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The Role of Media in Childhood Obesity
C H A P T E R
33 The Role of Media in Childhood Obesity Amy B. Jordan School of Communication and Information, Rutgers the State University of New Jersey, New Brunswick, NJ, United States
33.1 CHILDREN’S MEDIA USE PATTERNS High levels of media use are linked to obesity throughout the life course, and this association is observed starting in early childhood [1]. Although the American Academy of Pediatrics (AAP) initially recommended that screen media use be limited to no more than 2 hours per day [2], more recent studies have led them to suggest that setting limits of TV viewing to between 1 and 1.5 hours a day may be more effective to prevent obesity than the 2-hour standard presented in their earlier recommendation [3]. Surveys of US parents find that most families do not adhere to these recommendations, however [4]. Although children’s time spent with television has decreased over the past decade [5], time with new media platforms has risen dramatically. A 2012 survey of parents with children ages 16 and under found that children spend, on average, 2.8 hours watching television, 1.4 hours using the computer, and 1.1 hours playing video games [4]. Another national sample of 13–18-year-olds found that American teens use up to 6 hours of screen media daily, not including for school or homework [6]. Their analyses showed that children from lower-income homes and black and Hispanic children spend far more time with media—especially screen media—than white children and children from higher- and middle-income homes. Unfortunately, these same children are disproportionally at risk for overweight [7]. Not surprisingly, children’s time spent with media is significantly associated with parent’s time spent with media [4, 8, 9]. One reason children spend so much of their leisure time watching television may lie in the ubiquity of media throughout American homes [4, 9]. According to a 2015 Common Sense Media report, 9 in 10 homes with tweens and teens has a television set, 8 in 10 has a video game console, 8 in 10 has a smartphone, between 7 and 8 in 10 has a tablet, and 7 in 10 has a laptop computer. A majority also has a desktop computer and a portable game player [6]. The average family owns 4 working television sets, the majority subscribe to cable or satellite services that provide hundreds of channels, more than two-thirds of children have a television set in the bedroom, and 4 in 10 families have a TV in the dining room or kitchen [4]. Children’s increased access to television—particularly in the bedroom—has been linked to heavier viewing [4, 10]. A second reason children spend so much time with electronic media may lie in the fact that, for some, there may be fewer free-time alternatives. Family income is negatively related to children’s television time [6]. This may be due to the lack of income needed to afford activities that might limit children’s viewing time—for example, dues necessary to play in community-organized sports or membership costs of local youth-serving organizations such as the YMCA. The link between low socioeconomic status and heavy viewing may also be related to the quality of the neighborhood environment and parents’ comfort level in sending their children “out to play.” In one study, parents were asked about the challenges they might face in bringing their child’s viewing in line with the AAP recommendations. Those from lower-income communities worried that, without the TV and video games to keep them indoors and occupied, their children might be less safe or more likely to get into trouble [11]. Another longitudinal survey, which tracked children from kindergarten through fourth grade, found that children who watched more television lived in neighborhoods that were perceived by parents as less safe [12]. A third reason for children’s heavy media use may lie in the notion that patterns of media use are passed on from parents to children. Children are socialized regarding their attitudes toward television viewing (e.g., it is a waste of
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time versus a pleasurable activity) and their preferences for media content (e.g., educational versus entertainment oriented), and they may adopt media use habits that provide a tempo to their day [13, 14]. Several studies have found that a strong predictor of children’s heavy media use is parents’ positive attitudes toward what media have to offer their children [9, 13].
33.2 THE RELATIONSHIP BETWEEN CHILDREN’S HEAVY MEDIA USE AND CHILDHOOD OVERWEIGHT Though researchers have long studied the effect of television viewing, video game playing, and even computer use on academic and social outcomes, they have recently turned their attention to the impact of media use on children’s physical well-being. The evidence for a relationship between children’s heavy media use and childhood obesity has been mounting. Cross-sectional surveys indicate that, as the number of hours children spend watching television rises, so too does their body fat percentage and risk of overweight [15–17]. Prospective studies also find childhood television viewing to be a risk factor for subsequent adiposity [18, 19]. Perhaps most persuasive are randomized controlled trials (RCTs), which have linked the reduction of television and other screen media use to decreased body mass index (BMI), waist circumferences, and triceps skin-fold thickness in elementary school-age children [20]; decreased overweight in middle school girls [21]; and weight loss among overweight 8- to 12-year-old children [22]. Unfortunately, the limited number of interventions targeting diverse populations and obesity risk behaviors beyond diet and physical activity inhibit the development of comprehensive, tailored interventions [23]. Although television remains the medium with which children spend the most time [6], the use of other sedentary media has risen since the late 1990s [6, 9]. Several studies suggest that the role of nontelevision media in childhood overweight should not be overlooked. Findings of a significant relationship between adolescent weight status and electronic game play and heavy computer use indicate that the focus should not remain exclusively with television [24, 25].
33.3 MECHANISMS FOR EXPLAINING THE ASSOCIATION If we accept the evidence that heavy media use is a contributing factor to childhood overweight, it is critical to understand the mechanisms that underlie the relationship. The following are three potential pathways that are likely independent contributors though not necessarily mutually exclusive.
33.3.1 Media Influence on Physical and Sedentary Activity One might intuitively believe that children’s heavy use of media displaces time spent in physical activity. One might also assume that children who are more physically active are less likely to be overweight. These relationships, however, are not always that straightforward. Although television viewing prevents physical activity in that moment, there is little evidence to suggest that, over the course of a day or week, the amount of time children spend watching TV is associated with the amount of time they spend engaged in physical activity. A systematic review by Marshall et al. on the relationship between media use and physical activity showed little support for the displacement hypothesis [26]. The association between physical activity and weight status is also complex. Research with adolescents has found that, as expected, physical activity is inversely associated with overweight status [27]. A large prospective cohort study of European children from the Identification and Prevention of Dietary- and Lifestyle-induced Health Effects In Children and Infants (IDEFICS) cohort found strong evidence for audio-visual media time and an inverse association of objectively determined physical activity [28]. It is possible that the lack of relationship between physical activity, media use, and overweight is due to unreliable measures of physical activity in children. More likely, however, there are distinct behavioral pathways to obesity for physical activity and inactivity [29–31]. Several studies have found that decreasing sedentary behaviors (i.e., television viewing and video game playing) is a more successful strategy for helping overweight children reduce BMI than increasing physical activity [32]. Epstein found that reductions in the targeted sedentary behavior (in this study, television viewing and computer use in overweight children aged 4–7) resulted in less energy intake and weight loss but did not lead to increased physical activity. That said, the best possible scenario for preventing overweight may be a combination of screen time reduction and frequent moderate-to-vigorous physical activity [32–35]. In addition, interventions that promote healthy home environments rather than just targeting child sedentary or physical activity may yield greater success [36]. VI. COMMENTARY AND RECOMMENDATIONS
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33.3.2 Media Influence on Dietary Habits The media may shape children’s food choices and caloric intake by exposing children to persuasive messages about food, cuing them to eat, and depressing satiety cues of eating while viewing. According to estimates by the Federal Trade Commission, children between the ages of 2 and 11 are exposed to 25,600 advertisements per year, of which 5500 (or 15 per day) are for food or beverages [37]. These advertisements are predominantly for foods high in salt, sugar, and fat, and low in nutritional value. In another study, conducted in New Zealand, 168 children (average age, 12.6) wore cameras to examine the frequency and nature of everyday exposure to food marketing across multiple media and settings for 4 consecutive days. On average, children were exposed to noncore (“junk food”) marketing messages 27.3 times per day. This was more than twice their average exposure to core (healthy) food messages. Sugary drinks, fast food, and sugary and snack foods were the most commonly encountered noncore foods [38]. Clearly children’s food consumption affects their weight status. But does children’s exposure to junk food advertisements affect their diets? A large body of research indicates that advertising influences children’s food preferences, their eating behaviors, and the purchase requests they direct to parents [39–41]. Though conventional wisdom suggests that, as children increase in age, they become better equipped to defend themselves against advertising’s negative effects, the persuasive techniques used in food and beverage marketing may make it difficult to be resistant to their messages. In addition, as more and more marketing goes into unregulated platforms, such as online branded games, children are less likely to process the advertisements and resist them [42, 43]. In one study, children watched a television show with or without food commercials and then participated in a simulated shopping trip with their mothers. Children exposed to the commercials requested significantly more products than children who did not see the commercials and requested a greater number of products that had been featured in the ads [40]. A study of children’s intake of meals where food brands were present or absent found that overweight children show greater responsiveness to food branding than nonoverweight children [44]. In another study, elementary school-age children watched a cartoon that contained either food advertising or advertising for other products and received a snack while watching. Results indicated that children consumed 45% more when exposed to food advertising, regardless of prior report of hunger or whether the food offered was the food advertised. The authors hypothesized that food advertisements prime children to eat while viewing and concluded that snacking while watching commercial TV with food advertisements for only 30 minutes per day would lead to a weight gain of almost 10 pounds per year if not compensated [45]. Researchers have found an association between heavy television viewing and more frequent snacking [46, 47], the consumption of sugary beverages [46, 47], and more frequent visits to fast-food chains [47]. Heavy television viewing is also negatively associated with the consumption of fruits and vegetables [48]. Although much of this research is crosssectional, it is possible that the heavy advertising of fast-food restaurants and highly sugared cereals and drinks contributes to youths’ belief that these are appropriate foods to eat as meals and snacks [45]. In addition, the practice of “product placement”—in which food companies pay to feature their product in children’s movies and general audience television shows—is becoming more frequent, but its effects are not well understood. Some scholars suggest that television affects weight status because children consume higher-calorie, nutritionally poor foods while viewing TV. Saelens et al. found cross-sectional and longitudinal associations between the number of meals children ate while viewing TV and the number of hours spent watching TV [46]. When television viewing is combined with eating, whether during mealtime [47] or snack time [49], children eat fewer fruits and vegetables and consume more calories, even when potential covariates such as socioeconomic factors are controlled. As mentioned earlier, food advertising during the television programs children watch could be priming young viewers to consume more and lower-quality food. However, other researchers suggest that television viewing decreases internal signals of satiety or the feeling of fullness. Blass and colleagues, for example, found that TV viewing, in contrast to music listening, significantly increased the amount of pizza and macaroni and cheese college students consumed in the experimental setting in which there were no advertisements at all [50].
33.3.3 Media Influence on Sleep Behaviors A third potential mechanism underlying the connection between media use and childhood overweight may lie in the influence of media on sleep patterns. An estimated 20%–30% of young children have some type of sleep difficulty, including bedtime resistance, sleep onset delay, anxiety around sleep, and shortened sleep duration [51]. Snell, Adam, and Duncan found that 13% of the 3- to 7-year-old children in their nationally representative sample slept less than 9 hours per night (11 hours is recommended) [52]. Researchers have found short sleep duration to be an independent VI. COMMENTARY AND RECOMMENDATIONS
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risk factor for overweight and obesity in children [53]. Insufficient sleep may result in less energy to be physically active and a greater likelihood to snack on sugary foods for an energy boost [54]. There is evidence that children’s media use may be causing or exacerbating children’s sleep problems. Owen and colleagues found that bedtime television viewing by 4- to 10-year-olds was significantly associated with bedtime resistance, sleep onset delay, and decreased sleep duration [55]. Paavonen et al. similarly found that watching TV at bedtime was associated with sleeping difficulties for 5- to 6-year-olds [56]. Children themselves report using television as a sleep aid. More than one-third of a sample of 5th- to 10th-grade Dutch youth reported that they turn on the TV to help them fall asleep; however, nighttime TV viewing was negatively related to their number of hours of sleep per week [57]. The widespread use of portable electronic devices, particularly in the nighttime hours, is accompanied by a high prevalence of insufficient sleep in a majority of adolescents [58]. What is not clear from the existing body of research is whether screen media use creates sleep problems or whether those suffering from sleep problems turn to media as a sleep aid. A national telephone survey of parents of 6-month-olds to 6-year-olds found that 53% said that television viewing can help calm their child [59]. In this study, 30% of parents said that a motivation for putting a TV in the child’s bedroom was because it helps the child fall asleep.
33.4 CAN MEDIA BE A PART OF THE SOLUTION? Though it may be ironic to create mass media-based interventions to encourage physical activity and more healthful eating, evaluations of such campaigns have found some success. The Centers for Disease Control and Prevention ran the VERB campaign to encourage “tweens” (9- to 12-year-olds) to become more physically active. By encouraging adolescents to find their “verb”—activities that might define them or that they most enjoy—campaign designers aimed to help children develop more positive attitudes about exercise and participate more frequently in physical activities. An evaluation of the campaign over time found that youth who were more aware of the VERB campaign and reported being exposed to more of the campaign’s messages were more likely to feel self-efficacy in their ability to exercise, were more likely to find social support in their efforts to exercise, and were more likely to participate in regular physical activity. This held true even after their initial physical activity beliefs and behaviors before the start of the campaign were factored in, although it was more evident after 2 years of campaign exposure than it was after only 1 year [60]. Another campaign, based in Philadelphia, used media messages to encourage parents to substitute healthy beverages (milk, water, 100% juice), for sugar-sweetened beverages. Parents exposed to the campaign were significantly more likely to believe that if they cut back on children’s sugary beverage consumption it would make them feel that they were doing something good for their family, it would decrease the likelihood that their child would gain weight, and it would decrease the likelihood that their child would be at risk for type 2 diabetes [61]. Calvert and colleagues point out that not all screen exposure is equally created in terms of physical movement. The rise of “exergames”—games like Wii and Dance Dance Revolution—actually encourage children to move and have resulted in more energy expenditure than sedentary video game play and have in fact been shown to yield as much calorie burning as walking at a 3 mile-per-hour pace. They argue that exergames and other new digital media “exercise technology” offer an “untapped promise to get youth to exercise and even lose weight” [62].
33.5 RECOMMENDATIONS The good news about research on the impact of children’s media use on childhood obesity is that we are closer to identifying behaviors that are potentially modifiable [63]. 1. Discourage nighttime media use. It must be recognized that, with the growing convergence of media platforms, TVs in the bedroom are no longer the sole contributors to heavy media use or disrupted sleep. Raising awareness of the problems associated with bedtime media use may reduce overall screen time and may help to limit nighttime interference with children’s healthy sleep. 2. Encourage mindful viewing by monitoring screen media watched, budgeting media time, and fostering media literacy. The AAP recommends that families create a personalized Family Media Use Plan, to encourage parents to purposefully think about the role of media in families’ lives, and to create goals and rules in line with the family’s values (https://www.healthychildren.org/English/media/Pages/default.aspx).
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3. Turn off screens while eating. Disconnecting food from TV viewing may increase awareness of food consumption while also increasing family communication, and decreasing total TV watching time. One important first step may be to create a family policy that all devices be put away during family mealtimes. 4. Use school-based curricula to reduce children’s screen time. Schools are an excellent forum for efficiently and effectively reaching a large number of youth with a focused curriculum. School-based curricula have been found to be successful in reducing television viewing and, in some cases, reducing weight gain [64, 65]. 5. Provide training for health care professionals to counsel them on reducing children’s media use. The medical community has become more and more interested in the role of media in children’s health and well-being. Providing training and support for health care professionals on issues related to reducing children’s use of media can be an important step, particularly because pediatricians are an important source of trusted information for most parents [66].
33.6 IS THERE A ROLE FOR PUBLIC POLICY? In 2005, the Institute of Medicine declared that food and beverage marketing to children and youth in the United States is out of balance with healthful diets [45]. The response to this report has been a call to increase industry self-regulation and, if progress is not made, to move toward increased government regulation. Other national governments have moved to prohibit advertising to children (for example, Norway and Sweden ban ads aimed at children aged 12 and younger) and have specifically banned junk-food advertising on television programs designed for children or that have children as a large part of its audiences (for example, the United Kingdom has strict nutritional criteria that must be met for food advertised to children under the age of 16). However, in the United States, policy makers are loath to interfere with the marketplace economy or impose restrictions on the First Amendment rights of broadcasters. Broadcasters have instead pledged to increase their “healthy lifestyle” messages and, according to one study, seem to be doing so; however, it is not clear how such messages are received [67]. If a child watches an advertisement in which Ronald McDonald and children ride their bikes to McDonald’s, are child viewers more likely to want to exercise and less likely to consume fast food? In addition, the Council of Better Business Bureaus’ Children’s Advertising Review Unit (CARU) has asked its members to encourage “responsible use” of food and beverages. There are no sanctions for noncompliance if CARU determines a member violates its voluntary code. Another public policy that has been considered involves limiting the use of television and other “passive” or “sedentary” media use in federally funded schools and childcare centers. Christakis and Garrison conducted a telephone survey of licensed childcare programs in four states across the United States and found that nearly 70% of homebased daycare and almost 36% of center-based childcare programs reported using television with preschool-aged children [68]. The mean time of daily television use for preschoolers in a daycare setting in which television was used was 3.4 hours in home-based programs and 1.2 hours in center-based programs. Jordan’s observations of the use of television in a low-income, federally subsidized daycare center indicates that there is much opportunity to educate teachers and caregivers about ways to extend the educational potential of viewing, including tying favorite TV characters and programs to hands-on experiences and using TV lessons as teachable moments [69]. In addition to educating teachers and providers about appropriate screen media use, daycare centers and schools have been effective settings for delivering interventions to reduce screen time. In a preschool setting, Dennison and colleagues were effective in reducing children’s television/video viewing with a health promotion curriculum that consisted of seven interactive 20-minute sessions [70]. In an elementary school setting, children were encouraged to participate in a 10-day TV turnoff period, and their families were provided with a device called a TV Allowance, which automatically turns off the electronic device once the maximum preset time has been reached. Children participating in this intervention decreased television viewing by about one-third of their baseline viewing and significantly reduced the number of meals and snacks consumed while watching TV [20]. Another school-based approach involves media literacy training designed to increase children’s understanding of the functions and purposes of various media forms (e.g., the primary purpose of advertising is to persuade) and to encourage the critical evaluation of media messages. Not surprisingly, research suggests that children easily learn the content of media literacy curricula [64]. There is less evidence, however, that children apply these lessons while using media [65]. Thus a child may understand that food commercials intend to persuade, but this knowledge may not mitigate the influence of the ads. More research is needed to identify the types of media literacy training that are most likely to stimulate critical thinking skills. Curricula that combine media literacy and media reduction may prove to be the most effective.
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33.7 CONCLUSION Children who are excessively involved in screen media use have an increased risk of overweight during childhood and are more likely to be overweight as adults. Indeed, in a longitudinal study of 1037 New Zealand men followed between the ages of 5 and 32, childhood television viewing was a better predictor of adult BMI and fitness than adult viewing and remained a significant predictor of these outcomes even after adjusting for adult viewing [71]. The research reviewed in this chapter highlights the need to educate parents and children about healthy media diets when children are still quite young. Although much remains to be understood about exactly how children’s heavy media use contributes to childhood obesity, there is now a solid evidence base that can be used to design screen time reduction interventions. Health care providers, moreover, can suggest simple steps that families can implement to limit screen time as a strategy for combating overweight, discouraging media use at bedtime, highlighting the negative effects of exposure to food marketing, and developing a conscious and purposeful strategy for incorporating media use into the day-to-day life of the family.
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[44] Forman J, Halford JCG, Summe H, MacDougall M, Keller KL. Food branding influences ad libitum intake differently in children depending on weight status: results of a pilot study. Appetite 2009;53:76–83. [45] Institute of Medicine. Preventing childhood obesity: Health in the balance. Washington, DC: The National Academies Press; 2005. [46] Saelens BE, Sallis JF, Nader PR, Broyles SL, Berry CC, Taras HL. Home environmental influences on children’s television watching from early to middle childhood. J Dev Behav Pediatr 2002;23(3):127–32. [47] Coon KA, Goldberg J, Rogers BL, Tucker KL. Relationships between use of television during meals and children’s food consumption patterns. Pediatrics 2001;107:E7. [48] Dubois L, Farmer A, Girard M, Peterson K. Social factors and television use during meals and snacks is associated with higher BMI among preschool children. Public Health Nutr 2008;11(12):1267–79. [49] Matheson DM, Wang Y, Klesges M, Beech BM, Kraemer HC, Robinson TN. African-American girls’ dietary intake while watching television. Obes Res 2004;12(Suppl. 1):32S–37S. [50] Blass EM, Anderson DR, Kirkorian HL, Pempek TA, Price I, Koleini MF. On the road to obesity: television viewing increases intake of highdensity foods. Physiol Behav 2006;88:597–604. [51] Magee L, Hale L. Longitudinal associations between sleep duration and subsequent weight gain: a systematic review. Sleep Med Rev 2012;16:231–41. [52] Snell E, Adam E, Duncan G. Sleep and the body mass index and overweight status of children and adolescents. Child Dev 2007;78(1):309–23. [53] Nixon GM, Thompson J, Han DY, Becroft DM, Clark PM, Robinson E, Waldie KE, Wild CJ, Black PN, Mitchell EA. Short sleep duration in middle childhood: risk factors and consequences. Sleep 2008;31(1):71–8. [54] Taheri S. The link between short sleep duration and obesity: we should recommend more sleep to prevent obesity. Arch Dis Child 2006;91:881–4. [55] Owens J, Maxim R, McGuinn M, Nobile C, Msall M, Alario A. Television viewing habits and sleep disturbance in school children. Pediatrics 1999;104:e27. [56] Paavonen E, Pennonen M, Roine M, Valkonen S, Lahikainen A. TV exposure associated with sleep disturbances in 5- to 6-year old children. J Sleep Res 2006;15(2):154–61. [57] Eggermont S, van den Bulck J. Nodding off or switching off? The use of popular media as a sleep aid in secondary school children. J Paediatr Child Health 2006;42(7–8):428–33. [58] Falbe J, Davison K, Franckle R, Ganter C, Gortmaker S, Smith L, Land T, Taveras E. Sleep duration, restfulness, and screens in the sleep environment. Pediatrics 2015;135(2):e367–75. https://doi.org/10.1542/peds.2014-2306.
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[59] Rideout V, Vandewater E, Wartella E. Electronic media in the lives of infants, toddlers, and preschoolers. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2003. [60] Huhman ME, Potter LD, Duke JC, Judkins DR, Heitzler CD, Wong FL. Evaluation of a national physical activity intervention for children: VERB campaign, 2002–2004. Am J Prev Med 2007;32(1):38–43. [61] Bleakley A, Jordan A, Mallya G, Hennessy M, Piotrowski JT. Do you know what your kids are drinking? Evaluation of a media campaign to reduce consumption of sugar-sweetened beverages, Am J Health Promot 2017;1–8. http://journals.sagepub.com/doi/pdf/10. 1177/0890117117721320. [62] Calvert SL, Staiano AE, Bond B. Electronic gaming and the obesity crisis. In: Blumberg FC, Fisch SM, editors. Digital games: A context for cognitive development. New directions for child and adolescent development, vol. 139. 2013. p. 51–7. [63] Jordan A, Robinson T. Children, television viewing, and weight status. Ann Am Acad Pol Soc Sci 2008;615(January):119–32. [64] Donohue TR, Henke LL, Meyer TP. Learning about television commercials: the impact of instructional units on children’s perceptions of motive and intent. J Broadcast 1983;27:251–61. [65] Livingstone S, Helsper E. Does advertising literacy mediate the effects of advertising on children?: a critical examination of two linked research literatures in relation to obesity and food choice. J Commun 2006;56:560–84. [66] Moseley KL, Freed GL, Goold SD. Which sources of child health advice do parents follow? Clin Pediatr 2011;50(1):50–6. [67] Jordan A. Food marketing on children’s television: A multi-year comparison. In: Paper presented at the biennial meeting of the Society for Research on Child Development: Boston, MA; 2007. [68] Christakis DA, Garrison MM. Preschool-aged children’s television viewing in child care settings. Pediatrics 2009;124(6):1627–32. [69] Jordan A. Learning to use books and television: an exploratory study in the ecological perspective. Am Behav Sci 2005;48(5):523–38. [70] Dennison BA, Russo TJ, Burdick PA, Jenkins PL. An intervention to reduce television viewing by preschool children. Arch Pediatr Adolesc Med 2004;158:170–6. [71] Lanhuis CE, Poulton R, Welch D, Hancox RJ. Programming obesity and poor fitness: the long-term impact of childhood television. Obesity 2008;16:1457–9.
Further Reading [72] Harris JL, Bargh JA, Brownell KD. Priming effects of television food advertising on eating behavior. Health Psychol 2009;28(4):404–13. [73] Snoek HM, Van Strien T, Janssens JM, Engels RC. The effect of television viewing on adolescents’ snacking: individual differences explained by external, restrained and emotional eating. J Adolesc Health 2006;(3):448–51. [74] Utter J, Neumark-Sztainer D, Jeffery R, Story M. Couch potatoes or French fries: are sedentary behaviors associated with body mass index, physical activity, and dietary behaviors among adolescents? J Am Diet Assoc 2003;103(10):1298–305. [75] Miller SA, Taveras EM, Rifas-Shiman SL, Gillman MW. Association between television viewing and poor diet quality in young children. Int J Pediatr Obes 2008;3(3):168–76.
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33 The Role of Media in Childhood Obesity Amy B. Jordan School of Communication and Information, Rutgers the State University of New Jersey, New Brunswick, NJ, United States
33.1 CHILDREN’S MEDIA USE PATTERNS High levels of media use are linked to obesity throughout the life course, and this association is observed starting in early childhood [1]. Although the American Academy of Pediatrics (AAP) initially recommended that screen media use be limited to no more than 2 hours per day [2], more recent studies have led them to suggest that setting limits of TV viewing to between 1 and 1.5 hours a day may be more effective to prevent obesity than the 2-hour standard presented in their earlier recommendation [3]. Surveys of US parents find that most families do not adhere to these recommendations, however [4]. Although children’s time spent with television has decreased over the past decade [5], time with new media platforms has risen dramatically. A 2012 survey of parents with children ages 16 and under found that children spend, on average, 2.8 hours watching television, 1.4 hours using the computer, and 1.1 hours playing video games [4]. Another national sample of 13–18-year-olds found that American teens use up to 6 hours of screen media daily, not including for school or homework [6]. Their analyses showed that children from lower-income homes and black and Hispanic children spend far more time with media—especially screen media—than white children and children from higher- and middle-income homes. Unfortunately, these same children are disproportionally at risk for overweight [7]. Not surprisingly, children’s time spent with media is significantly associated with parent’s time spent with media [4, 8, 9]. One reason children spend so much of their leisure time watching television may lie in the ubiquity of media throughout American homes [4, 9]. According to a 2015 Common Sense Media report, 9 in 10 homes with tweens and teens has a television set, 8 in 10 has a video game console, 8 in 10 has a smartphone, between 7 and 8 in 10 has a tablet, and 7 in 10 has a laptop computer. A majority also has a desktop computer and a portable game player [6]. The average family owns 4 working television sets, the majority subscribe to cable or satellite services that provide hundreds of channels, more than two-thirds of children have a television set in the bedroom, and 4 in 10 families have a TV in the dining room or kitchen [4]. Children’s increased access to television—particularly in the bedroom—has been linked to heavier viewing [4, 10]. A second reason children spend so much time with electronic media may lie in the fact that, for some, there may be fewer free-time alternatives. Family income is negatively related to children’s television time [6]. This may be due to the lack of income needed to afford activities that might limit children’s viewing time—for example, dues necessary to play in community-organized sports or membership costs of local youth-serving organizations such as the YMCA. The link between low socioeconomic status and heavy viewing may also be related to the quality of the neighborhood environment and parents’ comfort level in sending their children “out to play.” In one study, parents were asked about the challenges they might face in bringing their child’s viewing in line with the AAP recommendations. Those from lower-income communities worried that, without the TV and video games to keep them indoors and occupied, their children might be less safe or more likely to get into trouble [11]. Another longitudinal survey, which tracked children from kindergarten through fourth grade, found that children who watched more television lived in neighborhoods that were perceived by parents as less safe [12]. A third reason for children’s heavy media use may lie in the notion that patterns of media use are passed on from parents to children. Children are socialized regarding their attitudes toward television viewing (e.g., it is a waste of
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time versus a pleasurable activity) and their preferences for media content (e.g., educational versus entertainment oriented), and they may adopt media use habits that provide a tempo to their day [13, 14]. Several studies have found that a strong predictor of children’s heavy media use is parents’ positive attitudes toward what media have to offer their children [9, 13].
33.2 THE RELATIONSHIP BETWEEN CHILDREN’S HEAVY MEDIA USE AND CHILDHOOD OVERWEIGHT Though researchers have long studied the effect of television viewing, video game playing, and even computer use on academic and social outcomes, they have recently turned their attention to the impact of media use on children’s physical well-being. The evidence for a relationship between children’s heavy media use and childhood obesity has been mounting. Cross-sectional surveys indicate that, as the number of hours children spend watching television rises, so too does their body fat percentage and risk of overweight [15–17]. Prospective studies also find childhood television viewing to be a risk factor for subsequent adiposity [18, 19]. Perhaps most persuasive are randomized controlled trials (RCTs), which have linked the reduction of television and other screen media use to decreased body mass index (BMI), waist circumferences, and triceps skin-fold thickness in elementary school-age children [20]; decreased overweight in middle school girls [21]; and weight loss among overweight 8- to 12-year-old children [22]. Unfortunately, the limited number of interventions targeting diverse populations and obesity risk behaviors beyond diet and physical activity inhibit the development of comprehensive, tailored interventions [23]. Although television remains the medium with which children spend the most time [6], the use of other sedentary media has risen since the late 1990s [6, 9]. Several studies suggest that the role of nontelevision media in childhood overweight should not be overlooked. Findings of a significant relationship between adolescent weight status and electronic game play and heavy computer use indicate that the focus should not remain exclusively with television [24, 25].
33.3 MECHANISMS FOR EXPLAINING THE ASSOCIATION If we accept the evidence that heavy media use is a contributing factor to childhood overweight, it is critical to understand the mechanisms that underlie the relationship. The following are three potential pathways that are likely independent contributors though not necessarily mutually exclusive.
33.3.1 Media Influence on Physical and Sedentary Activity One might intuitively believe that children’s heavy use of media displaces time spent in physical activity. One might also assume that children who are more physically active are less likely to be overweight. These relationships, however, are not always that straightforward. Although television viewing prevents physical activity in that moment, there is little evidence to suggest that, over the course of a day or week, the amount of time children spend watching TV is associated with the amount of time they spend engaged in physical activity. A systematic review by Marshall et al. on the relationship between media use and physical activity showed little support for the displacement hypothesis [26]. The association between physical activity and weight status is also complex. Research with adolescents has found that, as expected, physical activity is inversely associated with overweight status [27]. A large prospective cohort study of European children from the Identification and Prevention of Dietary- and Lifestyle-induced Health Effects In Children and Infants (IDEFICS) cohort found strong evidence for audio-visual media time and an inverse association of objectively determined physical activity [28]. It is possible that the lack of relationship between physical activity, media use, and overweight is due to unreliable measures of physical activity in children. More likely, however, there are distinct behavioral pathways to obesity for physical activity and inactivity [29–31]. Several studies have found that decreasing sedentary behaviors (i.e., television viewing and video game playing) is a more successful strategy for helping overweight children reduce BMI than increasing physical activity [32]. Epstein found that reductions in the targeted sedentary behavior (in this study, television viewing and computer use in overweight children aged 4–7) resulted in less energy intake and weight loss but did not lead to increased physical activity. That said, the best possible scenario for preventing overweight may be a combination of screen time reduction and frequent moderate-to-vigorous physical activity [32–35]. In addition, interventions that promote healthy home environments rather than just targeting child sedentary or physical activity may yield greater success [36]. VI. COMMENTARY AND RECOMMENDATIONS
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33.3.2 Media Influence on Dietary Habits The media may shape children’s food choices and caloric intake by exposing children to persuasive messages about food, cuing them to eat, and depressing satiety cues of eating while viewing. According to estimates by the Federal Trade Commission, children between the ages of 2 and 11 are exposed to 25,600 advertisements per year, of which 5500 (or 15 per day) are for food or beverages [37]. These advertisements are predominantly for foods high in salt, sugar, and fat, and low in nutritional value. In another study, conducted in New Zealand, 168 children (average age, 12.6) wore cameras to examine the frequency and nature of everyday exposure to food marketing across multiple media and settings for 4 consecutive days. On average, children were exposed to noncore (“junk food”) marketing messages 27.3 times per day. This was more than twice their average exposure to core (healthy) food messages. Sugary drinks, fast food, and sugary and snack foods were the most commonly encountered noncore foods [38]. Clearly children’s food consumption affects their weight status. But does children’s exposure to junk food advertisements affect their diets? A large body of research indicates that advertising influences children’s food preferences, their eating behaviors, and the purchase requests they direct to parents [39–41]. Though conventional wisdom suggests that, as children increase in age, they become better equipped to defend themselves against advertising’s negative effects, the persuasive techniques used in food and beverage marketing may make it difficult to be resistant to their messages. In addition, as more and more marketing goes into unregulated platforms, such as online branded games, children are less likely to process the advertisements and resist them [42, 43]. In one study, children watched a television show with or without food commercials and then participated in a simulated shopping trip with their mothers. Children exposed to the commercials requested significantly more products than children who did not see the commercials and requested a greater number of products that had been featured in the ads [40]. A study of children’s intake of meals where food brands were present or absent found that overweight children show greater responsiveness to food branding than nonoverweight children [44]. In another study, elementary school-age children watched a cartoon that contained either food advertising or advertising for other products and received a snack while watching. Results indicated that children consumed 45% more when exposed to food advertising, regardless of prior report of hunger or whether the food offered was the food advertised. The authors hypothesized that food advertisements prime children to eat while viewing and concluded that snacking while watching commercial TV with food advertisements for only 30 minutes per day would lead to a weight gain of almost 10 pounds per year if not compensated [45]. Researchers have found an association between heavy television viewing and more frequent snacking [46, 47], the consumption of sugary beverages [46, 47], and more frequent visits to fast-food chains [47]. Heavy television viewing is also negatively associated with the consumption of fruits and vegetables [48]. Although much of this research is crosssectional, it is possible that the heavy advertising of fast-food restaurants and highly sugared cereals and drinks contributes to youths’ belief that these are appropriate foods to eat as meals and snacks [45]. In addition, the practice of “product placement”—in which food companies pay to feature their product in children’s movies and general audience television shows—is becoming more frequent, but its effects are not well understood. Some scholars suggest that television affects weight status because children consume higher-calorie, nutritionally poor foods while viewing TV. Saelens et al. found cross-sectional and longitudinal associations between the number of meals children ate while viewing TV and the number of hours spent watching TV [46]. When television viewing is combined with eating, whether during mealtime [47] or snack time [49], children eat fewer fruits and vegetables and consume more calories, even when potential covariates such as socioeconomic factors are controlled. As mentioned earlier, food advertising during the television programs children watch could be priming young viewers to consume more and lower-quality food. However, other researchers suggest that television viewing decreases internal signals of satiety or the feeling of fullness. Blass and colleagues, for example, found that TV viewing, in contrast to music listening, significantly increased the amount of pizza and macaroni and cheese college students consumed in the experimental setting in which there were no advertisements at all [50].
33.3.3 Media Influence on Sleep Behaviors A third potential mechanism underlying the connection between media use and childhood overweight may lie in the influence of media on sleep patterns. An estimated 20%–30% of young children have some type of sleep difficulty, including bedtime resistance, sleep onset delay, anxiety around sleep, and shortened sleep duration [51]. Snell, Adam, and Duncan found that 13% of the 3- to 7-year-old children in their nationally representative sample slept less than 9 hours per night (11 hours is recommended) [52]. Researchers have found short sleep duration to be an independent VI. COMMENTARY AND RECOMMENDATIONS
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risk factor for overweight and obesity in children [53]. Insufficient sleep may result in less energy to be physically active and a greater likelihood to snack on sugary foods for an energy boost [54]. There is evidence that children’s media use may be causing or exacerbating children’s sleep problems. Owen and colleagues found that bedtime television viewing by 4- to 10-year-olds was significantly associated with bedtime resistance, sleep onset delay, and decreased sleep duration [55]. Paavonen et al. similarly found that watching TV at bedtime was associated with sleeping difficulties for 5- to 6-year-olds [56]. Children themselves report using television as a sleep aid. More than one-third of a sample of 5th- to 10th-grade Dutch youth reported that they turn on the TV to help them fall asleep; however, nighttime TV viewing was negatively related to their number of hours of sleep per week [57]. The widespread use of portable electronic devices, particularly in the nighttime hours, is accompanied by a high prevalence of insufficient sleep in a majority of adolescents [58]. What is not clear from the existing body of research is whether screen media use creates sleep problems or whether those suffering from sleep problems turn to media as a sleep aid. A national telephone survey of parents of 6-month-olds to 6-year-olds found that 53% said that television viewing can help calm their child [59]. In this study, 30% of parents said that a motivation for putting a TV in the child’s bedroom was because it helps the child fall asleep.
33.4 CAN MEDIA BE A PART OF THE SOLUTION? Though it may be ironic to create mass media-based interventions to encourage physical activity and more healthful eating, evaluations of such campaigns have found some success. The Centers for Disease Control and Prevention ran the VERB campaign to encourage “tweens” (9- to 12-year-olds) to become more physically active. By encouraging adolescents to find their “verb”—activities that might define them or that they most enjoy—campaign designers aimed to help children develop more positive attitudes about exercise and participate more frequently in physical activities. An evaluation of the campaign over time found that youth who were more aware of the VERB campaign and reported being exposed to more of the campaign’s messages were more likely to feel self-efficacy in their ability to exercise, were more likely to find social support in their efforts to exercise, and were more likely to participate in regular physical activity. This held true even after their initial physical activity beliefs and behaviors before the start of the campaign were factored in, although it was more evident after 2 years of campaign exposure than it was after only 1 year [60]. Another campaign, based in Philadelphia, used media messages to encourage parents to substitute healthy beverages (milk, water, 100% juice), for sugar-sweetened beverages. Parents exposed to the campaign were significantly more likely to believe that if they cut back on children’s sugary beverage consumption it would make them feel that they were doing something good for their family, it would decrease the likelihood that their child would gain weight, and it would decrease the likelihood that their child would be at risk for type 2 diabetes [61]. Calvert and colleagues point out that not all screen exposure is equally created in terms of physical movement. The rise of “exergames”—games like Wii and Dance Dance Revolution—actually encourage children to move and have resulted in more energy expenditure than sedentary video game play and have in fact been shown to yield as much calorie burning as walking at a 3 mile-per-hour pace. They argue that exergames and other new digital media “exercise technology” offer an “untapped promise to get youth to exercise and even lose weight” [62].
33.5 RECOMMENDATIONS The good news about research on the impact of children’s media use on childhood obesity is that we are closer to identifying behaviors that are potentially modifiable [63]. 1. Discourage nighttime media use. It must be recognized that, with the growing convergence of media platforms, TVs in the bedroom are no longer the sole contributors to heavy media use or disrupted sleep. Raising awareness of the problems associated with bedtime media use may reduce overall screen time and may help to limit nighttime interference with children’s healthy sleep. 2. Encourage mindful viewing by monitoring screen media watched, budgeting media time, and fostering media literacy. The AAP recommends that families create a personalized Family Media Use Plan, to encourage parents to purposefully think about the role of media in families’ lives, and to create goals and rules in line with the family’s values (https://www.healthychildren.org/English/media/Pages/default.aspx).
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3. Turn off screens while eating. Disconnecting food from TV viewing may increase awareness of food consumption while also increasing family communication, and decreasing total TV watching time. One important first step may be to create a family policy that all devices be put away during family mealtimes. 4. Use school-based curricula to reduce children’s screen time. Schools are an excellent forum for efficiently and effectively reaching a large number of youth with a focused curriculum. School-based curricula have been found to be successful in reducing television viewing and, in some cases, reducing weight gain [64, 65]. 5. Provide training for health care professionals to counsel them on reducing children’s media use. The medical community has become more and more interested in the role of media in children’s health and well-being. Providing training and support for health care professionals on issues related to reducing children’s use of media can be an important step, particularly because pediatricians are an important source of trusted information for most parents [66].
33.6 IS THERE A ROLE FOR PUBLIC POLICY? In 2005, the Institute of Medicine declared that food and beverage marketing to children and youth in the United States is out of balance with healthful diets [45]. The response to this report has been a call to increase industry self-regulation and, if progress is not made, to move toward increased government regulation. Other national governments have moved to prohibit advertising to children (for example, Norway and Sweden ban ads aimed at children aged 12 and younger) and have specifically banned junk-food advertising on television programs designed for children or that have children as a large part of its audiences (for example, the United Kingdom has strict nutritional criteria that must be met for food advertised to children under the age of 16). However, in the United States, policy makers are loath to interfere with the marketplace economy or impose restrictions on the First Amendment rights of broadcasters. Broadcasters have instead pledged to increase their “healthy lifestyle” messages and, according to one study, seem to be doing so; however, it is not clear how such messages are received [67]. If a child watches an advertisement in which Ronald McDonald and children ride their bikes to McDonald’s, are child viewers more likely to want to exercise and less likely to consume fast food? In addition, the Council of Better Business Bureaus’ Children’s Advertising Review Unit (CARU) has asked its members to encourage “responsible use” of food and beverages. There are no sanctions for noncompliance if CARU determines a member violates its voluntary code. Another public policy that has been considered involves limiting the use of television and other “passive” or “sedentary” media use in federally funded schools and childcare centers. Christakis and Garrison conducted a telephone survey of licensed childcare programs in four states across the United States and found that nearly 70% of homebased daycare and almost 36% of center-based childcare programs reported using television with preschool-aged children [68]. The mean time of daily television use for preschoolers in a daycare setting in which television was used was 3.4 hours in home-based programs and 1.2 hours in center-based programs. Jordan’s observations of the use of television in a low-income, federally subsidized daycare center indicates that there is much opportunity to educate teachers and caregivers about ways to extend the educational potential of viewing, including tying favorite TV characters and programs to hands-on experiences and using TV lessons as teachable moments [69]. In addition to educating teachers and providers about appropriate screen media use, daycare centers and schools have been effective settings for delivering interventions to reduce screen time. In a preschool setting, Dennison and colleagues were effective in reducing children’s television/video viewing with a health promotion curriculum that consisted of seven interactive 20-minute sessions [70]. In an elementary school setting, children were encouraged to participate in a 10-day TV turnoff period, and their families were provided with a device called a TV Allowance, which automatically turns off the electronic device once the maximum preset time has been reached. Children participating in this intervention decreased television viewing by about one-third of their baseline viewing and significantly reduced the number of meals and snacks consumed while watching TV [20]. Another school-based approach involves media literacy training designed to increase children’s understanding of the functions and purposes of various media forms (e.g., the primary purpose of advertising is to persuade) and to encourage the critical evaluation of media messages. Not surprisingly, research suggests that children easily learn the content of media literacy curricula [64]. There is less evidence, however, that children apply these lessons while using media [65]. Thus a child may understand that food commercials intend to persuade, but this knowledge may not mitigate the influence of the ads. More research is needed to identify the types of media literacy training that are most likely to stimulate critical thinking skills. Curricula that combine media literacy and media reduction may prove to be the most effective.
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33.7 CONCLUSION Children who are excessively involved in screen media use have an increased risk of overweight during childhood and are more likely to be overweight as adults. Indeed, in a longitudinal study of 1037 New Zealand men followed between the ages of 5 and 32, childhood television viewing was a better predictor of adult BMI and fitness than adult viewing and remained a significant predictor of these outcomes even after adjusting for adult viewing [71]. The research reviewed in this chapter highlights the need to educate parents and children about healthy media diets when children are still quite young. Although much remains to be understood about exactly how children’s heavy media use contributes to childhood obesity, there is now a solid evidence base that can be used to design screen time reduction interventions. Health care providers, moreover, can suggest simple steps that families can implement to limit screen time as a strategy for combating overweight, discouraging media use at bedtime, highlighting the negative effects of exposure to food marketing, and developing a conscious and purposeful strategy for incorporating media use into the day-to-day life of the family.
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