decreasing television viewing of children: guidance document strategies barbara polhamus, phd, mph,...

Decreasing Television Viewing of Children: Guidance Document Strategies

Barbara Polhamus, PhD, MPH, RDBeverly Kingsley, PhD, MPH

Division of Nutrition, Physical Activity and Obesity

TV Viewing in ChildrenRationale for document focus

– Majority of evidence is related to TV viewing and children

– Other forms of media are important but limited evidence

– CDC recommends that communities reduce screen time in child care centers and schools

– American Academy of Pediatrics recommends limiting total media time for infants and children

Recommended Strategies

• Child Care and School-Based Strategies

Strategy 1: Establish Regulations, Legislation, Policies to Reduce TV Strategy 2: Develop and Implement Curricula to Reduce TV Viewing

• Medical-Based Strategies

Strategy 3: Promote Counseling by Health Care Providers

Strategy 4: Promote Continuing Medical Education Curricula for Physicians

• Community-Based Strategies Strategy 5: Develop and Implement Community Awareness

Campaigns

TV Viewing: Child Care and Schools

Establish Regulations, Legislation and Policies in Child Care

• No federal standards for child care• Child care provides opportunity to promote limited TV • Each one-hour increment of TV viewing per day

increases intake of energy dense food 1

Miller SA, Taveras EM, Rifas-Shiman SL, Gillman MW. Int J Obes 2008:3(3):168-76.


Evidence of Effectiveness • Limited peer reviewed literature• NYC and DE have made regulatory changes to

limit TV viewing • An evaluation of the NYC amendment is

currently in progress


Potential Action Steps• Develop partnerships that can move forward policy

change in child care• Provide training to child care providers on effects of TV

viewing• Work toward state-mandated elements in child care

facilities to require adoption of AAP recommendations for TV and screen time


Program Examples

• New York City Amendment to the Health Code

• Delaware Child Care Policy to Improve Children’s Health


Develop and Implement Curricula

• Curriculum interventions can be incorporated into existing curricula or designed for families

• Curricula have a broad reach


Program Examples • Brocodile the Crocodile (preschool curriculum)

• Planet Health (middle school curriculum)


Evidence of Effectiveness• In child care, there has been mixed success in reducing

TV viewing and BMI• In schools, some but not all curricula have shown a

reduction in TV viewing time and obesity prevalence


Potential Action Steps• Work with the Department of Education to inform teachers about available curricula that include TV limits

• Partner with organizations and businesses to fund purchase of curricula

• Train child care providers and staff on available curricula

TV Viewing: Medical

Promote Counseling by Health Care Providers • Medical care visits provide valuable opportunity for guidance

• State organizations can promote using AAP guidelines at health care visits.

• Many parents not aware of AAP guidelines or of the link between TV viewing and obesity.

• State policy to promote counseling (at every visit) on limiting TV could influence viewing practices.

TV Viewing: Medical

Evidence of Effectiveness • No peer reviewed literature on state policy to promote (physician)

counseling on TV viewing

• Gentile et al. 2004: Evaluation of pediatrician awareness, implementation of AAP Guidelines. Showed AAP successful in educating pediatricians (90% familiar with Guidelines)

• However, only 41% of pediatricians always provided counseling to children and parents on guidelines

• Although no evaluation, reasonable strategy

TV Viewing: Medical

Potential Action Steps• Promote dissemination of AAP Guidelines through State Medical

Associations

• Address system barriers to counseling: develop strategies for overcoming barriers

• Develop additional training materials, tool kits and programs for physician counseling

• Disseminate and teach the use of AAP Media History form

TV Viewing: Medical

Program Examples• Keep Me Healthy

• 5-2-1-0 Approach • ME Youth Overweight Collaborative, ME AAP, ME Center for

PH

• KidShape Program• Comprehensive family-based pediatric weight management

program• Includes diet, PA, reduction of TV time, healthy behaviors

TV Viewing: MedicalPromote Specific Continuing Medical Education

(CME) Curricula for Physicians• State agencies/medical associations can promote increasing specific

knowledge of physicians: CME on limiting TV for prevention/mitigation of overweight/obesity

• States have the ability to mandate CME content

• Examples: H1N1, HIV/AIDS, Child Abuse, Ethics CME

• Although no currently required CME requirements on screen time/childhood obesity to evaluate, this is a potential strategy

TV Viewing: Medical

Evidence of Effectiveness• CME in certain topic areas is effective (at least to some degree) in

increasing knowledge among physicians.

• No program examples of CME requirements with specific screen time/childhood obesity component

• No peer reviewed literature.

TV Viewing: Medical

Potential Action Steps• In partnership with state or national medical associations, include

information about strategies to limit television and other screen time in CME curricula.

• Develop additional training materials, tool kits and programs for physicians

• Disseminate/teach the use of AAP Media History form

TV Viewing: Medical

Program Examples

• No program examples of state health departments requiring/promoting CME courses which address importance of limiting TV/screen time BUT very possible

• Development of CME courses for physicians and other health care providers would be advantageous.

TV Viewing: CommunityDevelop and Implement Community Awareness

Campaigns• Community campaigns valuable method to promote healthy

behaviors; can create awareness about the importance of limiting TV viewing in the home

• Opportunity to create awareness of specific issues using multiple media formats

• Evidence that media campaigns can affect health behaviors of youth [VERB – national, multicultural social marketing campaign to promote PA in children]

TV Viewing: Community

Evidence of Effectiveness• VERB campaign evaluation - effectiveness in increasing physical activity

and positive attitudes about physical activity in children

• TV Turnoff Week– example of community campaign but not formally evaluated

• No peer reviewed literature evaluating specific community campaign to reduce TV viewing; mixed results on other studies on effectiveness of community campaigns

TV Viewing: Community Potential Action Steps• Form coalitions that include faith based organizations, neighborhood

groups, libraries to develop and implement or participate in community campaigns.

• Identify physical and social environments that encourage/enable safe and enjoyable physical activity as alternatives to TV viewing.

• Plan a community wide event to heighten awareness of excess TV

viewing and impact of television viewing on overweight and obesity; link this effort to other activities for children.

TV Viewing: Community

Program Examples• Nickelodeon Network Turn off the TV and Go Outside

Network stopped broadcasting for 3 hrs one Saturday and urged children to go out/play. Reached 1.5 M viewers

• Communities promote TV turn off weekNew Hampshire Dept of Health [Health Promotion in Motion]

TV Viewing in Children

Summary• Currently, evidence is limited for policy and

environmental approaches to reduce TV viewing

• The majority of strategies presented are emerging

Acknowledgements

• Dr. Bettylou Sherry, DNPAO• Dr. Deborah Galuska, DNPAO• Dr. Sarah Lee, DASH• Dr. Bill Dietz, DNPAO

The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention .

Four State Level Data Sources Four State Level Data Sources for TV Viewing/Screen Time for TV Viewing/Screen Time

DataData

Bettylou Sherry, PhD, RDBettylou Sherry, PhD, RD

Obesity Prevention and Control BranchObesity Prevention and Control Branch

DNPAO/NCCDPHP/CDCDNPAO/NCCDPHP/CDC

March, 2010March, 2010

Pediatric Nutrition Surveillance Pediatric Nutrition Surveillance System AnnualSystem Annual

Children viewing Children viewing << 2 hours of 2 hours of television/day - includes television/day - includes videotapes and DVDs (2-5 years)videotapes and DVDs (2-5 years)

National Survey of Children’s National Survey of Children’s Health 2007, 2011 - Every 4 Health 2007, 2011 - Every 4

yearsyears Hours of TV viewing time, video games (0-18 Hours of TV viewing time, video games (0-18

years)years)

TV in child's bedroom (6-17 years)TV in child's bedroom (6-17 years)

Family rules on TV programs watched (6-17 Family rules on TV programs watched (6-17 years)years)

Average weekday computer use (not schoolwork) Average weekday computer use (not schoolwork) (6-17 years)(6-17 years)

School Health ProfilesSchool Health Profiles 2010 - Biannual 2010 - Biannual

School-based curricula to reduce School-based curricula to reduce TV/screen timeTV/screen time

Youth Risk Behavior Surveillance Youth Risk Behavior Surveillance System (YRBSS)System (YRBSS)2009 - Biannual 2009 - Biannual

TV: number of hours on average school dayTV: number of hours on average school day

Video games/computer for non-school purpose: Video games/computer for non-school purpose: number of hours on average school daynumber of hours on average school day

National Resource Center for National Resource Center for Health and Safety in Child CareHealth and Safety in Child Care

(Public access database)(Public access database)

Policies to limit TV viewing at child care facilitiesPolicies to limit TV viewing at child care facilities

– Limit defined as AAP guidelines Limit defined as AAP guidelines

<2 hrs per day for children 2-18 yrs<2 hrs per day for children 2-18 yrs

No TV time for children <2 yrsNo TV time for children <2 yrs

Solomon Mezgebu , Massachsuetts Department of Public Health

School Based Intervention Helps Reduce TV Watching Among Middle School Students

Solomon Mezgebu

Massachusetts Department of Public Health


5-2-1 Go!

Planet Health classroom curriculum, focused on individual behavior and

School wide initiative focused on policy and system changes to

$2500 grant/school (two years)


The 5-2-1 Goals

5- Consume 5-9 servings of fruits and vegetables a day

2- Reduce screen time to no more than 2 hours a day

1- Participate in at least 1 hour of physical activity each

day


Hypothesis & Indicators Hypothesis 1: Reduce the prevalence of overweight and at-risk-of-overweight among

middle school students.– Measure: Improvement of weight status between baseline and follow-up. (Reduction

in overweight or at risk or remaining normal)

Hypothesis 2: Increase the number of students achieving the recommended level of physical activity

– Measure 1: Moderate Activity=increased number of days by at least one of moderate activity from baseline to follow-up compared with no improvement or decrease.

– Measures 2-4 ( similar as above: for vigorous, strength activities and walking to and from school)

Hypothesis 3: Increase the percentage of students eating five servings of fruits and vegetables per day.

– Measure: increased number of servings of fruits and/or vegetables per day compared to no improvement or decrease.

Hypothesis 4: The intervention will decrease the percentage of students watching more than two hours of television per day.

– Measure: increased number of days by at least one of watching less than two hours of television per day compared to no improvement or decrease.

Hypothesis 5: The intervention will create nutrition and physical activity policy and/or environmental changes at schools.

• Measure: increased number of policies or environmental changes compared to no change.


Improvement in Daily Participation in PE (from baseline, at least by a day)

9.2%

15.4%

4.7% 4.6%

0.0%

10.0%

20.0%

Girls Boys

Control

Intervention

** P< .001


Participation in Moderate Physical Activity (from baseline, Percent of kids who met daily

recommendation for moderate PA)*

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Moderate PAIncreased**

Moderate PAdecreased***

Control

Intervention

** p <.001

*** p <.001


Findings Contd... Hypothesis 3: Increase the percentage of students eating

five servings of fruits and vegetables per day.– There was no difference between intervention and control

students regarding intake of fruits and vegetables.

H 4: The intervention will decrease the percentage of students watching more than two hours of television per day.– After adjusting for age, race, number of televisions in the

house, whether or not the student had a television in his/her room, and restriction on television watching, the intervention students had improved almost 50 percent more in meeting the standard of watching less than 2 hours per day on weekdays

(Monday-Thursday) (O.R.1.36; CI 1.10,1.68). TGIF…? – Spent less time playing video games during the week (9.7%; p<0.001)

and weekends (4.5%; p=0.071). There was no difference in reduction of television watching

between the intervention and control students during weekends.


Sedentary Behavior on Weekdays(Other than TV Watching)

Change in % (at least 1/2hr)

0 . 0 %

1 0 . 0 %

2 0 . 0 %

3 0 . 0 %

4 0 . 0 %

5 0 . 0 %

V id e o / D V DT im e W k

L o w e r ( % )

W e b T im e W kL o w e r ( % )

G a m e T im eW k L o w e r

( % ) *

H o m e w o r kT im e W k

H ig h e r ( % )

In te r v e n t i o nn = 6 9 5

C o n t r o ln = 9 5 1

* P<.001


Sedentary Behavior on Weekends(Other than TV Watching)

0 .0 %1 0 .0 %

2 0 .0 %3 0 .0 %

4 0 .0 %5 0 .0 %

V i d e o /D V DT i m e W k

L o w e r ( % )

W e b T i m eW k L o w e r

( % )

G a m eT i m e W k

L o w e r( % ) *

H o m e w o r kT i m e W k

H i g h e r ( % )

In t e r v e n t io nn = 6 9 5C o n t r o l n = 9 5 1

** p=.002

**

Change in % (at least 1/2hr)


TGIF… TV Time!!!

00 . 5

11 . 5

22 . 5

33 . 5

Ba

se

line

Co

ntr

ol

Fo

llow

-up

Ba

se

line

Inte

rve

ntio

n

Fo

llow

-up

T V W a t c h in g B e h a v io r ( H o u r s /D a y )

M o n - T h u r s

F r id a y

S a t u r d a y

S u n d a y

p < 0.001


Change in TV Watching Behavior > 2 Hrs/Day

B a s e l i n e A t F o l l o w - u p% C h a n g e P - va l u eM o n d a y In t e r ve n t i o n 4 1 . 8 % 4 0 . 6 % - 1 . 2 0 %

C o n t r o l 3 7 . 6 % 3 9 . 6 % 2 . 0 0 %T u e s d a y In t e r ve n t i o n 4 0 . 8 % 3 9 . 9 % - 0 . 9 0 %

C o n t r o l 3 6 . 1 % 4 1 . 0 % 4 . 9 0 %W e d n e s d a yIn t e r ve n t i o n 3 9 . 3 % 3 7 . 8 % - 1 . 5 0 %

C o n t r o l 3 5 . 7 % 4 0 . 3 % 4 . 6 0 %T h u r s d a y In t e r ve n t i o n 4 1 . 4 % 4 0 . 1 % - 1 . 3 0 %

C o n t r o l 3 7 . 7 % 3 8 . 5 % 0 . 8 0 %F r i d a y In t e r ve n t i o n 5 9 . 9 % 5 3 . 5 % - 6 . 4 0 %

C o n t r o l 5 2 . 4 % 4 8 . 8 % - 3 . 6 0 %S a t u r d a y In t e r ve n t i o n 6 7 . 7 % 5 7 . 1 % - 1 0 . 6 0 %

C o n t r o l 6 0 . 1 % 5 5 . 1 % - 5 . 0 0 %S u n d a y In t e r ve n t i o n 5 7 . 2 % 5 1 . 5 % - 5 . 7 0 %

C o n t r o l 5 5 . 1 % 5 1 . 9 % - 3 . 2 0 %

0 . 1 1 3

0 . 0 2 3

0 . 2 1 7

0 . 0 3 9

0 . 8 3 4

0 . 0 5 7

0 . 1 3 5


Policy and Environment

H5: The intervention will create nutrition and physical activity policy and/or environmental changes at schools.– All six intervention schools made positive changes during the study

period and five out of the six schools increased their composite score by about a third or more.

– The seven control schools followed a less consistent trend. On average, they did not perform as well as intervention schools.

• 3 schools had (-) changes (-4%, -16%, -18%)

• Scores for 2 schools increased by 17%

• Scores for 2 remaining schools increased on a par with Intervention schools (38% and 72%)


Summary* The 5-2-1Go! intervention was effective in increasing

the amount of moderate physical activity of students and decreasing TV watching time. (Implications for ‘TV Turn-off Day’ type efforts)

* The 5-2-1Go! intervention was effective in changing school policies and environments.

* Similar preliminary findings from ‘Healthy Choices Initiative’ (more comprehensive, B/A School programs, 3 years, $9,000)* Admin Buy-in and On-going TA

Establish Regulations, Establish Regulations, Legislation and Policies Legislation and Policies to Reduce TV Viewing to Reduce TV Viewing

Time in Child CareTime in Child Care

Amendments to Article 47 of the New York City Health Code

Article 47Article 47• Licensed group day care centers in New

York City are regulated under Article 47 of the New York City Health Code.

• The New York City Board of Health enacts changes to the health code.

• The amendments were adopted by the Board of Health in June 2006, and took effect in January 2007.

Article 47 AmendmentsArticle 47 Amendments

• Enhanced outdoor and indoor physical activities

• Nutrition standards

• Limits on TV viewing

Physical ActivityPhysical Activity

• Minimum Requirements:– 12 months and up, at least 60 minutes/day– 3 years and older, at least 30 of 60 minutes

must be structured and guided – Children shall not be sedentary for more

than 60 minutes consecutively, except when sleeping.

NutritionNutrition• Beverages with added sweeteners shall not

be provided.

• 100% juice limited to 6oz/day; shall not be offered in a bottle.

• 1% or fat-free milk for children ages 2 years and older.

• Water shall be made available and easily accessible throughout the day, and offered at all meals and snacks.

Television ViewingTelevision Viewing

• Television, video and other visual recordings:– Shall not be used with children under two

years of age.– Shall be limited to not more than 60

minutes/day* of educational or movement-oriented programs for children ages 2 and older.*prorated for children in less than full-day programs

MonitoringMonitoring

• Television viewing is monitored by Sanitarians and Early Childhood Specialists who regularly inspect and consult with centers.

EvaluationEvaluation

Evaluating Whether NYC Group Daycares Meet New

City-Mandated Physical Activity, Screen Time, and

Nutrition Policies and Perceived Implementation Issues

Principal Investigator: Beth Dixon, PhD, MPH

Associate Professor and Director, Public Health Nutrition

Department of Nutrition, Food Studies and Public Health

New York University

Supported by the RWJF Healthy Eating Research Program

9/1/07 – 6/30/09

NYU Daycare Study Design NYU Daycare Study Design and Methods and Methods

C. BrooklynC. Brooklyn(n=10) Daycare

Centers

ManhattanManhattan(n=10) Daycare

Centers

Physical Activity and Nutrition Practices and PoliciesPhysical Activity and Nutrition Practices and Policies(n = 40 licensed group daycare centers)

Direct Observation; Direct Observation; AccelerometersAccelerometers

Daily Schedule of Daily Schedule of Activities andActivities and

MenusMenus

S. Bronx S. Bronx (n=10) Daycare

Centers

E. & C. HarlemE. & C. Harlem(n=10) Daycare

Centers

Director Survey Director Survey

Results – TV ViewingResults – TV Viewing• Director Survey Centers allowing TV viewing 58%

<30 minutes 61%

30-60 minutes 22%

90-120 minutes 6%

View TV 1-2 times/week 29%

Rarely/inclement weather 63%

Never 8%

• Direct Observation – One DayTV viewing observed at 4 centers:

<30 minutes at 3 centers

31-60 minutes at 1 center

Results – Computer UseResults – Computer Use• Director Survey Centers allowing computer use 92%

<30 minutes 94%

30-60 minutes 3%

Never 3%

Daily use 73%

1-2 times/week 14%

Rarely or never 3%

• Direct Observation – One Day Computer use observed at 10 centers

Children spent < 30 minutes at 8 centers

Children spent 31-60 minutes at 2 centers

ContactsCathy Nonas, MS, RD

Director, Physical Activity and Nutrition Program

New York City Department of Health and Mental [email protected]

L. Beth Dixon, PhD, MPH

Associate Professor, Public Health Nutrition

Dept. of Nutrition, Food Studies and Public Health

New York [email protected]

Sara Bonam Welge, MS, RD

Nutrition Coordinator, Obesity Prevention Program

New York State Department of [email protected]

mailto:[email protected]



decreasing television viewing of children: guidance document strategies barbara polhamus, phd, mph,...

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