Decreasing Television Viewing for Prevention and Control of Obesity Beverly S. Kingsley PhD, MPH Barbara Polhamus PhD, MPH, RD Bettylou Sherry PhD, RD.

Decreasing Television Viewing for Prevention and Control of Obesity

Beverly S. Kingsley PhD, MPHBarbara Polhamus PhD, MPH, RD

Bettylou Sherry PhD, RD

CDC State Orientation Meeting Crowne Plaza

November 12, 2008

Session Outline

• Background / Descriptive Epidemiology

• Health Outcomes

• Intervention Strategies

• State and Local Policies/ Programs

• Barriers

• Tools / Resources and Contacts

• Discussion

Background

• TV/Screen Time• Children and Adolescents• TV Viewing• Consideration of total screen time

Prevalence of Obesity by Hours of TV per Day

NHES Youth Aged 12-17 in 1967-70 and NLSY Youth Aged 10-15 in 1990

TV Hours Per Day (Youth Report)

(0-1) (1-2) (3-4) (4-5) (>5)(2-3)

Background • Expert Panel highlights growing concern

about contribution of media use to childhood obesity*– TV viewing positively associated with obesity

(Dietz and Gortmaker,1985)

– Decreasing TV viewing may be an effective strategy for preventing and controlling obesity

( Robinson T 1999; Gortmaker S et. al., 1999)

*Source: Jordan A and Robinson T. The Annals of the American Academy of Political and Social Science, 2008

Healthy People 2010

• Objective 22-11 - Increase the proportion of adolescents who view television 2 or fewer hours on a school day.

• Target: 75 percent.• Baseline: 57 percent of students in grades 9

through 12 viewed television 2 or fewer hours per school day in 1999.

• Data source: Youth Risk Behavior Surveillance System (YRBSS), CDC, NCCDPHP.

Descriptive Epidemiology

Daily Television Viewing by Children and Youth by

Hours

1 Hour or less19%

0 Hours17%

More than 5 Hours17%

3 to 5 Hours16%

1 to 3 Hours31%

Kids and Media at the New Millennium, Kaiser Family Foundation, 1999

Patterns of TV and Media Use • 61% children < 2 use screen media; 43% watch TV

every day

• 41% 2-3 yr olds, 43% 4-6 yr olds use screen media >2 hrs/day

• Children 8-18 watch average 3 hrs/day

• Average family owns 4 TV sets

• African- American/Hispanic kids watch>TV white kids

• Children < 6, low SES households watch more TV

Source: Jordan A and Robinson T 2008; Kaiser Family Foundation 2006.

Health Outcomes Associated with TV Viewing

• Overweight and obesity

• Negative influence on food choice

• Increase in food intake during TV time

• Sedentary Behavior

• Replacement for Physical Activity

Overweight and Obesity

• Cross-sectional studies Dose-response association of TV viewing and body fat

percentage and overweight

• Prospective studiesTV viewing risk factor for subsequent weight gain and overweight higher BMI (as well as lower cardiorespiratory fitness, increased cigarette smoking)

• Randomized Controlled Trials Reduced TV Viewing/other screen media results in decreased

BMI, waist circumference, triceps skinfold thicknesses in elementary school children; decreased overweight in middle school girls; weight loss in overweight 8-12 yr old children

Sources: Anderson 1998;Hernandez et al 1999; Gortmaker 1996; Hancox and Poulton 2006; Dietz and Gortmaker; Hancox et al 2004;VIner and Cole 2005; Gortmaker 1999; Epstein et al 1995, 2000.

Overweight and ObesityTV Advertising

• 1990 estimates: children view 40,000 TV commercials/year ~50% for food and beverages, possibly decreasing

• Content analysis research indicates nutritional characteristics of advertised food generally high calorie and low nutrient food and beverage

• Strong evidence that exposure to television advertising associated with adiposity in children 2-11 and teens 12-18

BUT Evidence for causal relationship is not conclusive

Source: Food Marketing to Children and Youth. Institute of Medicine 2006.

Negative Influence on Food Choice

TV advertising influences food and beverage choices

• TV is largest media carrier of food and beverage marketing to children and adolescents

Source: Food and Marketing to Children and Youth. Institute of Medicine 2006

Negative Influence on Food Choice

Effects on 2-11 year olds• Strong evidence

– Food and beverage preferences– Food and beverage purchase requests– Short-term consumption

• Moderate evidence– Food and beverage beliefs– Usual dietary intake (2-5 years)

Source: Food and Marketing to Children and Youth. Institute of Medicine 2006; Miller and Taveras 2008

Negative Influence on Food Choice and Increase in Food Intake

• For each incremental hour of TV viewing, Sugar Sweetened Beverage consumption increased by 0.06 serving

• Children watching TV > 2 hr/day more likely to consume energy-dense, low-fiber, high-fat diet

• Children who eat while watching TV more likely to become obese

Sources: Miller and Taveras 2008;Johnson et al 2008; Matheson et al. 2004

Sedentary Behavior

• Multiple studies provide evidence for association between TV viewing and sedentary behavior

• suggests TV viewing weakly related to physical activity • sedentary behavior effects on children’s adiposity

independent of physical activity.

• TV in bedroom associated with unhealthy eating and exercise habits in teens

Sources: Jordan and Robinson 2008; Barr-Anderson et al., 2008

TV Viewing as Replacement for Physical Activity

• Research suggests TV viewing and related sedentary behavior can compete with physical activity, and lower energy expenditure.

however • Reducing television viewing and computer use may

have an important role in preventing obesity and lowering BMI in young children, and these changes may be more related to changes in energy intake

than to changes in physical activity.

Source: Epstein et al, 2008

Proposed Mechanisms for Association Between TV and Obesity

• Reduction of Resting Metabolic Rate• Treuth et al 2000

• Displacement of physical activity• Williams and Handford 1986; Lowry et. al., 2002

• Consumption of more energy dense foods during meals

• Coon and Tucker 2002; Miller and Taveras 2008.

• Exposure to marketing of high energy dense food

• Institute of Medicine 2006.

Evidence BaseInterventions to Reduce TV Viewing

• Few published reports on intervention to reduce TV viewing

• Some that have shown success: • Curricula for child care settings• Elementary and middle school intervention

curricula• Clinic based interventions• After-school dance program • Home delivered interventions

Source: DNPAO TA Manual

Intervention Settings to Reduce TV Viewing

• Medical/Health Care

• School/Childcare

• Worksite

• Community

Medical/ Health Care

• Provide training for health care professionals to counsel on reducing children’s media use

– Because media use accounts for such a substantial part of most children’s lives, panel suggested training on children and media should be included in curricula at all stages, and made a required content area for child health professional accreditation, certification, and continuing education

Source: Rich and Bar-on, 2001

Medical / Health CareEvidence of Effective Interventions

Randomized controlled studies

• Reducing sedentary behaviors (TV/media) as effective as increasing physical activity to

decrease obesity (Epstein et al 2000)• Pilot/Feasibility

behavioral intervention included electronic television time manager: marginally effective

(Ford et al 2002)• TV Budget

reduction in TV viewing plus computer use associated with significant decreases in BMI z- score (Epstein et al 2008)

Medical/Health Care

• “Keep Me Healthy” Tool kit developed by the Maine Youth Overweight Collaborative. Practical support and guidance to health care practices, organizations and individuals across the state to help improve care and outcomes for overweight and obese youth. www.mcph.org/Major_Activities/keepmehealthy.htm

• Children, Television, and Weight Status: Summary and Recommendations from Expert Panel

Provide training for health care professionals on reducing children’s media use (Jordan and Robinson 2008)

http://ann.sagepub.com/cgi/content/refs/615/1/119

Medical/ Health Care

• AAP Recommendations for pediatricians and other health care professionals

– Remain knowledgeable about the effects of television – Use the AAP Media History Form to help parents recognize the

extent of their children’s media consumption– Work with local schools to implement media education

programs– Serve as good role models– Become involved in AAP’s Media Resource Team– Ensure appropriate entertainment options available for

hospitalized children– Support Children’s Television Act of 1990 and 1996 rules– Monitor television ratings system

Schools/Childcare Evidence of Interventions to Reduce TV Viewing

Preschools Brocodile the Crocodile

Elementary schools SMART

Middle SchoolsPlanet Health

Sources: Dennison et al., 2004; Robinson 1999; Gortmaker et al., 1999

Preschool : Brocodile the Crocodile• Preschool and daycare in upstate NY: 16 sites

• Children aged 2.6 – 5.5 years old

• 1hr/week interactive session to reduce TV ( 7 sessions TV focused/39 total health promotion curriculum)

• Intervention reduced TV/video watching by 3.1 hr/wk vs. increased 1.6 hr/wk in non-intervention group

• Percentage of children watching TV/videos more than 2h/d decreased significantly from 33% to 18% ( compared with increase in non intervention)

• Reduction in obesity not significant.

Source: Dennison et al. 2004

Elementary School InterventionSMART

• Randomized controlled school-based trial• 18 lesson, 6 month classroom curriculum to reduce

TV, video tape/video game use. • TV monitor: monitors and budgets TV time/pp • Statistically significant reduction in BMI ( -.45kg/m2)

TSFT, waist circumference, waist-to-hip ratio • Accompanied by reduction in TV viewing: decreased

by 5.53 hrs TV, and -1.5 hr of video tape use, -2.5 hr video games

• 1st experimental study demonstrates a direct association between television, video tape/video game use

Source: Robinson 1999

Middle School Intervention Planet Health

• Randomized controlled field trial• Evaluate impact of school-based health behavior

intervention; ethnically diverse grades 6-7 • 2 school years sessions included within existing

curricula• Focus: decrease TV, high fat foods; increasing

fruits/veggies and physical activity• Increase in remission of obesity (OR 2.16, girls). • TV+video reduced in boys and girls (0.40, 0.58/d). • Every hour TV reduction (girls) independently

associated w/reduction obesity prevalence OR 0.85

Gortmaker et al. 1999

Intervention SettingsWorksite

?

Community

• Family based intervention: Stanford GEMS Pilot Study: reduced BMI -.32 and reduced TV/video use – 4.96 hrs/wk

• SWITCH: community, school, family based intervention to modify behaviors related to childhood obesity (study protocol only to date)

Robinson et al. 2003; Eisenman 2008

Examples of Intervention Activities to Decrease TV Viewing

• Reduce TV viewing time – sponsor a “Turn off TV Night” in community; offer alternatives

• Partner with health care providers to encourage activity instead of TV viewing.

• Provide information to parents for reducing TV viewing time of children.

• Provide parenting programs addressing parental monitoring/setting of rules

http://www.healthysd.gov/Documents/StrategiesNPA1.pdf

Examples of Intervention Activities to Decrease TV Viewing (cont’d)

• Provide safe and engaging activities for children instead of watching TV.

• Use multiple channels for interventions,, 7.

• Conduct community-wide healthy eating and physical activity special events, regular programming, and media campaigns.

• Encourage mindful viewing

http://www.healthysd.gov/Documents/StrategiesNPA1.pdf

Environment and Policy

U.S. State Regulations for Obesity Prevention in Child Care

Indicator

Child Care Centers

(# of states)

Family Child Care Homes (# of states)

Water freely available

41 34

Limit SSB 7 7Limit low nutr. foods 9 7No forcing to eat 32 32No food as rewards 10 5Support BrstFeeding 9 3Limit screen time 17 15Required PhysActiv 3 3

U.S. State Regulations for Obesity Prevention in Child Care

• Child Care Centers– 17 states regulate screen time (AL, AK,AZ, CO, DE,

FL, GA, IL, IN, MN, MS, NM, SC, TN, TX, VT, WV)

• Family Child Care Homes– 15 states regulate screen time (AK, CO, DE, MS, MT,

OR, PA, RI, SD, TN, UT, VT, VA, WA, WV)

• Require parental permission to use TV during child care hours (DE, CO)

Benjamin SE et al. BMC Public Health. 2008:8:188

TV Interventions Reported by CDC Funded States

• 155 interventions reported, 35 contain component to reduce TV viewing (most at individual level)

• Intervention described by states included:• We Can! (KY)• Statewide TV-Turnoff Week (NY)• Health and Fitness by Age 5 Program (NY)• WA Active Bodies Active Minds (WAABAM)

Source: Progress Monitoring Report January 1-June 30, 2007

Barriers to Decreasing TV Viewing

• TV viewing is ubiquitous• TV viewing pleasurable/habitual• TV viewing not seen as harmful

• societal norm shift needed

• Alternative activities require additional time and effort by parents

• Parents would have to model reduced TV viewing

• Limited evidence base for effective interventions to decrease TV viewing

Tools and Resources • Guidance Document

• RE-AIM www.re-aim.org

• AAP Guidelines and Recommendations http://aappolicy.aappublications.org/cgi/content/full/pediatrics;107/2/423

• Existing Interventions

• Report of the Expert Panel http://ann.sagepub.com/cgi/content/refs/615/1/119

• DNPAO www.cdc.gov/dnpao

TV Guidance Document

• TV Guidance Document Focus: • Children and Adolescents• TV Viewing• Consideration of total screen time

DNPAO Guidance Documents

• Resources for States

• Produced and disseminated “Guide to Breastfeeding Interventions”

• Guidance Documents in progress for DNPAO’s 5 other target behaviors

Use of RE-AIM to Select and Evaluate Interventions

• Systematic way for researchers, practitioners, and policy makers to evaluate health behavior interventions

• Use to estimate the potential impact of interventions on public health

Translatability and public health impact best evaluated by examining:

RReach into the target populationeach into the target populationEEfficacy or effectiveness fficacy or effectiveness AAdoption by target settings/institutions doption by target settings/institutions IImplementation: consistency of delivery of mplementation: consistency of delivery of

intervention intervention MMaintenance of intervention effects in individuals aintenance of intervention effects in individuals

and and populationspopulations over timeover time. . www.re-aim.org

2001 AAP Guidelines for TV Viewing

• Limit children’s total media time to no more than 1-2 hours quality programming per day

• Discourage television viewing for children younger than 2 years

• Remove television sets from children’s bedrooms

Source: AAP, Pediatrics 2001

2001 AAP Guidelines for TV Viewing (cont’d)

• Monitor shows children and adolescents viewing• View television programs with children/discuss

content• Use controversial programming to initiate

discussions• Use VCR wisely for educational programming• Support efforts to establish comprehensive

media-education programs in schools• Encourage alternative entertainment for

children, e.g. reading, athletics, hobbies, creative play.

Source: AAP Pediatrics 2001

CDC’s Division of Nutrition, Physical Activity and Obesity

• Collaborate with state, local and other partners

• Evaluate promising environmental and policy approaches

To reduce TV Viewing and other screen time behaviors to prevent and decrease childhood obesity

Contact Information

Division of Nutrition, Physical Activity and Obesity

State Project Officers

www.cdc.gov/dnpao

Discussion

Discussion

• Is the content of the guide appropriate?

Does it meet you program planning needs?

If not, what is missing?

• What do you need most to ensure the effectiveness of your efforts to decrease TV viewing?

• How can CDC and State Partners best work together to advance this area?