Original quantitative research – Strength-training and balance activities in Canada: historical trends and current prevalence

Abstract

Introduction: Muscle-strengthening and balance activities are associated with the prevention of illness and injury. Age-specific Canadian 24-Hour Movement Guidelines include recommendations for muscle/bone-strengthening and balance activities. From 2000–2014, the Canadian Community Health Survey (CCHS) included a module that assessed frequency in 22 physical activities. In 2020, a healthy living rapid response module (HLV-RR) on the CCHS asked new questions on the frequency of muscle/bone-strengthening and balance activities. The objectives of the study were to (1) estimate and characterize adherence to meeting the muscle/bone-strengthening and balance recommendations; (2) examine associations between muscle/bone-strengthening and balance activities with physical and mental health; and (3) examine trends (2000–2014) in adherence to recommendations.

Methods: Using data from the 2020 CCHS HLV-RR, we estimated age-specific prevalence of meeting recommendations. Multivariate logistic regressions examined associations with physical and mental health. Using data from the 2000–2014 CCHS, sex-specific temporal trends in recommendation adherence were explored using logistic regression.

Results: Youth aged 12 to 17 years (56.6%, 95% CI: 52.4–60.8) and adults aged 18 to 64 years (54.9%, 95% CI: 53.1–56.8) had significantly greater adherence to the muscle/bone-strengthening recommendation than adults aged 65 years and older (41.7%, 95% CI: 38.9–44.5). Only 16% of older adults met the balance recommendation. Meeting the recommendations was associated with better physical and mental health. The proportion of Canadians who met the recommendations increased between 2000 and 2014.

Conclusion: Approximately half of Canadians met their age-specific muscle/bone-strengthening recommendations. Reporting on the muscle/bone-strengthening and balance recommendations elevates their importance alongside the already recognized aerobic recommendation.

Keywords: muscle, physical activity, recommendations, 24H Guidelines, physical health, mental health, youth, adults, older adults, adherence

Introduction

The benefits of regular aerobic physical activity (PA) are well established.^{Footnote 1Footnote 2Footnote 3} Aerobic PA is often the centrepiece of health promotion initiatives targeting health behaviours,^{Footnote 4} with adherence to this recommendation the cornerstone of PA surveillance.^{Footnote 5} The recently released Canadian 24-Hour Movement Guidelines (“24H Guidelines”) recommend a minimum of 60 min/d of moderate-to-vigorous intensity physical activity (MVPA) for children and youth (5–17 years old) and 150 min/wk for adults (18–64 years) and older adults (≥65 years).^{Footnote 6} The guidelines also recommend muscle and bone strengthening for children and youth (≥3 d/wk), muscle strengthening for adults aged 18 to 65 years (≥2 d/wk) and muscle-strengthening and balance activities for adults 65 years and older (strength: ≥2 d/wk; balance: no minimum frequency).^{Footnote 6}

The recommendations for MVPA, muscle/bone and balance activities were also part of the Canadian Physical Activity Guidelines^{Footnote 7} that were released a decade earlier, in 2011. (The 24H Guidelines no longer have the requirement for 10-minute bouts of MVPA.)

Muscle-strengthening exercise refers to resistance training using free or machine weights, elastic bands or one’s own body weight.^{Footnote 8} This type of exercise plays a unique and independent role in preventing disease and premature mortality.^{Footnote 8Footnote 9} Health benefits include increased skeletal muscle mass and strength and bone mineral density, improved cardiometabolic and physical functioning, reduced musculoskeletal symptoms and reduced symptoms of anxiety and depression.^{Footnote 10Footnote 11Footnote 12Footnote 13}

Muscle-strengthening exercise has often been described as the “forgotten” PA guideline.^{Footnote 5Footnote 14Footnote 15} A 2018 review of international efforts identified only five surveys that included direct/explicit questions about muscle strengthening.^{Footnote 5} There is also evidence to suggest that the combined health benefits of aerobic PA and strength-training activities is greater than those of either activity alone.^{Footnote 16Footnote 17}

Bone-strengthening and balance-training activities are also key components of a healthy PA profile. Bone strengthening, which increases resistance to fracture, includes “movements that create impact- and muscle-loading forces on the bone” such as jumping, skipping and hopping.^{Footnote 3} Balance-training activities include movements that challenge postural control; these activities help resist forces that can lead to falls^{Footnote 18} and maintain physical functioning.^{Footnote 19} Some activities provide simultaneous muscle and bone strengthening and balance training, making it difficult to define them separately. The overlap between muscle- and bone-strengthening exercises is particularly challenging to assess independently. For the purpose of this paper, we use the expression “muscle/bone strengthening” to recognize that some activities may have benefits for both.

In Canada, the Physical Activity, Sedentary Behaviour and Sleep (PASS) Indicators provide important surveillance information on the PA levels of children, youth and adults.^{Footnote 20Footnote 21} The proportion of Canadians meeting PA recommendations has traditionally been reported as the proportion meeting the aerobic component of the 24H Guidelines (i.e. 60 min/d for children and youth or 150 min/wk for adults),^{Footnote 20} consistent with the PASS surveillance recommendations released alongside the 24H Guidelines.^{Footnote 22Footnote 23} Until recently, there has been a lack of national data to assess adherence to the muscle/bone-strengthening and balance components of the 24H Guidelines (and the previous Canadian PA Guidelines). As a result, the PASS Indicators do not report on the proportion of Canadians meeting the age-specific muscle/bone-strengthening or balance recommendations.

In 2020, the Public Health Agency of Canada funded the development of the healthy living rapid response module (HLV-RR) in the Canadian Community Health Survey (CCHS). The HLV-RR module includes two questions to assess muscle/bone-strengthening and balance activities and allows the reporting of current prevalence of meeting the muscle/bone-strengthening and balance components of the 24H Guidelines, as well as meeting the combined PA recommendations (MVPA + muscle/bone strengthening + balance).

The PA module (PAC) in earlier cycles of the annual CCHS (2000–2014) asked participants to self-report frequency of 22 activities over the previous 3 months. Several of the activities could be considered to be muscle/bone-strengthening and/or balance exercises. While using a list of activities to establish adherence to muscle-strengthening exercise is possible,^{Footnote 5} there has been no known attempt to examine the PAC in this way.

Our study objectives were to:

1. estimate the proportion of Canadian youth (12–17 years), adults (18–64 years) and older adults (≥65 years) currently meeting the age-specific muscle/bone-strengthening and balance-activity recommendations of the 24H Guidelines;
2. compare the demographic and clinical characteristics of those categorized as meeting the muscle/bone-strengthening and balance recommendations with those meeting the combined recommendations (MVPA + muscle/bone strengthening + balance), the aerobic PA only recommendations (MVPA) and none of the recommendations;
3. examine the association between meeting combinations of the recommendations and measures of physical and mental health; and
4. examine age group–specific trends in muscle/bone-strengthening and balance activities among Canadians, using the CCHS (2000–2014).

Methods

Data source

To meet objectives 1, 2 and 3, we used the HLV-RR data from the 2020 CCHS, and to meet objective 4, we used annual data from older cycles of the CCHS (2000–2014). The CCHS is an ongoing, cross-sectional survey conducted by Statistics Canada. The survey collects self-reported health information from a representative sample of the Canadian household-dwelling population aged 12 years and older living in the provinces and territories. The CCHS excludes individuals living on reserves and Crown Lands, institutionalized residents, full-time members of the Canadian forces, youth aged 12 to 17 years living in foster care and residents in certain remote regions; this is approximately 2% of the Canadian population aged 12 years and older.

The HLV-RR data were collected between January and March 2020, prior to the COVID-19 pandemic. Those who completed the HLV-RR also participated in the 2020 CCHS during the data collection period, except that the HLV-RR excluded respondents living in the three territories and proxy respondents. In total, 11 105 non-proxy respondents completed the HLV-RR. At the national level, the HLV-RR had a household-level response rate of 57.0%.^{Footnote 24}

Study population

The study population included those who completed the strength and balance questions of the 2020 CCHS HLV-RR (N = 10 775) or the annual CCHS (N = 57 070 to N = 124 685, depending on the year) for the years 2000 to 2014. The CCHS provided estimates for 2 years combined from 2000 to 2006, and annual estimates from 2007 onwards.

Study variables

Independent variables

Table 1 shows the variables used to explore current prevalence (2020 CCHS HLV-RR) and trends (2000–2014 CCHS PACs) in age-specific muscle/bone-strengthening and balance recommendations.

Table 1. Description of methods used to derive the independent variables used to explore current prevalence and trends in PA

Derived variable	Questions used	Variable derivation
Adherence to muscle or muscle/bone-strengthening recommendations To classify PA as strength training, we used the following definition: “contracting the muscles against a resistance to ‘overload’ and bring about a training effect in the muscular system. The resistance is an external force, which can be one’s own body placed in an unusual relationship to gravity (e.g. prone back extension) or an external resistance (e.g. free weight)”.Footnote 25 In addition to strength training, many PAs involve impact that benefits and strengthens muscle and bone. Impact exercise was considered any activity with a GRF ≥1 × body weight on the lower extremitiesFootnote 26Footnote 27 including low-impact exercise (GRF 1.1–1.5 × body weight), e.g. rollerblading and skateboarding; moderate impact exercise (GRF 1.51–3.10 × body weight), e.g. jogging, soccer and baseball; and high impact exercise (GRF ≥3.11 × body weight), e.g. jumping rope, ballet, volleyball.
Current prevalence (HLV-RR 2020)	In the past 7 days, on how many days did you do activities that increase bone or muscle strength? Examples of muscle/bone-strengthening activities included with the question: lifting weights; carrying heavy loads; shovelling [snow]; doing sit-ups; or running, jumping or doing sports that involve a quick change in direction.	Youth (12–17 years) muscle/bone strengthening: ≥3 days Adults (18–64 years) muscle strengthening: ≥2 days Older adults (≥65 years): muscle strengthening: ≥3 days
Historical trends (CCHS 2000–2014)	The PAC asked respondents to self-report the frequency of participating in 22 specific activities over the previous 3 months. It was hypothesized that impact, weight training or both combined are important for muscle/bone strengthening. The strategy was to look at weight training alone and then combined with moderate-to-high impact activities. A sensitivity analysis led to understanding how adding low-impact activities affects the actual proportion of Canadians meeting the muscle/bone-strengthening recommendation. Muscle/bone-strengthening activities were examined as strength training (i.e. weight training); moderate-to-high impact activities (i.e. jogging and running, tennis, volleyball, basketball, soccer) + weight training; and low-impact activities (i.e. walking for exercise, gardening or yard work, popular or social dance, ice hockey, ice skating, in-line skating or rollerblading, golfing, exercise class or aerobics, downhill skiing or snowboarding, baseball or softball) + moderate-to-high impact activities + weight training.	The total 3-month frequency of each activity was divided by 12 to generate an average weekly frequency (assumed 4 weeks/month). Youth (12–17 years) muscle/bone-strengthening adherence: ≥3 days Adults (18–64 years) muscle-strengthening adherence: ≥2 days Older adults (≥65 years) muscle-strengthening adherence: ≥3 days
Adherence to balance recommendation To classify the balance activities, we applied the following definition from the Prevention of Falls Network Europe (ProFaNE) Taxonomy: “…involv[ing] the efficient transfer of body weight from one part of the body to another or challenges specific aspects of the balance system (e.g. vestibular systems). Balance retraining activities range from re-education of basic functional movement patterns to a wide variety of dynamic activities that target more sophisticated aspects of balance”.Footnote 25 Examples include tai chi, static balance exercise (e.g. standing on one foot), dynamic balance exercise (e.g. tandem walking) or PAs with a reduced base of support or moving to the limits of stability (e.g. downhill skiing, golfing).
Current prevalence (HLV-RR 2020)	In the past 7 days, on how many days did you do any activities that improve balance? Examples of activities included yoga, tai chi, dance, tennis, volleyball and balance training.	Older adults (≥65 years): balance activities ≥2 days and 7 days. The 24H Guidelines for Adults 65 Years and Older do not explicitly state a minimum weekly frequency for balance activities. We explored adherence to twice-weekly and daily frequencies because clinical trials generally measure twice-weekly balance activities, but documentation supporting the 24H Guidelines suggests that older adults should engage daily in activities that routinely challenge balance.Footnote 28
Historical trends (CCHS 2000–2014)	The PAC module asked respondents to self-report the frequency of 22 specific activities over the previous 3 months. Balance activities were examined as: (1) sports-related activities that may challenge balance (i.e. popular or social dance, ice hockey, ice skating, in-line skating and rollerblading, jogging or running, golfing, downhill skiing or snowboarding, bowling, baseball or softball, tennis, volleyball, basketball, soccer); (2) sports or exercise or leisure activities that may challenge balance (i.e. sports-related + walking for exercise, gardening or yard work, bicycling, home exercises, exercise class or aerobics, weight training).	The total 3-month frequency of each activity was divided by 12 to generate an average weekly frequency (assumed 4 weeks/month). Older adults (≥65 years): balance activities ≥2 days

Dependent variables

Population characteristics

Characteristics examined included age (12–17, 18–64, ≥65 years); sex (male, female); immigration status (landed immigrant, non-immigrant); cultural/racial background (White, non-White; the category “White” does not include Indigenous people); household education (secondary or less, postsecondary graduate); distribution of household income quintile (relative measure of household income to household income of all other respondents); and marital status (married/common law, single [widowed/divorced/separated/never married]). Disaggregations for gender were calculated, but too few respondents identified as gender diverse to generate stable results.

Health behaviours

Self-reported health behaviours included smoking status; meeting the leisure screen time recommendation (≤2 hours per day for youth; ≤3 hours per day for adults); and meeting the sleep recommendations (youth 12–13 years, 9–11.99 hours/night; youth 14–17 years: 8–10.99 hours/night; adults 18–64 years: 7–9.99 hours/night; adults ≥65 years: 7–8.99 hours/night).

Physical and mental health

Measures of health included self-reported general health (“excellent/very good” vs. “good/fair/poor”); self-reported mental health (“excellent/very good” vs. “good/fair/poor”); self-reported body mass index (BMI; under/normal weight vs. overweight/obesity; youth: based on age- and sex-specific BMI cut-points as defined by the World Health Organization; adults: based on Health Canada and World Health Organization body weight classification systems, corrected using the methods of Connor Gorber et al.^{Footnote 29}); and multimorbidity (self-reported diagnoses of ≥2 of asthma, arthritis, cancer, diabetes, heart disease, stroke, chronic respiratory disease [in those ≥35 years] and mood disorders).

Statistical analyses

Analyses were performed using SAS Enterprise Guide v.7.1 (SAS Institute Inc., Cary, NC, US). For objective 1, we used proportions and 95% confidence intervals (CIs) conducted with proc surveyfreq to describe adherence to the age-specific aerobic PA only (MVPA), muscle/bone strengthening only, balance only and combined (muscle/bone strengthening/balance + aerobic PA) recommendations, overall and by sex and age group (youth, adults and older adults).

For objective 2, we also present characteristics of those meeting the recommendations using proportions or means and 95% CIs. Comparisons between those meeting and those not meeting the various combinations of recommendations were assessed using independent sample t tests (proc surveyreg) for continuous outcomes or chi-square (proc surveyfreq) for categorical outcomes.

For objective 3, we assessed the association between meeting the recommendations or combinations of the recommendations and measures of physical and mental health using age-specific multivariate logistic regression models controlling for sex, household income and smoking status conducted using proc surveylogistic.

For objective 4, we present the historical prevalence (2000–2014) of those meeting the age-specific muscle/bone-strengthening/balance recommendations by age and sex using weighted proportions and 95% CIs (proc surveyfreq). The prevalence of meeting each recommendation was graphed against time in years. Age- and sex-specific temporal trends in prevalence were explored using logistic regression with time (CCHS cycle) as a continuous variable to assess if time was a significant predictor of meeting the recommendations conducted using proc surveylogistic.

All analyses were weighted using appropriate cycle survey weights. To account for survey design effects, 95% CIs were estimated using the bootstrap balanced repeated replication technique with 500 replicate weights for the 2000–2014 CCHS, and 1000 replicate weights for the 2020 CCHS. Statistical significance was set at p < 0.05.

Results

Current adherence to recommendations (Objective 1)

In 2020, youth (56.6%, 95% CI: 52.4–60.8%) and adults aged 18–64 years (54.9%, 95% CI: 53.1–56.8%) had significantly greater adherence to the muscle/bone-strengthening recommendation than older adults aged 65 years and older (41.7%, 95% CI: 38.9–44.5%).

Characteristics of adherence to recommendations (Objective 2)

Across all age groups, males were significantly more likely than females to meet the muscle-strengthening recommendation (see Table 2). Males aged 12–17 years and 18–64 years were also more likely to meet the combined PA recommendations than their female counterparts.

Table 2. Canadians’ adherence to individual and combined aerobic, muscle/bone-strengthening and balance PA recommendations, by age and sex, 2020

Recommendation met	Youth (12–17 years)						Adults (18–64 years)						Older adults (≥65 years)
	Males			Females			Males			Females			Males			Females
	%	LCL	UCL	%	LCL	UCL	%	LCL	UCL	%	LCL	UCL	%	LCL	UCL	%	LCL	UCL
Aerobic	65.8	59.3	72.3	49.3Footnote *	43.0	55.7	62.3	59.2	65.3	53.9Footnote *	51.1	56.6	46.6	42.3	50.9	35.7Footnote *	32.4	38.9
Muscle and bone strength	61.8	56.0	67.6	51.2Footnote *	44.9	57.4	61.2	53.4	64.1	48.7Footnote *	46.0	51.4	49.3	44.9	53.7	35.4Footnote *	32.1	38.6
Balance ≥2 d/wk	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	13.8	11.1	16.6	18.1Footnote *	15.2	21.1
Balance 7 d/wk	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	5.8Footnote E	3.8	7.9	4.5Footnote E	3.0	6.0
Combined muscle/bone + aerobic (+ balance in older adults)	50.3	43.2	57.3	32.9Footnote *	26.9	39.0	46.6	43.6	49.9	34.9Footnote *	32.3	37.5	8.6	6.5	10.8	9.2	6.8	11.5

Because very few older adults met the 7-day balance recommendation compared to the 2-day requirement, for all further analyses we applied the twice-weekly requirement. Older (≥65 years) females were more likely than older males to meet the balance recommendation.

The proportion of Canadians meeting the strength recommendation was lower among landed immigrants, non-White ethnicities, those with a lower household education and those with lower household income (see Table 3). The same differences were observed for the combined PA recommendations except for no difference by cultural/racial background. Among older adults, adherence to the balance recommendation (≥2 times per week) was significantly lower among those with lower household education than those with higher household education.

Table 3. Characteristics associated with meeting the muscle/bone-strengthening, balance and combined PA recommendations, Canada, 2020

Characteristics	Muscle/bone strength recommendation (total sample)			Balance recommendation (older adults)			Combined muscle/bone + aerobic (+ balance in older adults) (total sample)
	%Footnote a	LCL	UCL	%Footnote a	LCL	UCL	%Footnote a	LCL	UCL
Demographics
Age, years
12–17	56.6Footnote *	52.4	60.8	N/A	N/A	N/A	41.7Footnote *	36.9	46.4
18–64	54.9Footnote *	53.1	56.8	N/A	N/A	N/A	40.7Footnote *	38.8	42.7
≥65	41.7Footnote *	38.9	44.5	16.2	14.1	18.3	8.9Footnote *	7.3	10.5
Sex
Male	59.1Footnote *	56.8	61.5	13.8Footnote *	11.1	16.6	40.0Footnote *	37.7	42.4
Female	46.1Footnote *	44.0	48.3	18.1Footnote *	15.2	21.1	29.5Footnote *	27.4	31.5
Marital status
Married or common law	52.8	50.6	55.0	16.4	13.6	19.2	33.7	31.6	35.7
SingleFootnote b	52.2	49.7	54.6	15.9	13.0	18.8	36.0	33.7	38.4
Immigration status
Landed immigrant	45.4Footnote *	41.4	49.5	18.0	12.8	23.2	26.3Footnote *	22.7	30.0
Non-immigrant	54.9Footnote *	53.1	56.6	15.8	13.5	18.1	37.3Footnote *	35.6	38.9
Cultural/racial background
Non-White	47.5Footnote *	43.2	51.7	18.7Footnote E	10.3	27.1	31.4	26.9	36.0
White	53.8Footnote *	52.1	55.4	15.8	13.7	17.9	35.1	33.4	36.9
Highest household education level
Secondary or less	42.4Footnote *	38.9	45.8	12.2Footnote *	8.9	15.6	20.6Footnote *	17.8	23.4
Postsecondary graduate	54.6Footnote *	52.8	56.3	18.0Footnote *	15.4	20.6	37.7Footnote *	35.9	39.5
Distribution of household income quintile
Q1 (Lowest)	41.3Footnote *	38.2	44.4	14.4	10.7	18.1	25.3Footnote *	22.4	28.3
Q2	51.1Footnote *	47.6	54.7	14.6	10.9	18.3	30.8Footnote *	27.4	34.2
Q3	52.0Footnote *	48.0	56.1	14.3	10.1	18.5	34.0Footnote *	30.1	37.9
Q4	59.9Footnote *	56.1	63.7	22.8	17.2	28.4	41.0Footnote *	36.8	45.1
Q5 (Highest)	58.6Footnote *	54.9	62.3	17.9	12.5	23.4	42.1Footnote *	38.6	45.7
Health behaviours
Smoking status
Smoker	52.4	47.8	56.9	8.0Footnote EFootnote *	3.3	12.7	33.0	28.6	37.3
Non-smoker	52.6	50.8	54.3	17.1Footnote *	14.8	19.5	34.9	33.3	36.6
Leisure screen time recommendationFootnote c
Met recommendation	56.3Footnote *	54.3	58.2	18.2Footnote *	15.4	21.0	37.6Footnote *	35.6	39.7
Did not meet recommendation	46.0Footnote *	43.4	48.5	13.6Footnote *	10.6	16.7	29.4Footnote *	26.9	31.9
Sleep time recommendationFootnote d
Met recommendation	55.4Footnote *	53.5	57.4	18.8Footnote *	15.4	22.1	38.2Footnote *	36.2	40.2
Did not meet recommendation	46.9Footnote *	43.8	50.1	12.7Footnote *	10.2	15.2	27.2Footnote *	24.2	30.1
MVPAFootnote e
Met recommendation	68.2Footnote *	66.3	70.2	28.6Footnote *	26.4	30.9	100Footnote *	N/A	N/A
Did not meet recommendation	33.2Footnote *	30.9	35.4	9.6Footnote *	8.3	10.9	0Footnote *	N/A	N/A

Health behaviours and adherence to recommendations (Objective 2)

Among youth and adults, there was no statistically significant difference between smokers and non-smokers for meeting the muscle/bone-strengthening or combined PA recommendations (see Table 3). Those who met the screen time, sleep and aerobic PA recommendations were more likely to meet muscle/bone-strengthening combined recommendations than those who did not.

Among older adults, statistically significant differences were observed across all recommendations with non-smokers and those who met the screen, sleep and aerobic PA recommendations more likely to meet the balance recommendation.

Association between recommendation adherence and health (Objective 3)

Meeting the age-specific muscle/bone-strengthening, balance and combined PA recommendations was associated with a significantly reduced likelihood of multimorbidity and increased likelihood of excellent and very good perceived mental and general health (see Table 4). In addition, among older adults, meeting the balance recommendations was associated with a reduced likelihood of overweight and obesity.

Table 4. Associations between meeting the muscle/bone-strengthening, balance and combined PA recommendations and health outcomes, Canada, 2020

Health outcomes	Muscle/bone strength recommendation (total sample)						Balance recommendation (older adults)						Combined muscle/bone + aerobic (+ balance in older adults) (total sample)
	%Footnote a	LCL	UCL	aORFootnote b	LCL	UCL	%Footnote a	LCL	UCL	aORFootnote c	LCL	UCL	%Footnote a	LCL	UCL	aORFootnote b	LCL	UCL
BMI categoryFootnote d
Overweight and obese	51.9	49.7	54.1	0.91	0.77	1.07	13.8Footnote *	11.5	16.0	0.54	0.39	0.74	33.8	31.6	35.9	0.98	0.82	1.17
Under and normal weight	54.5	51.7	57.4	1.00	N/A	N/A	22.0Footnote *	17.9	26.2	1.00	N/A	N/A	37.2	34.2	40.1	1.00	N/A	N/A
Multimorbidity statusFootnote e
2+ chronic conditions	37.4Footnote *	33.8	41.1	0.68	0.57	0.82	9.9Footnote *	7.5	12.2	0.47	0.34	0.66	18.9Footnote *	15.8	22.0	0.79	0.62	1.00
<2 chronic conditions	54.5Footnote *	52.8	56.3	1.00	N/A	N/A	18.7Footnote *	16.0	21.5	1.00	N/A	N/A	36.8Footnote *	35.0	38.5	1.00	N/A	N/A
Self-reported mental health
Excellent/very good	55.5Footnote *	53.6	57.4	1.36	1.18	1.56	17.5Footnote *	14.9	20.2	1.43	1.01	2.02	36.7Footnote *	34.9	38.6	1.32	1.12	1.57
Good/fair/poor	46.7Footnote *	43.9	49.4	1.00	N/A	N/A	12.6Footnote *	9.7	15.6	1.00	N/A	N/A	30.5Footnote *	27.6	33.4	1.00	N/A	N/A
Self-reported general health
Excellent/very good	58.3Footnote *	56.2	60.4	1.65	1.44	1.90	20.5Footnote *	17.1	23.9	1.80	1.33	2.44	41.2Footnote *	39.1	43.2	1.84	1.55	2.18
Good/fair/poor	43.2Footnote *	40.7	45.6	1.00	N/A	N/A	11.9Footnote *	9.7	14.1	1.00	N/A	N/A	24.2Footnote *	21.7	26.7	1.00	N/A	N/A

Trends in adherence to recommendations (Objective 4)

Figures 1 and 2 show age- and sex-specific trends in meeting the muscle/bone-strengthening and balance recommendations, respectively. The difference between Figures 2a and 2b are largely due to the addition of leisure activities; these can—but do not always—challenge balance. Walking, gardening/yard work and cycling are three of the most popular leisure activities, with 71% of older adults reporting walking, 49% reporting gardening/yard work and 24% reporting cycling in 2014. Removal of these activities to assess balance resulted in a decline in adherence to the balance recommendation from 76.1% to 46.9% (data not shown).

Figure 1 - Text description

Percent of youth (12-17 years) meeting the strength training recommendation by lifting weights

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	10.74854	9.658143351	11.83894574
	Females	2.596307	2.002758078	3.189855675
2002-03	Males	13.87895	12.45975907	15.29813965
	Females	3.363153	2.711093925	4.015211796
2004-05	Males	13.66253	12.33481502	14.99025047
	Females	2.29997	1.811258552	2.788680754
2006-07	Males	12.36218	10.43543968	14.28891401
	Females	2.780633Footnote E	1.787663926	3.773601522
2008	Males	13.20677	11.31517245	15.09837546
	Females	2.445849Footnote E	1.532331745	3.35936545
2009	Males	15.10212	12.88887426	17.31536823
	Females	2.514115Footnote E	1.655699765	3.372529653
2010	Males	12.61818	10.59940939	14.63695574
	Females	2.135786Footnote E	1.350680215	2.92089129
2011	Males	14.94864	12.84289062	17.05439196
	Females	4.307524	3.017766352	5.597281041
2012	Males	11.74511	9.819911762	13.6703014
	Females	3.349675Footnote E	1.951407667	4.747943002
2013	Males	14.64639	12.45503648	16.83774371
	Females	3.334147Footnote E	1.996497574	4.671796349
2014	Males	13.68332	11.74518314	15.62146139
	Females	3.722934	2.544518804	4.901349091
2020	Males	61.78177	55.97882271	67.5847267
	Females	51.16955	44.89769028	57.44141399

Percent of adults (18-64 years) meeting the strength training recommendation by lifting weights

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	11.32106	10.81814	11.82399
	Females	6.186992	5.864525	6.50946
2002-03	Males	14.78706	14.23323	15.34088
	Females	9.132783	8.689821	9.575744
2004-05	Males	14.79677	14.15049	15.44305
	Females	9.518243	9.010415	10.02607
2006-07	Males	14.37782	13.57721	15.17842
	Females	8.677797	8.046111	9.309483
2008	Males	14.60139	13.83956	15.36321
	Females	8.828437	8.199563	9.457312
2009	Males	16.64767	15.70382	17.59153
	Females	9.707218	9.022684	10.39175
2010	Males	16.11195	15.17849	17.04542
	Females	9.283709	8.619773	9.947645
2011	Males	17.3763	16.33291	18.4197
	Females	10.28864	9.539301	11.03797
2012	Males	16.41054	15.3798	17.44127
	Females	8.785843	8.040066	9.531621
2013	Males	17.82385	16.75468	18.89302
	Females	9.431802	8.741984	10.12162
2014	Males	17.86699	16.88071	18.85326
	Females	9.605791	8.864763	10.34682
2020	Males	61.23258	58.39845	64.06672
	Females	48.72198	46.00388	51.44008

Percent of older adults (65+ years) meeting the strength training recommendation by lifting weights

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	2.069746	1.666703	2.472788
	Females	0.829796Footnote E	0.54186	1.117732
2002-03	Males	3.759292	3.136386	4.382199
	Females	1.264979	1.025878	1.504079
2004-05	Males	4.039303	3.379674	4.698932
	Females	1.884873	1.523563	2.246183
2006-07	Males	4.671785	3.902236	5.441335
	Females	2.333324	1.793253	2.873394
2008	Males	4.477515	3.642319	5.312711
	Females	2.585797	1.976135	3.195459
2009	Males	5.242921	4.309197	6.176645
	Females	2.638782	2.072293	3.205271
2010	Males	5.481843	4.401126	6.562561
	Females	2.457883	1.972021	2.943744
2011	Males	5.943533	4.767426	7.11964
	Females	3.143817	2.514177	3.773456
2012	Males	5.743785	4.669492	6.818078
	Females	3.20853	2.611311	3.805749
2013	Males	6.384513	5.384511	7.384515
	Females	3.350926	2.753229	3.948624
2014	Males	6.085631	5.18021	6.991051
	Females	3.172021	2.663664	3.680379
2020	Males	49.30484	44.93607	53.67362
	Females	35.35068	32.08791	38.61345

Percent of youth (12-17 years) meeting the strength training recommendation by moderate-to-high impact activities and lifting weights

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	36.61708	34.89752	38.33664
	Females	24.40898	22.82668	25.99128
2002-03	Males	46.13715	44.42489	47.84941
	Females	33.80704	32.04977	35.56432
2004-05	Males	46.88926	44.98115	48.79737
	Females	31.74044	29.97998	33.50089
2006-07	Males	47.71262	44.50159	50.92365
	Females	33.30038	30.06888	36.53189
2008	Males	49.5751	46.60419	52.54601
	Females	30.99351	28.36917	33.61786
2009	Males	47.78705	44.62693	50.94717
	Females	34.00423	31.24808	36.76039
2010	Males	48.07891	45.18399	50.97384
	Females	30.85795	27.89548	33.82041
2011	Males	46.35302	43.47261	49.23344
	Females	36.23855	33.12962	39.34748
2012	Males	47.80503	44.50077	51.1093
	Females	32.76515	29.69335	35.83695
2013	Males	47.34908	44.23436	50.4638
	Females	34.61367	31.66496	37.56238
2014	Males	50.16394	47.12845	53.19943
	Females	31.58395	28.51257	34.65533
2020	Males	61.78177	55.97882	67.58473
	Females	51.16955	44.89769	57.44141

Percent of adults (18-64 years) meeting the strength training recommendation by moderate-to-high impact activities and lifting weights

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	17.67316	17.08029	18.26604
	Females	10.49069	10.08478	10.8966
2002-03	Males	23.43494	22.78145	24.08844
	Females	15.13441	14.5992	15.66962
2004-05	Males	23.77116	22.926	24.61632
	Females	16.62756	15.85293	17.40219
2006-07	Males	23.32551	22.25685	24.39417
	Females	15.94077	15.04342	16.83811
2008	Males	23.9538	23.00933	24.89828
	Females	16.22222	15.44606	16.99838
2009	Males	26.43375	25.33692	27.53059
	Females	17.54882	16.71742	18.38021
2010	Males	26.17849	25.0894	27.26759
	Females	17.43046	16.55488	18.30604
2011	Males	27.55326	26.34407	28.76245
	Females	19.1255	18.1918	20.0592
2012	Males	25.6728	24.49691	26.84868
	Females	18.02958	17.08631	18.97286
2013	Males	28.25071	27.04697	29.45445
	Females	19.25333	18.3349	20.17175
2014	Males	27.52429	26.36445	28.68413
	Females	18.97385	18.00708	19.94062
2020	Males	61.23258	58.39845	64.06672
	Females	48.72198	46.00388	51.44008

Percent of older adults (65+ years) meeting the strength training recommendation by moderate-to-high impact activities and lifting weights

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	3.332451	2.751335	3.913567
	Females	1.220842	0.898975	1.542709
2002-03	Males	5.093026	4.365199	5.820854
	Females	1.844811	1.536401	2.153221
2004-05	Males	5.991236	5.217593	6.76488
	Females	2.3027	1.897707	2.707694
2006-07	Males	6.382709	5.382906	7.382512
	Females	2.957962	2.260896	3.655028
2008	Males	6.573284	5.435002	7.711565
	Females	3.291487	2.589688	3.993286
2009	Males	6.99407	5.951793	8.036347
	Females	3.429575	2.802393	4.056757
2010	Males	6.983925	5.782162	8.185688
	Females	3.32122	2.636971	4.005469
2011	Males	7.698683	6.429034	8.968332
	Females	3.884517	3.210272	4.558763
2012	Males	8.184136	6.798596	9.569676
	Females	3.879207	3.247466	4.510948
2013	Males	7.721702	6.674637	8.768767
	Females	4.091259	3.446125	4.736392
2014	Males	9.338352	8.012573	10.66413
	Females	4.391573	3.706441	5.076705
2020	Males	49.30484	44.93607	53.67362
	Females	35.35068	32.08791	38.61345

Percent of youth (12-17 years) meeting the strength training recommendation by low-to-high impact activities and lifting weights

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	64.94651	63.06604	66.82697
	Females	61.30891	59.44474	63.17308
2002-03	Males	70.59676	69.04116	72.15235
	Females	69.10061	67.26475	70.93648
2004-05	Males	72.65523	70.88344	74.42702
	Females	67.6134	65.76172	69.46508
2006-07	Males	70.59213	67.84376	73.3405
	Females	69.99683	67.21115	72.78251
2008	Males	74.2686	71.80117	76.73603
	Females	65.86882	62.84063	68.89702
2009	Males	72.42177	69.56558	75.27796
	Females	68.45306	65.63099	71.27514
2010	Males	72.14187	69.47357	74.81017
	Females	68.78342	66.03888	71.52797
2011	Males	73.01297	70.21597	75.80998
	Females	70.99095	68.28889	73.69301
2012	Males	71.77571	68.95201	74.5994
	Females	70.39815	67.11127	73.68502
2013	Males	73.06579	70.36549	75.76608
	Females	67.18681	64.106	70.26761
2014	Males	73.3168	70.54801	76.08559
	Females	68.29786	65.24078	71.35494
2020	Males	61.78177	55.97882	67.58473
	Females	51.16955	44.89769	57.44141

Percent of adults (18-64 years) meeting the strength training recommendation by low-to-high impact activities and lifting weights

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	61.79226	61.01996	62.56457
	Females	65.34994	64.67741	66.02247
2002-03	Males	68.05041	67.25205	68.84876
	Females	70.12242	69.32812	70.91671
2004-05	Males	68.31288	67.17845	69.44731
	Females	71.97421	70.89123	73.0572
2006-07	Males	68.0141	66.62862	69.39957
	Females	70.54401	69.51371	71.57431
2008	Males	69.05573	67.90125	70.21022
	Females	69.41958	68.25428	70.58488
2009	Males	70.12362	68.97591	71.27134
	Females	70.99268	69.88074	72.10462
2010	Males	69.32637	67.99563	70.6571
	Females	71.31274	70.13042	72.49506
2011	Males	71.14256	69.86135	72.42377
	Females	72.35521	71.22139	73.48902
2012	Males	69.83532	68.49296	71.17768
	Females	72.8163	71.74575	73.88686
2013	Males	71.66757	70.36373	72.9714
	Females	72.94384	71.65937	74.22831
2014	Males	70.66234	69.38025	71.94444
	Females	71.41359	70.16909	72.65809
2020	Males	61.23258	58.39845	64.06672
	Females	48.72198	46.00388	51.44008

Percent of older adults (65+ years) meeting the strength training recommendation by low-to-high impact activities and lifting weights

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	65.72683	64.19546	67.25819
	Females	56.07955	54.7606	57.3985
2002-03	Males	70.93138	69.5656	72.29716
	Females	60.09043	58.7644	61.41647
2004-05	Males	70.74298	69.28986	72.1961
	Females	63.10098	61.672	64.52995
2006-07	Males	70.20537	68.11109	72.29965
	Females	63.73272	61.31009	66.15535
2008	Males	71.80598	69.8967	73.71526
	Females	62.49795	60.67592	64.31998
2009	Males	71.78762	69.94077	73.63448
	Females	62.86526	61.23496	64.49556
2010	Males	70.12057	68.03036	72.21078
	Females	63.26067	61.53543	64.98592
2011	Males	71.67726	69.66856	73.68596
	Females	64.56508	62.79714	66.33301
2012	Males	69.8261	67.8548	71.79741
	Females	66.05275	64.40187	67.70363
2013	Males	74.70816	72.90159	76.51472
	Females	68.80525	67.26541	70.34508
2014	Males	73.61263	71.91619	75.30908
	Females	67.45674	65.97362	68.93986
2020	Males	49.30484	44.93607	53.67362
	Females	35.35068	32.08791	38.61345

Figure 2 - Text description

Percent of older adults (65+ years) meeting the balance recommendation by sports-related activities

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	7.623666	6.710987	8.536345
	Females	3.916308	3.39889	4.433726
2002-03	Males	8.833507	7.978919	9.688095
	Females	4.328802	3.719742	4.937861
2004-05	Males	8.505164	7.713251	9.297078
	Females	3.851828	3.386737	4.316919
2006-07	Males	7.346709	6.220483	8.472935
	Females	4.356598	3.628703	5.084492
2008	Males	7.795129	6.553429	9.036829
	Females	4.696012	3.892101	5.499922
2009	Males	8.743208	7.577226	9.909189
	Females	4.368939	3.622158	5.11572
2010	Males	7.91528	6.733278	9.097282
	Females	5.126436	4.28078	5.972093
2011	Males	8.44725	7.3696	9.5249
	Females	4.300374	3.670194	4.930554
2012	Males	8.944861	7.750878	10.13884
	Females	3.834343	3.214461	4.454225
2013	Males	8.32129	7.27144	9.37114
	Females	4.612948	3.930549	5.295347
2014	Males	10.00534	8.631371	11.37931
	Females	5.219159	4.513431	5.924888
2020	Males	13.84019	11.07065	16.60973
	Females	18.14565	15.23895	21.05234

Percent of older adults (65+ years) meeting the balance recommendation by sports or exercise or leisure activities

Year	Sex	%	95% Lower Confidence limit	95% Upper confidence limit
2000-01	Males	70.86536	69.39408	72.33663
	Females	62.29354	61.00647	63.58061
2002-03	Males	75.90169	74.64382	77.15957
	Females	67.57667	66.30729	68.84605
2004-05	Males	75.6806	74.3014	77.0598
	Females	70.27939	68.90917	71.64961
2006-07	Males	75.33169	73.30118	77.36219
	Females	70.2749	67.91283	72.63697
2008	Males	76.5777	74.8023	78.3531
	Females	69.56805	67.82784	71.30826
2009	Males	76.66226	74.88542	78.4391
	Females	69.48032	67.9123	71.04833
2010	Males	75.54502	73.5925	77.49753
	Females	69.69547	67.98076	71.41017
2011	Males	77.46299	75.65019	79.27579
	Females	70.7867	69.09526	72.47814
2012	Males	75.77338	73.91014	77.63663
	Females	72.81493	71.21675	74.41311
2013	Males	79.28882	77.65187	80.92576
	Females	75.39324	73.98561	76.80087
2014	Males	78.55255	76.92971	80.17539
	Females	74.0049	72.58331	75.42649
2020	Males	13.84019	11.07065	16.60973
	Females	18.14565	15.23895	21.05234

 

At all ages, the odds of adhering to the muscle/bone-strengthening recommendations, regardless of the activities (i.e. weight lifting, moderate-to-high or low-to-high impact), increased over time, with the greatest increase observed among older adults. Among older adults, the odds of adhering to the balance recommendation using either sports or combined sports/exercise/leisure activities also increased over time. While results indicate a small, but linear association with cycle/year, Figures 1 and 2 show cycle-by-cycle differences are not necessarily linear.

Discussion

Our findings show that approximately 57% of youth aged 12–17 years, 55% of adults aged 18–64 years, and 42% of older adults aged ≥65 years currently (in 2020) meet the muscle/bone-strengthening PA recommendations from the 24H Guidelines. In addition, 16% of older adults engage in activities that challenge balance at least twice per week. Meeting either the muscle/bone-strengthening or balance recommendations alone or in combination with sufficient MVPA was associated with better physical and mental health. Results of the time trend analysis found that in all age groups, there was a small but significant increase in the proportion of Canadians who met the muscle/bone-strengthening and balance recommendations from 2000 to 2014.

Comparisons with the literature

Very few national surveillance systems include ways to assess participation in muscle- and bone-strengthening activities and almost none assess balance activities.^{Footnote 5} Internationally, the prevalence of meeting the strength-training recommendation ranges from 16% to 57% among youth (≥3 times per week)^{Footnote 14Footnote 30Footnote 31Footnote 32Footnote 33Footnote 34} and from 3% to 70% among adults (most report between 10–30%; ≥2 times per week).^{Footnote 35} Prevalence of sufficient balance training among older adults ranges from 9% to 34%.^{Footnote 1Footnote 4Footnote 36Footnote 37} The Canadian prevalence estimates for muscle/bone-strengthening and balance recommendations tend towards the higher end of this range. Comparing prevalence globally should be done with caution, however, given the variation in survey questions and methods.

Other studies have also shown that females,^{Footnote 14Footnote 30Footnote 31Footnote 32Footnote 34Footnote 38Footnote 39Footnote 40Footnote 41Footnote 42} older adults,^{Footnote 14Footnote 30Footnote 34Footnote 38Footnote 39Footnote 40Footnote 41Footnote 42Footnote 43} people living at or in households with lower education,^{Footnote 34Footnote 38Footnote 39Footnote 40Footnote 43} people at lower income,^{Footnote 34Footnote 39Footnote 40Footnote 41Footnote 42} some non-White ethnicities,^{Footnote 31} those with poorer self-rated health,^{Footnote 38Footnote 39Footnote 40Footnote 42} current smokers^{Footnote 38Footnote 42} and those with overweight or obesity^{Footnote 30Footnote 31Footnote 38Footnote 39Footnote 40Footnote 41Footnote 42} are less likely to meet the strength-training recommendation. In addition, among older adults, sufficient balance exercise is lower with increasing age,^{Footnote 14} among females^{Footnote 8Footnote 35Footnote 36} and among those with lower education,^{Footnote 36Footnote 37} lower income,^{Footnote 36} poor self-rated health^{Footnote 37} or obesity.^{Footnote 36Footnote 37}

Evidence gathered in Janssen and LeBlanc’s systematic review,^{Footnote 44} which informed the 24H Guidelines recommendations,^{Footnote 3} suggests that youth that engage in high impact activities (e.g. jumping) have better bone mass accrual or bone structure. Muscle-strength training has been consistently associated with a reduction in all-cause mortality and in cardiovascular disease incidence and better physical functioning among adults.^{Footnote 8} Similarly, older adults’ (≥65 years) engagement in balance and functional training is associated with better physical functioning.^{Footnote 19}

Findings from the present study confirm associations between meeting the recommendation and multimorbidity and perceived physical and mental health. The findings also suggest that meeting either recommendation alone or in combination with sufficient MVPA is associated with better physical and mental health. This supports the concept that all activity is health promoting and provides people with choice for being active. While the effect of strength or balance training on adults’ health-related quality of life is uncertain,^{Footnote 8Footnote 19} our results for self-reported physical health suggest a cross-sectional association.

Results of the present study do not show a significant association between meeting the strength-training recommendation and self-reported overweight/obesity. While others have observed an association (with self-reported and objectively measured BMI),^{Footnote 45Footnote 46Footnote 47Footnote 48} BMI may not be an ideal health outcome in relation to strength training. Strength training may not result in substantial changes to a person’s BMI,^{Footnote 49} and conversely, BMI does not provide a complete picture of body composition.^{Footnote 50Footnote 51} Future work would benefit from looking at other measures of adiposity and health status.

A significant time trend (2000–2014) was observed for all age groups, suggesting small increases in adherence to the muscle-strengthening and balance recommendations. Bennie et al.,^{Footnote 31} using data from the COMPASS study, found that the prevalence of meeting the strength-training recommendation among secondary school students declined significantly, from 57.0% to 48.5%, between 2015 and 2019.

Other studies have observed increasing trends in muscle-strengthening exercise among adults. In Canada, using longitudinal data from the National Population Health Survey, which assessed PA using the same module from the 2000–2014 CCHS, Perks^{Footnote 52} found that weight training significantly increased from 1994 to 2011. Alongside increases in weight training, increases in total leisure PA were observed except among those aged 65 years and older.^{Footnote 52} Among Australian adults, the prevalence of sufficient muscle-strengthening activity increased from 6.4% to 12.0% (p_trend < 0.0001) between 2001 and 2010.^{Footnote 43} Using data from Behavioral Risk Factor Surveillance System surveys, Bennie et al.^{Footnote 53} found a small but statistically significant increase (29.1% to 30.3%, p_trend < 0.0001) in the prevalence of sufficient muscle-strengthening activity among adults in the United States between 2011 and 2017. There are no known studies that have looked at time trends in balance exercise.

Surveillance considerations

While using the 2000–2014 CCHS PAC provided a way to compare previous data with more recent data from the HLV-RR module, several differences between the modules limit the comparison. These differences include the sampling frame of the surveys; seasons of data collection; recall period (3 months for the older PAC vs. past 7 days for the new HLV-RR module); number of questions (22 activities in the older PAC vs. 2 items with broad examples in the new HLV-RR module); and activities/examples (activities in the older PAC grouped under “weight training,” “moderate-to-high impact” and “low-to-high impact,” based on assumptions of strength/balance contributions vs. activities in the new HLV-RR module presenting broad examples of muscle/bone-strengthening activities [lifting weights, carrying heavy loads, shovelling, sit-ups, running, jumping sports] and balance activities [yoga, tai chi, dance, tennis, volleyball and balance training]).

The new 2020 module may provide more room for interpretation of balance and muscle strengthening, whereas the old module may misclassify some activities based on the applied assumptions of the movements conducted. The new module question likely also captures activities beyond traditional weight lifting.

It is, however, important to acknowledge that the range of strength-training options/activities has evolved over time, with power yoga, Pilates and weight-based workouts, for example, becoming more popular. Therefore, what is defined as strength training, its promotion or marketing (including through the 24H Guidelines) and the equipment and resources available for this training may have influenced prevalence over time. While the prevalence of strength training in 2020 is provided alongside 2000–2014 trends as an exploratory exercise, it is not appropriate to directly compare the estimates.

Current Canadian estimates of adherence to the muscle/bone-strengthening recommendations using the new 2020 CCHS HLV-RR module exceed those observed internationally. Prevalence estimates are likely influenced by variation in the surveillance question(s) used.^{Footnote 35} Most population surveys ask specific questions about strength training, but several ask about a range of activities that could strengthen muscles or improve balance. International estimates are largely based on questions referencing traditional forms of strength training such as weight lifting or calisthenics. In fact, some surveys ask respondents to not include aerobic activities in their responses.^{Footnote 40Footnote 54} Many activities that would improve aerobic fitness could also strengthen muscles and improve balance. It is, however, not clear to what extent different strength-training activities influence health outcomes.

The new module used in the CCHS HLV-RR does not include a measure of intensity or duration. While current recommendations are based on minimum weekly frequencies, future work is needed to understand whether intensity and duration have important implications for health. In addition, the muscle/bone-strengthening recommendation in the 24H Guidelines was informed by resistance training studies. Therefore, it is recommended that future measures also assess resistance training separately. Future work is also needed to assess the reliability of the HLV-RR module to assess trends and to better understand how including different examples may change estimates, and whether the module requires further adjustment.

Strengths and limitations

Strengths of this study include the use of large, nationally representative samples of Canadian youth and adults to examine historical trends and current prevalence of adherence to muscle/bone-strengthening and balance recommendations. Further, the HLV-RR module allowed for the examination of the sociodemographic and behavioural characteristics of those meeting recommendations. While it was not possible to assess the criterion validity of the new module, assessing associations with indicators of health provided a means to assess construct validity. Historically, the validity of muscle-strength training exercise questions has been rarely assessed,^{Footnote 35} largely due to a lack of comparison measures that require few resources to obtain.

All data used in this study are cross-sectional, making it impossible to examine causal associations with health or to ascertain within-person changes. However, repeated cross-sectional surveys account for the non-stationary nature of the Canadian population. It was also not possible to directly compare the older (2000–2014) and the newer (2020) results due to differences in methodology. Finally, in both modules, activities are self-reported and subject to recall and response biases.

Conclusions

Results of this study suggest that approximately half of Canadians meet the muscle/bone-strengthening recommendation but only 16% of older adults meet the balance recommendation from the 24H Guidelines. Temporal trends suggest that adherence to both recommendations increased between 2000 and 2014. Meeting either recommendation alone or in combination with sufficient MVPA is associated with better physical and mental health. Surveillance reporting on the muscle/bone-strengthening and balance components of the Canadian 24H Guidelines alongside the already recognized aerobic PA recommendation provides important information on another health behaviour associated with optimal health among Canadians.

Conflicts of interest

None.

Authors’ contributions and statement

All authors contributed to the conceptualization and design of the study and interpretation of the data. SAP undertook the analysis with verification by JJL. SAP wrote the original draft. All authors critically revised and approved the final paper.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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