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.
TV Viewing: Child Care and Schools
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
TV Viewing: Child Care and Schools
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
TV Viewing: Child Care and Schools
Program Examples
• New York City Amendment to the Health Code
• Delaware Child Care Policy to Improve Children’s Health
TV Viewing: Child Care and Schools
Develop and Implement Curricula
• Curriculum interventions can be incorporated into existing curricula or designed for families
• Curricula have a broad reach
TV Viewing: Child Care and Schools
Program Examples • Brocodile the Crocodile (preschool curriculum)
• Planet Health (middle school curriculum)
TV Viewing: Child Care and Schools
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
TV Viewing: Child Care and Schools
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
Solomon Mezgebu , Massachsuetts 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)
Solomon Mezgebu , Massachsuetts Department of Public Health
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
Solomon Mezgebu , Massachsuetts Department of Public Health
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.
Solomon Mezgebu , Massachsuetts Department of Public Health
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
Solomon Mezgebu , Massachsuetts Department of Public Health
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
Solomon Mezgebu , Massachsuetts Department of Public Health
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.
Solomon Mezgebu , Massachsuetts Department of Public Health
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
Solomon Mezgebu , Massachsuetts Department of Public Health
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)
Solomon Mezgebu , Massachsuetts Department of Public Health
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
Solomon Mezgebu , Massachsuetts Department of Public Health
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
Solomon Mezgebu , Massachsuetts Department of Public Health
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%)
Solomon Mezgebu , Massachsuetts Department of Public Health
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]