHHR population, but because age and gender is not representative, the urban/rural results may not be representative either. Collecting a more representative sample will ensure we can measure the needs of our population more accurately. Anthropometric measures and Interpretive Analysis: Waist circumference (WC) gives an indication of abdominal obesity, which in turn is the most common cause of the metabolic syndrome, which includes a specific atherogenic dyslipidemia, insulin resistance, impaired fibrinolysis, and an inflammatory profile. Abdominal obesity is the most prevalent form of the metabolic syndrome. 14 Because of its critical role in the etiology of the metabolic syndrome, abdominal obesity should be assessed in clinical practice. Consideration should be given to measuring both BMI and waist circumference in all patients, giving a composite measure of health risk. 14 These are useful tools in screening for, and assessing progress, with prevention and management of specific chronic disease risk factors. Using a combination of BMI and WC to classify health risk, 72 % of study participants are at some risk of developing health problems. This ranges from some increased risk (7%), to very high risk (30%). Primary prevention is the most cost-effective prevention mode. Knowledge is a basic foundation underpinning the assuming of responsibility for one s own health. The survey indicated that people have a reasonable knowledge of physical activity requirements, for example, but overestimate the actual intensity of the exercise they do. This is compounded by excess energy intake (food). Study participants shared a number of barriers to healthy eating practices ranging from factors such as personal preferences and busy schedules. Musculoskeletal fitness scores indicate that 18% of participants need improve their overall fitness, whilst 30% have a barely adequate fitness rating. This means that 48% of participants do not reap the health benefits associated with good fitness levels. In order to reap health benefits, a balance is needed between energy input (food), and appropriate energy expenditure (exercise). This survey indicates that despite reasonable levels of knowledge of this principle, that this sample of FHHR residents, shows that we have a long way to go towards an overall healthy lifestyle. Questionnaires: From the Physical Activity Questionnaire, almost all participants indicate that they do some type of physical activity. Many participants say this activity is 3-7 days a week and 31

at least 15 minutes. Many say they do light to moderate activity, but when asked what activities they participate in, they are more sedentary or light. When activity intensity is taken with frequency and duration, almost half of participants are not getting enough physical activity. The Godin Leisure-time Exercise Questionnaire also indicated that almost half of participants are not sufficiently active. Both these questionnaires measure physical activity in different ways but both support the finding that almost half of participants are not sufficiently active. Participants have a reasonable knowledge of how much physical activity they should be doing. There is however a disconnection between the intensity of the activity chosen and the duration required to support optimal fitness and health. More education focusing on the intensity of the activity related to duration may help people when trying to be optimally physically active. The Nutrition Questionnaire indicated almost 10% of participants do not consume breakfast and that many participants do not eat the recommended number of food groups at meals and snacks. Some of the barriers they indicated were established eating habits, prep time, work demands and lack of time. And many participants choose food based on like and dislikes. People know they need to eat the four food groups as indicated; thus knowledge appears to be adequate, but personal preferences and schedules override this. These are issues that individuals have to acknowledge and try and work around, towards eating healthier meals and snacks. From the Oswestry Disability Questionnaire, most participants have little to no disability and can deal with the activities of daily living. Disability does not seem to be a factor affecting participant s daily lives, including light to moderate activities that would contribute to a person s overall physical activity requirement. 32

5.0 References 1. The Canadian Physical Activity, Fitness & Lifestyle Approach (CPAFLA): CSEP- Health & Fitness Program's Health-Related Appraisal and Counselling Strategy (3rd edition). Canadian Society for Exercise Physiology. 2004: 7-1 to 7-57 Available Online: www.csep.ca 2. Saskatchewan Health. Covered population 2006. Available Online: http://www.health.gov.sk.ca/mc_dp_covpop2006/covpopbook2006.pdf 3. Spencer EA, Appleby PN, Davey GK, and Key TJ. Validity of self-reported height and weight in 4808 EPIC-Oxford participants. Public Health Nutrition. 2002; 5(4): 561-565. 4. Steward AW, Jackson RT, Ford MA, and Beaglehole R. Underestimation of relative weight by use of self-reported height and weight. American Journal of Epidemiology. 1987; 125(1): 122-126. 5. Health Canada. Canadian guidelines for body weight classification in adults. Available Online: http://www.hc-sc.gc.ca/fnan/alt_formats/hpfbdgpsa/pdf/nutrition/cg_quick_ref-ldc_rapide_ref_e.pdf 6. American Council of Fitness. Available Online: http://www.acefitness.org/ 7. Campbell N. Canadian Hypertension Education program. 2007 Canadian Education program recommendations Annual Update. Available Online: www.hypertension.ca 8. Public health Agency of Canada and Canadian Society of Exercise Physiology. Physical Activity Guide. Available Online: http://www.phac-aspc.gc.ca/pauuap/fitness/pdf/guideeng.pdf 9. Godin G and Shephard RJ. A simple method to assess exercise behavior in the community. Canadian Journal of Applied Sport Sciences. 1985; 10: 141 146. 10. García Bengoechea E, Spence JC, and McGannon K. Gender differences in perceived environmental correlates of physical activity. International Journal of Behavioral Nutrition and Physical Activity. 2005; 2: 12. 11. Fairbanks JCT, Couper J, Davies JB, et al. The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy. 1980;66:271-273. 12. Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Physical Therapy. 2001;81:776-788. 13. Fairbanks JCT, Pynsent PB. The Oswestry Disability Index. Spine. 2000; 25(22): 2940-2952. 33

14. Despres J and Tchernof A. Classification of overweight and obesity in adults. Canadian Medical Association Journal. 2007; 175(8):Online 21-26. 34

6.0 Acknowledgements We would like to acknowledge the members of the Population Health Promotion working group, the Adult and Seniors Public Health Team and the Dr. Kell from the University of Regina, Kinesiology & Health Studies Department, for their contribution to the survey development and to interpretation of the results. We thank the surveyors for their hard work in collecting participants and disseminating the survey; as well as the participants of the Five Hills Health Region, for their valuable information. We are grateful to the Five Hills Health Region for funding this project. 35

7.0 Appendices 7.1: Physical Activity Questionnaire 7.2: Nutrition Questionnaire 7.3: Godin Leisure-time Questionnaire 7.4: Oswestry Disability Questionnaire 7.5: Physical Activity Readiness Questionnaire 7.6: Canadian Guidelines for body weight classification in adults 7.7: Health Benefits Zones for Body Composition and Musculoskeletal fitness 7.8: Percent Body Fat Guidelines 7.9: Healthy Musculoskeletal Fitness Norms for Males and Females 7.10: Physical Activity Guide 36

7.1 Physical Activity Questionnaire URN: First Name: Physical Activity Physical activity is all leisure and non-leisure body movements. It typically includes any form of exercise or movement. Physical activity may include planned activity such as walking, running, basketball, or other sports, As well as other daily activities such as household chores, yard work, walking the dog, etc. The following is a list of activities based on intensity/effort (see handout as well): Minimal Effort Light Effort 60+ min/day Moderate Effort 30-60 min/day Vigorous Effort 20-30 min/day Maximum Effort Daily 4-7 days/week 4-7 days/week Dusting Gardening Brisk walking Jogging Sprinting TV Vacuuming Biking Aerobics Racing Tai Chi Swimming Hockey Light walking Dancing Basketball 1A. Are you presently doing any type of physical activity? Yes No Don t know If Yes: 1B. On average, how many days a week do you do physical activity? One Two Three Four Five Six Seven 2B. On the days physical activity is preformed, on average, how much time is spent doing the physical activity (in minutes)? 1-14 15-29 30-44 45-59 60+ 3B. On average, what is your intensity/effort level of physical activity? Minimal Light Moderate Vigorous Maximum 37

7.2 Nutrition Questionnaire URN: First Name: Nutrition Food has an important role in our lives. It is the major provider of the nutrients we need to survive and thrive. There are four main food groups in which foods are categorized. Other consists of foods that are comprised of mostly salt, sugar and/or fat. Water is not a food but is part of dietary intake. The following is a table of examples of the four main food groups and other foods (also refer to handout): Vegetables Grain Milk & Meat & Other & Fruit Products Alternatives Alternatives Fresh Bread Milk Beef Cake Frozen Rice Yogurt Eggs Chips Canned 100% Fruit Juice Cereal Cheese Nuts Fish Legumes French fries Chocolate Typically, what food groups do you eat at the following sittings (check all that apply for each question 1-6): 1. Breakfast: Vegetables & Fruit Grain Products Milk & Alternatives Meat & Alternatives Other Water Don t eat breakfast 2. Morning Snack: Vegetables & Fruit Grain Products Milk & Alternatives Meat & Alternatives Other Water Don t eat a morning snack 3. Lunch: Vegetables & Fruit Grain Products Milk & Alternatives Meat & Alternatives Other Water Don t eat lunch 4. Afternoon Snack: Vegetables & Fruit Grain Products Milk & Alternatives Meat & Alternatives Other Water Don t eat afternoon snack 38

5. Supper: Vegetables & Fruit Grain Products Milk & Alternatives Meat & Alternatives Other Water Don t eat supper 6. Evening Snack: Vegetables & Fruit Grain Products Milk & Alternatives Meat & Alternatives Other Water Don t eat an evening snack 7. What prevents you from eating as healthy as you would like? yes no No opinion refused a. Lack of dietary/nutrition knowledge b. Lack of interest/motivation c. Lack of time d. Work demands (ie. shift work, traveling, etc.) e. Season f. Cost g. Eating Habits h. Preparation Time of food i. No one to eat with j. Few nutritious choices (at work, home, etc.) k. Don t know how or don t want to cook l. Other: please specify 8. What is the Number One factor you consider when choosing what foods to eat? (check only one answer) Likes/dislikes Price/cost Nutritious value Convenience Finances available Medical condition Other: 39

7.3 Godin Leisure-Time Exercise Questionnaire 1. During a typical 7-Day period (a week), how many times on the average do you do the following kinds of exercise for more than 15 minutes during your free time (write on each line the appropriate number). Times Per Week a) STRENUOUS EXERCISE (HEART BEATS RAPIDLY) (e.g., running, jogging, hockey, football, soccer, squash, basketball, cross country skiing, judo, roller skating, vigorous swimming, vigorous long distance bicycling) b) MODERATE EXERCISE (NOT EXHAUSTING) (e.g., fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, alpine skiing, popular and folk dancing) c) MILD EXERCISE (MINIMAL EFFORT) (e.g., yoga, archery, fishing from river bank, bowling, horseshoes, golf, snow-mobiling, easy walking) 2. During a typical 7-Day period (a week), in your leisure time, how often do you engage in any regular activity long enough to work up a sweat (heart beats rapidly)? OFTEN SOMETIMES NEVER/RARELY CALCULATIONS For the first question, weekly frequencies of strenuous, moderate, and light activities are multiplied by nine, five, and three, respectively. Total weekly leisure activity is calculated in arbitrary units by summing the products of the separate components, as shown in the following formula: Weekly leisure activity score = (9 Strenuous) + (5 Moderate) + (3 Light) The second question is used to calculate the frequency of weekly leisure-time activities pursued long enough to work up a sweat (see questionnaire). EXAMPLE Strenuous = 3 times/wk Moderate = 6 times/wk Light = 14 times/wk Total leisure activity score = (9 3) + (5 6) + (3 14) = 27 + 30 + 42 = 99 40

7.4 Oswestry Disability Questionnaire This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem. Section 1: Pain Intensity I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment Section 2: Personal Care (Washing, Dressing, etc.) I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but can manage most of my personal care I need help every day in most aspects of self care I do not get dressed, wash with difficulty and stay in bed Section 3: Lifting I can lift heavy weights without extra pain I can lift heavy weights but it gives me extra pain Pain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed e.g. on a table Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned I can only lift very light weights I cannot lift or carry anything Section 4: Walking Pain does not prevent me walking any distance Pain prevents me from walking more than 2 kilometers Pain prevents me from walking more than 1 kilometer Pain prevents me from walking more than 500 meters I can only walk using a stick or crutches I am in bed most of the time 41

Section 5: Sitting I can sit in any chair as long as I like I can only sit in my favourite chair as long as I like Pain prevents me sitting more than one hour Pain prevents me from sitting more than 30 minutes Pain prevents me from sitting more than 10 minutes Pain prevents me from sitting at all Section 6: Standing I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing for more than 1 hour Pain prevents me from standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all Section 7: Sleeping My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep Because of pain I have less than 4 hours sleep Because of pain I have less than 2 hours sleep Pain prevents me from sleeping at all Section 8: Social Life My social life is normal and gives me no extra pain My social life is normal but increases the degree of pain Pain has no significant effect on my social life apart from limiting my more energetic interests e.g. sport Pain has restricted my social life and I do not go out as often Pain has restricted my social life to my home I have no social life because of pain Section 9: Traveling I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over two hours Pain restricts me to journeys of less than one hour Pain restricts me to short necessary journeys under 30 minutes Pain prevents me from traveling except to receive treatment 42

Section 10: Employment/Homemaking My normal homemaking/job activities do not cause pain. My normal homemaking/job activities increase my pain, but I can still perform all that is required of me. I can perform most of my homemaking/job activities, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming). Pain prevents me from doing anything but light duties. Pain prevents me from doing even light duties. Pain prevents me from performing any job or homemaking chores. Score: ( / )x 100 = % Scoring: For each section the total possible score is 5: if the first statement is marked the section score = 0, if the last statement is marked it = 5. If all ten sections are completed the score is calculated as follows: Example: 16 (total scored) / 50 (total possible score) x 100 = 32% If one section is missed or not applicable the score is calculated: 16 (total scored) / 45 (total possible score) x 100 = 35.5% Minimum Detectable Change (90% confidence): 15 points Minimum Clinically Important Difference (90% confidence): 6 points 11, 12 Source: Fritz JM, Irrgang JJ. adapted from Fairbank et al. Oswestry Score Interpretation 0% to 20% Minimal disability The patient can cope with most living activities. Usually no treatment is indicated apart from advice on lifting sitting and exercise. 21% to 40% Moderate disability The patient experiences more pain and difficulty with sitting lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care sexual activity and sleeping are not grossly affected and the patient can usually be managed by conservative means. 41% to 60% Severe disability Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation. 61% to 80% Crippled Back pain impinges on all aspects of the patient's life. Positive intervention is required. 81% to 100% Bed-bound These patients are either bed-bound or exaggerating their symptoms. (adapted from Fairbank & Pynsent, 2000) 13 43

7.5 PAR-Q 44

http://www.csep.ca/communities/c574/files/hidden/pdfs/par-q.pdf 45

7.6 Canadian Guidelines for Body Weight Classification in Adults 46

http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/nutrition/cg_quick_refldc_rapide_ref_e.pdf 47

7.7 Health Benefits Zones for Body Composition and Musculoskeletal fitness Health Benefit Zone Excellent Optimal health benefits Very Good Considerable health benefits Good Many health benefits Fair Some health risk Needs Improvement Considerable health risk Adapted from CPAFLA, 2003 pp.7-21 and 7-51 7.8 Percent Body Fat Guidelines Males Females Essential fat 2-4% 10-12% Athletes 6-13% 14-20% Fitness 14-17% 21-24% Acceptable 18-25% 25-31% Obese 25+% 32+% Adapted from American council on exercise guidelines http://www.acefitness.org/ 48

7.9A Healthy Musculoskeletal Fitness Norms for Males Males Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 20-29 yrs (kg) (cm) Excellent 115 36 40 25 Very Good 104-114 29-35 34-39 21-24 Good 95-103 22-28 30-33 16-20 Fair 84-94 17-21 25-29 11-15 Needs 83 16 24 10 Improvement Males Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 30-39 yrs (kg) (cm) Excellent 115 30 38 25 Very Good 104-114 22-29 33-37 18-24 Good 95-103 17-21 28-32 15-17 Fair 84-94 12-16 23-27 11-14 Needs 83 11 22 10 Improvement Males Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 40-49 yrs (kg) (cm) Excellent 108 25 35 25 Very Good 97-107 17-24 29-34 18-24 Good 88-96 13-16 24-28 13-17 Fair 80-87 10-12 18-23 6-12 Needs 79 9 17 5 Improvement Males Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 50-59 yrs (kg) (cm) Excellent 101 21 35 25 Very Good 92-100 13-20 28-34 17-24 Good 84-91 10-12 24-27 11-16 Fair 76-83 7-9 16-23 8-10 Needs 75 6 15 7 Improvement Males Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 60-69 yrs (kg) (cm) Excellent 100 18 33 25 Very Good 91-99 11-17 25-32 16-24 Good 84-90 8-10 20-24 11-15 Fair 73-83 5-7 15-19 6-10 Needs Improvement 72 4 14 5 Adapted from CPAFLA, 2003 pp.7-47 49

7.9B Healthy Musculoskeletal Fitness Norms for Females Females Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 20-29 yrs (kg) (cm) Excellent 70 30 41 25 Very Good 63-69 21-29 37-40 18-24 Good 58-62 15-20 33-36 14-17 Fair 52-57 10-14 28-32 5-13 Needs 51 9 27 4 Improvement Females Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 30-39 yrs (kg) (cm) Excellent 71 27 41 25 Very Good 63-70 20-26 36-40 19-24 Good 58-62 13-19 32-35 10-18 Fair 51-57 8-12 27-31 6-9 Needs 50 7 26 5 Improvement Females Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 40-49 yrs (kg) (cm) Excellent 69 24 38 25 Very Good 61-68 15-23 34-37 19-24 Good 54-60 11-14 30-33 11-18 Fair 49-53 5-10 24-29 4-10 Needs 48 4 24 3 Improvement Females Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 50-59 yrs (kg) (cm) Excellent 61 21 39 25 Very Good 54-60 11-20 33-38 19-24 Good 49-53 7-10 30-32 10-18 Fair 45-48 2-6 25-29 6-9 Needs 44 1 24 5 Improvement Females Grip Strength Push-ups (#) Sit & Reach Curl-ups (#) 60-69 yrs (kg) (cm) Excellent 54 17 35 25 Very Good 48-53 12-16 31-34 17-24 Good 45-47 5-11 27-30 8-16 Fair 41-44 2-4 23-26 3-7 Needs Improvement 40 1 22 2 Adapted from CPAFLA, 2003 pp.7-48 50

7.10 Physical Activity Guide 51

http://www.phac-aspc.gc.ca/pau-uap/fitness/pdf/guideeng.pdf 52