consecutive patients, or confined to a b. Trial with high false-negative (a) error-a narrow spectrum of study individuals (or 'negative' trial that could not exclude the both), all of whom have undergone both real possibility of a clinically important the diagnostic test and the reference benefit or difference because of small standard; numbers.

* A diagnostic CDR not validated in a test Individual well-designed cohort study set 2c Audit or or "Outcomes" Research "Outcomes" Research Audit or or "Outcomes" Research "Outcomes" Research 3a Systematic review of case-control studies Prospective or retrospective cohort study Systematic review with h.o.m.ogeneity of 3b with h.o.m.ogeneity of adequate size, but with some studies limitations in methodology 3b Individual well-designed case-control study Study with independent blind comparison of an appropriate spectrum, but the reference standard was not applied to all study patients; Non-consecutive study

4.

Case-series; Poor quality prognostic cohort studies in Case-control study in which: Cohort and case-control studies that lack which sampling was biased or * Reference standard was un.o.bjective, defined comparison groups and/or did not measurement of outcomes achieved in unblinded or not independent; measure interventions & outcomes in <80% of="" study="" patients="" *="" positive="" and="" negative="" tests="" were="" not="" similar="" and="" appropriate="" ways="" verified="" using="" separate="" reference="" standards;="" or="" or="" *="" study="" was="" performed="" in="" an="" inappropriate="" spectrum="" of="" patients="">

5.

Expert opinion (individual or committee) Expert opinion without explicit critical Expert opinion without explicit critical without explicit critical appraisal appraisal, or based on physiology, bench appraisal, or based on physiology, bench research or "first principles"

research or "first principles"

adapted from Sackett DL. Rules of evidence and clinical recommendations. Can J Cardiol Can J Cardiol 1993;9:487-489 1993;9:487-489 and NHS Research and Development Centre for Evidence-Based Medicine 2001.

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Volume 11(6), June 2003

REFERENCES.

1. Janz KF, Burns TL, Torner JC, Levy SM, Paulos R, Willing MC et al. Physical activity and bone measures in young children: the Iowa bone development study. Pediatrics Pediatrics 2001; 107(6):1387-1393. Accessed at: http://home.mdconsult.com 2. Lloyd T, Chinchilli VM, Johnson-Rollings N, Kieselhorst K, Eggli DF, Marcus R. Adult female hip bone density reflects teenage sports-exercise patterns but not teenage calcium intake. 2001; 107(6):1387-1393. Accessed at: http://home.mdconsult.com 2. Lloyd T, Chinchilli VM, Johnson-Rollings N, Kieselhorst K, Eggli DF, Marcus R. Adult female hip bone density reflects teenage sports-exercise patterns but not teenage calcium intake. Pediatrics Pediatrics 2000; 106(1 Pt 1):40-44. 2000; 106(1 Pt 1):40-44.

PMID:10878147.

3. Rowlands AV, Eston RG, Ingledew DK. Relationship between activity levels, aerobic fitness, and body fat in 8- to 10-yr-old children. J Appl Physiol J Appl Physiol 1999; 86(4):1428-1435. Accessed on: Jan. 8, 2003 at http://www.j.a.p.org 4. Patrick K, Sallis JF, Prochaska JJ, Lydston DD, Calfas KJ, Zabinski MF et al. A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents. 1999; 86(4):1428-1435. Accessed on: Jan. 8, 2003 at http://www.j.a.p.org 4. Patrick K, Sallis JF, Prochaska JJ, Lydston DD, Calfas KJ, Zabinski MF et al. A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents. Arch Pediatr Adolesc Med Arch Pediatr Adolesc Med 2001; 155(8):940-946. 2001; 155(8):940-946.

PMID:11483123.

5. Canadian Fitness and Lifestyle Research Inst.i.tute (CFLRI). Understanding Youth Physical Activity. The Research File The Research File 2000; Reference No. 00-05. 2000; Reference No. 00-05.

6. Bright Futures in Practice: Physical Activity Bright Futures in Practice: Physical Activity. Arlington, VA: National Center for Education in Maternal Child Health, 2001.

7. Kirkcaldy BD, Shephard RJ, Siefen RG. The relationship between physical activity and self-image and problem behaviour among adolescents. Soc Psychiatry Psychiatr Epidemiol Soc Psychiatry Psychiatr Epidemiol 2002; 37(11):544-550. 2002; 37(11):544-550.

8. California Department of Education. New Study Supports Physically Fit Kids Perform Better Academically. National National a.s.sociation for Sport and Physical Education a.s.sociation for Sport and Physical Education 2002. Accessed on Jan. 3, 2003 at http://www.aahperd.org/naspe 9. Boreham C, Twisk J, Neville C, Savage M, Murray L, Gallagher A. a.s.sociations between physical fitness and activity patterns during adolescence and cardiovascular risk factors in young adulthood: the Northern Ireland Young Hearts Project. 2002. Accessed on Jan. 3, 2003 at http://www.aahperd.org/naspe 9. Boreham C, Twisk J, Neville C, Savage M, Murray L, Gallagher A. a.s.sociations between physical fitness and activity patterns during adolescence and cardiovascular risk factors in young adulthood: the Northern Ireland Young Hearts Project.

Int J Sports Med 2002; 23 Suppl 1:S22-S26. PMID: 12012258 2002; 23 Suppl 1:S22-S26. PMID: 12012258 10. Schmitz KH, Jacobs DR, Jr., Hong CP, Steinberger J, Moran A, Sinaiko AR. a.s.sociation of physical activity with insulin sensitivity in children. Int J Obes Relat Metab Disord Int J Obes Relat Metab Disord 2002; 26(10):1310-1316. PMID: 12355326 2002; 26(10):1310-1316. PMID: 12355326 11. Evidence for Policy and Practice (EPPI-Centre). Young people and physical activity: a systematic review of research on barriers and facilitators. Information and Co-ordinating Centre, editor. 1-186. 2001. London, UK, Social Science Research Unit; University of London. Accessed on Jan. 10, 2003 at : http://eppi.ioe.ac.uk 12. Craig CL, Russell SJ, Cameron C. Physical activity and the media. What messages are Canadians receiving? 1998 media 1998 media study: an inmedia a.n.a.lysis study: an inmedia a.n.a.lysis 1998. Canadian Fitness and Lifestyle Research Inst.i.tute1998 Capacity Study 13. Sallis JF, Prochaska JJ, Taylor WC. A review of correlates of physical activity of children and adolescents. 1998. Canadian Fitness and Lifestyle Research Inst.i.tute1998 Capacity Study 13. Sallis JF, Prochaska JJ, Taylor WC. A review of correlates of physical activity of children and adolescents. Med Sci Sports Med Sci Sports Exerc Exerc 2000; 32(5):963-975. PMID:10795788 2000; 32(5):963-975. PMID:10795788 14. Canadian Fitness and Lifestyle Research Inst.i.tute. 2001 Physical Activity Monitor. The data for the North: Interim report.

2001 Physical Activity Monitor 2002. Accessed at: http://www.cflri.ca 15. Corbin CB, Pangrazi RP. Guidelines for Appropriate Physical Activity for Elementary School Children. 2003 Update. 2002. Accessed at: http://www.cflri.ca 15. Corbin CB, Pangrazi RP. Guidelines for Appropriate Physical Activity for Elementary School Children. 2003 Update.

National a.s.sociation for Sport and Physical Education 2002; Position Statement. Council for Physical Education for Children (COPEC). Accessed on Jan.7 at http://www.aahperd.org/naspe 16. Bar-Or O. Physical Activity in Children and Youth - Practice Based Small Group Learning Program. 23-4-2003. Personal Communication 2002; Position Statement. Council for Physical Education for Children (COPEC). Accessed on Jan.7 at http://www.aahperd.org/naspe 16. Bar-Or O. Physical Activity in Children and Youth - Practice Based Small Group Learning Program. 23-4-2003. Personal Communication 17. Health Canada. Teacher's Guide to physical activity for youth 10-14 years of age. Canada's Physical Activity Guide to Canada's Physical Activity Guide to Healthy Active Living Healthy Active Living 2002. Accessed online at http://www.healthcanada.ca/paguide or 1-888-334-9769 2002. Accessed online at http://www.healthcanada.ca/paguide or 1-888-334-9769 18. Epstein LH, Paluch RA, Kalakanis LE, Goldfield GS, Cerny FJ, Roemmich JN. How much activity do youth get? A quant.i.tative review of heart-rate measured activity. Pediatrics Pediatrics 2001; 108(3):E44. PMID:11533362 2001; 108(3):E44. PMID:11533362 19. Pipe A. Get active about physical activity. Ask, advise, a.s.sist: get your patients moving. Can Fam Physician Can Fam Physician 2002; 48:13-13. 2002; 48:13-13.

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Volume 11(6), June 2003 PMID:11852603.

20. Canadian Fitness and Lifestyle Research Inst.i.tute (CFLRI). Helping Children to Be Active. The Research File The Research File 1999; Reference No. 99-02. 1999; Reference No. 99-02.

21. Sallis JF, Pate RR. Determinants of youth physical acitivity: FITNESSGRAM FITNESSGRAM Reference Guide. The FITNESSGRAM The FITNESSGRAM Reference Guide 2001. Accessed at: http://www.cooperinst.org 22. Canadian Fitness and Lifestyle Research Inst.i.tute (CFLRI). Influences on Children's Activity. 2001. Accessed at: http://www.cooperinst.org 22. Canadian Fitness and Lifestyle Research Inst.i.tute (CFLRI). Influences on Children's Activity. The Research File The Research File 2001; Reference No. 01-01. 2001; Reference No. 01-01.

23. Royal Australian College of General Pract.i.tioners TR. Putting prevention into practice. A guide for the implementation in the Putting prevention into practice. A guide for the implementation in the general practice setting (Green Book) general practice setting (Green Book), 1st edition ed. Melbourne, Australia: RACPG, 1998.

Accessed on Feb. 13, 2003 at http://www.racgp.org.au 24. Stapleton S. Fat chance: How physicians can help patients lighten their load. The directions are clear: Eat your vegetables.

Drink water. Exercise regularly. Still the numbers on the scale go up. How can doctors get patients to comply?

amednews.com The Newspaper for America's Physician. 18-11-2002. Accessed on Nov. 11, 2002 at http://www.ama-a.s.sn.org 25. Sallis JF, Prochaska JJ, Taylor WC, Hill JO, Geraci JC. Correlates of physical activity in a national sample of girls and boys in grades 4 through 12. Health Psychol Health Psychol 1999; 18(4):410-415. PMID:10431943 1999; 18(4):410-415. PMID:10431943 26. Kennedy M. Physical Activity in Youth and Children. 11-4-2003. Personal e-mail Communication.

27. Canadian Fitness and Lifestyle Research Inst.i.tute (CFLRI). Active & Safe Travel to School. The Research File The Research File 2001; Reference No. 01-09. 2001; Reference No. 01-09.

28. Sallis JF, Conway TL, Prochaska JJ, McKenzie TL, Marshall SJ, Brown M. The a.s.sociation of school environments with youth physical activity. Am J Public Health Am J Public Health 2001; 91(4):618-620. PMID:11291375 2001; 91(4):618-620. PMID:11291375 29. Crotty MT. Parents advised to find balance between TV viewing, Video Games, Computers, Homework and Physical Activity for Children. National Heart Alliance press release . 2001. Accessed on Apr, 2003 at http://www.irishheart.ie/news/NHApressrelease.htm 30. Tudor-Locke C. Taking steps toward increased physical activity: Using pedometers to measure and motivate. The The President's Council on Physical Fitness and Sports Research Digest President's Council on Physical Fitness and Sports Research Digest 2002; Series 3(No. 17). Accessed on: Jan, 2003 at http://www.indiana.edu/~preschal 2002; Series 3(No. 17). Accessed on: Jan, 2003 at http://www.indiana.edu/~preschal 31. Rowland TW. Adolescence: A 'Risk Factor' for Physical Inactivity. Research Digest (President's Council on Physical Fitness Research Digest (President's Council on Physical Fitness and Sports) and Sports) 1999; Series 3(No. 6). Accessed on Dec. 20, 2002 at http://fitness.gov/activity 32. Katzmarzyk P.T., Malina RM. Contribution of organized sports partic.i.p.ation to estimated daily energy expenditure in youth. 1999; Series 3(No. 6). Accessed on Dec. 20, 2002 at http://fitness.gov/activity 32. Katzmarzyk P.T., Malina RM. Contribution of organized sports partic.i.p.ation to estimated daily energy expenditure in youth.

Pediatric Exercise Science 1998; 10(378):386. 1998; 10(378):386.

33. Health Canada. Canada's Physical Activity Guide for Children. Canada's Physical Activity Guide to Healthy Active Living Canada's Physical Activity Guide to Healthy Active Living 2002. Accessed online at http://www.healthcanada.ca/paguide or 1-888-334-9769 2002. Accessed online at http://www.healthcanada.ca/paguide or 1-888-334-9769 34. Health Canada. Canada's Physical Activity Guide for Youth. Canada's Physical Activity Guide to Healthy Active Living Canada's Physical Activity Guide to Healthy Active Living 2002. 2002.

Accessed online at: http://www.healthcanada.ca/paguide or 1-888-334-9769

12.

Appendix 1. SAMPLE INTERVIEW QUESTIONS, INFANT TO ADOLESCENT Sample interview questions that might be asked during a routine health exam of an infant (<1 year)="" (adapted="" from="" patrick,="" 2002)="" 6="" patrick,="" 2002)="" 6="" how="" often="" do="" you="" play="" with="" your="">

Do both you and your spouse play with your child?

What are some physical activities you do with him?

How often during the day is your child in an open environment, such as on the living room floor?

Sample interview questions that might be asked during a routine health exam of a 1- to 4-year-old (adapted from Patrick, 2002)6 Patrick, 2002)6 How often do you play with your child?

What are some physical activities that you do with your child?

How often does your child get a chance to run?

How much television do you allow your child to watch each day?

Is your neighbourhood a safe place for your child to play?

Do you partic.i.p.ate in physical activity? If so, which ones? Did you partic.i.p.ate in physical activity when you were a child? child?

Sample interview questions that might be asked during a routine health exam of a young child (>5 yrs) or an adolescent (>11 yrs) (adapted from Patrick, 2002) 6 adolescent (>11 yrs) (adapted from Patrick, 2002) 6 For the child

For the parent Do you think physical activity is important? Why? (or why Does your child regularly partic.i.p.ate in physical Does your child regularly partic.i.p.ate in physical not?) activity (for example on most, if not all, days of the Do you think you are in "good shape?" Do you think you are in "good shape?"

week?) Do you do something physically active most days of the How does your child spend his/her after school hours? How does your child spend his/her after school hours?

week?

What are your child's favourite physical activities?

What time of day are you most active? (e.g. after school, What physical activities does your child dislike What physical activities does your child dislike after supper, on the weekends?) partic.i.p.ating in?

What physical activities do you really enjoy doing? Which How much time each day do you allow your child to How much time each day do you allow your child to ones do you really dislike doing?

watch television, play video games, or watch movies?

Do you partic.i.p.ate in physical activities as a family? (for Are you physically active as a family? Are you physically active as a family?

example, walking, biking, hiking, skating, swimming, or How might you help your child become more active? How might you help your child become more active?

running?) How much time each day do you spend watching television or DVDs or playing computer games? or DVDs or playing computer games?

Appendix 2 Characteristics of Children's Physical Activity15 Children are naturally more active than adolescents or adults.

Activities need to be of short duration to maintain a young child's attention.

Children seek concrete reasons for consistently being active not abstract reasons such as "health".

Children learn skills by being physically active and in mastering these skills, increase in self-confidence.

Self-efficacy has a strong a.s.sociation with later in life adherence to a physically active lifestyle.

Skills learned in childhood will sustain leisure activities during adulthood.

High intensity activities may be discouraging for some children.

Although inactive children tend to become inactive adults, the opposite is not necessarily true.

Appendix 3. RESOURCES Free resources for children and youth 1. Health Canada. These resources are colourful and age-appropriate. Available to everyone (1-888-334-9769) or at http://www.healthcanada.ca/paguide (1-888-334-9769) or at http://www.healthcanada.ca/paguide For school-age children (ages 6-9) For Youth (ages 10-14) Gotta Move! Interactive magazine for children Let's Get Active! Interactive Magazine for Youth Physical Activity Guide for Children (single page) Physical Activity Guide for Youth (single page) Physical Activity Chart & Activity Stickers Helpful free resources for Parents

2. Health Canada (1-888-334-9769) or at http://www.healthcanada.ca/paguide Family Guide to Physical Activity for Children Family Guide to Physical Activity for Youth Helping your children become more physically active: Tips for parents and caregivers (fact sheet) at (fact sheet) at http://www.hc-sc.gc.ca http://www.hc-sc.gc.ca 3. Caring for Kids. http://www.caringforkids.cps.ca or telephone 1-613-526-9397 "Child health information from Canadian Paediatric Experts." Excellent resource on a wide variety of child- and teen-rearing topics, such as: teen-rearing topics, such as: Promoting good television habits Keeping kids safe.

Health active living.

4. Go for Green. http://www.goforgreen.ca Active and Safe Routes to School: brochure: activities one can start in the community Did you know? A child's ability to a.s.sess potential traffic dangers: Fact Sheet (the Canadian Inst.i.tute of Child A child's ability to a.s.sess potential traffic dangers: Fact Sheet (the Canadian Inst.i.tute of Child Health- CICH) Health- CICH) Walking/Cycling School Bus: brochure: practical tips and advice for starting.

5. Safe Kids Canada http://www.safekidscanada.ca Provides information on safety aspects for children under 5 years and a variety of other safety issues including Provides information on safety aspects for children under 5 years and a variety of other safety issues including winter, water, and playground safety. winter, water, and playground safety.

6. Caring for Kids Canadian Paediatric Society http://www.caringforkids.cps.ca 7. Keep Kids Healthy Free pediatrician's guide for all kinds of parenting issues 7. Keep Kids Healthy Free pediatrician's guide for all kinds of parenting issues http://www.keepkindshealthy.com Parenting Tips for newborn through adolescence for newborn through adolescence including Fitness and Exercise Guide including Fitness and Exercise Guide 8. Kids Health American Academy of Family Physicians http://www.kidshealth.org 8. Kids Health American Academy of Family Physicians http://www.kidshealth.org also http://www.familydoctor.org helpful tips on a variety of topics from exercise to preventing abductions, from also http://www.familydoctor.org helpful tips on a variety of topics from exercise to preventing abductions, from bicycle safety to weight management. bicycle safety to weight management.

The Parent Package http://www.ama-a.s.sn.org/ama/upload/mm/39/parentinfo.pdf http://www.ama-a.s.sn.org/ama/upload/mm/39/parentinfo.pdf A series of online booklets providing parents with information about their adolescents on 15 different topics A series of online booklets providing parents with information about their adolescents on 15 different topics including: including: PHYSICAL ACTIVITY PHYSICAL ACTIVITY, injuries, violence prevention, cigarettes, alcohol, illicit drugs, depression, s.e.x, HIV/AIDS, nutrition, making responsible choices, growth and development, and vaccinations HIV/AIDS, nutrition, making responsible choices, growth and development, and vaccinations 9. Pedometers 9. Pedometers For information: Watch Your Step: Pedometers and Physical Activity. WellSpring, 2003, Vol. 14(2) published by the Alberta Centre for Active Living. (8 pgs.) Available free of charge at (780) 4276949 (toll-free in Alberta only: 1-800-661-4551) or online at http://www.centre4activeliving.ca/Publications/WellSpring/index.htm the Alberta Centre for Active Living. (8 pgs.) Available free of charge at (780) 4276949 (toll-free in Alberta only: 1-800-661-4551) or online at http://www.centre4activeliving.ca/Publications/WellSpring/index.htm How to effectively use your pedometer! Step by step guide and Q & A. http://www.pedometer.com (Mar., 2003) How to effectively use your pedometer! Step by step guide and Q & A. http://www.pedometer.com (Mar., 2003) -Available at local sporting goods stores, the Running Room or fitness equipment stores -Bally Kids Go the Distance Pedometer, $14.99, currently available through Avon catalogues, also online auctions at http://cgi.ebay.com (Mar., 2003) at http://cgi.ebay.com (Mar., 2003) Pokemon, Pikachu 2,website information http://www.amazon.co.uk -A variety of pedometers (including Pokemon, Pikachu 2) available online through http://half.ebay.com/ or http://pages.ebay.ca/index.html (type in pedometer). Lots of choices, including a wrist.w.a.tch option. http://pages.ebay.ca/index.html (type in pedometer). Lots of choices, including a wrist.w.a.tch option.

Helpful resources, tools, fact sheets for physicians 10. Evidence-base Resource Sheets. Canadian Task Force on Preventive Health Care (CTFPHC) http://www.ctfphc.org http://www.ctfphc.org

Rourke Baby Records 11. Put Prevention into Practice (PPIP) Agency for Healthcare Research and Quality (AHRQ) http://www.ahcpr.gov contains physician preventive care fact sheets, charts, and reminder postcards http://www.ahcpr.gov contains physician preventive care fact sheets, charts, and reminder postcards 12. Putting Prevention into Practice The Royal Australian College of General Pract.i.tioners (RACPG) 12. Putting Prevention into Practice The Royal Australian College of General Pract.i.tioners (RACPG) a monograph on the implementation of preventive care in practice with helpful and practical appendices a monograph on the implementation of preventive care in practice with helpful and practical appendices http://www.racgp.org.au http://www.racgp.org.au