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

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Presentation on theme: "Decreasing Television Viewing for Prevention and Control of Obesity Beverly S. Kingsley PhD, MPH Barbara Polhamus PhD, MPH, RD Bettylou Sherry PhD, RD."— Presentation transcript:

1 Decreasing Television Viewing for Prevention and Control of Obesity Beverly S. Kingsley PhD, MPH Barbara Polhamus PhD, MPH, RD Bettylou Sherry PhD, RD CDC State Orientation Meeting Crowne Plaza November 12, 2008

2 Session Outline Background / Descriptive Epidemiology Health Outcomes Intervention Strategies State and Local Policies/ Programs Barriers Tools / Resources and Contacts Discussion

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

4 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)

5 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

6 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.

7 Descriptive Epidemiology

8 Daily Television Viewing by Children and Youth by Hours Kids and Media at the New Millennium, Kaiser Family Foundation, 1999

9 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.

10 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

11 Overweight and Obesity Cross-sectional studies Dose-response association of TV viewing and body fat percentage and overweight Prospective studies TV 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.

12 Overweight and Obesity TV 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.

13 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

14 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

15 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

16 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 childrens 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

17 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

18 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.

19 Evidence Base Interventions 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

20 Intervention Settings to Reduce TV Viewing Medical/Health Care School/Childcare Worksite Community

21 Medical/ Health Care Provide training for health care professionals to counsel on reducing childrens media use –Because media use accounts for such a substantial part of most childrens 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

22 Medical / Health Care Evidence 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)

23 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. Children, Television, and Weight Status: Summary and Recommendations from Expert Panel Provide training for health care professionals on reducing childrens media use (Jordan and Robinson 2008)

24 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 childrens media consumption –Work with local schools to implement media education programs –Serve as good role models –Become involved in AAPs Media Resource Team –Ensure appropriate entertainment options available for hospitalized children –Support Childrens Television Act of 1990 and 1996 rules –Monitor television ratings system

25 Schools/Childcare Evidence of Interventions to Reduce TV Viewing Preschools Brocodile the Crocodile Elementary schools SMART Middle Schools Planet Health Sources: Dennison et al., 2004; Robinson 1999; Gortmaker et al., 1999

26 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

27 Elementary School Intervention SMART 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/m 2 ) 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 1 st experimental study demonstrates a direct association between television, video tape/video game use Source: Robinson 1999

28 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

29 Intervention Settings Worksite ?

30 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

31 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

32 Examples of Intervention Activities to Decrease TV Viewing (contd) 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

33 Environment and Policy

34 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 4134 Limit SSB 77 Limit low nutr. foods 97 No forcing to eat 32 No food as rewards 105 Support BrstFeeding 93 Limit screen time 1715 Required PhysActiv 33

35 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

36 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

37 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

38 Tools and Resources Guidance Document RE-AIM AAP Guidelines and Recommendations full/pediatrics;107/2/423 full/pediatrics;107/2/423 Existing Interventions Report of the Expert Panel 19 19 DNPAO

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

40 DNPAO Guidance Documents Resources for States Produced and disseminated Guide to Breastfeeding Interventions Guidance Documents in progress for DNPAOs 5 other target behaviors

41 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: Reach into the target population Efficacy or effectiveness Adoption by target settings/institutions Implementation: consistency of delivery of intervention Maintenance of intervention effects in individuals and populations over time.

42 2001 AAP Guidelines for TV Viewing Limit childrens 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 childrens bedrooms Source: AAP, Pediatrics 2001

43 2001 AAP Guidelines for TV Viewing (contd) 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

44 CDCs 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

45 Contact Information Division of Nutrition, Physical Activity and Obesity State Project Officers

46 Discussion

47 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?

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