Television Viewing, Media and Advertising
Television viewing is the most common sedentary activity of children in the U.S. Children aged 2 through 17 years are estimated to spend approximately 4.5 hours a day watching television or videotapes, playing video games, using the computer, or browsing the internet (Woodard, 2000). Research has shown both television viewing and video game use to be associated with childhood obesity (Vandewater, Shim, Caplovitz, 2004; Robinson, 2001). An analysis of the Third National Health and Nutrition Examination Survey of children aged 8 through 16 years found that the prevalence of overweight was lowest among children watching one or fewer hours per day and highest among those watching 4 or more hours per day (Anderson, Crespo, Bartlett et al., 1998).
Although television viewing has been associated with childhood obesity in several epidemiologic studies (Robinson, 2001), inconsistencies in the research still exist regarding the relationship between television viewing and/or video game use and physical activity levels (Vandewater et al., 2004; Task Force on Community Preventive Services, 2002). Recent research by Vandewater et al., (2004) examined the link between overweight and activity level with children's television and video game use, and hypothesized three mechanisms through which television viewing might promote childhood obesity. First, there is some evidence that time spent viewing television and video game use displaces physical activity. Second, increased television viewing is associated with increased exposure to advertisements for high-fat, high-calorie foods of poor nutritional content and with increased intake of such foods. A third hypothesis is that television viewing is associated with decreased metabolic rates. Efforts to replicate this finding, however, have been unsuccessful and to date no studies have been conducted to examine the relationship between video game use and metabolic resting rates (Vandewater et al., 2004).
Studies have linked television viewing to factors in the family and the home (Woodard, 2000). Children of preschool age who have a television in their bedroom watched 4.8 hours per week more TV/video than those without (Dennison, Erb, Jenkins, 2002). Children who live in a home where the TV is on all the time, and those who spend more than half their TV time watching alone, tend to watch more hours per week. Parental behavior also is associated with TV time. Children whose parents watch fewer hours per week of television, monitor their children's TV viewing closely, are more consistent with children's TV viewing rules, and know more about the media and media effects, watch fewer hours per week of TV (Woodard, 2003; Brown, Childers and Bauman et al., 1990; Gentile, Walsh, 2002). Adolescents who reported watching a greater number of hours per day of television also reported eating high-fat foods, (Robinson and Killen, 2001) fast food, drinking soft drinks more frequently, and consuming fruits and vegetables less frequently. (French, Story, Neumark-Sztainer, 2001) In households where the television is on during meals, children consumed red meat, pizza, snack foods and soda more often, and fruits and vegetables less often (Coon, Goldberg, Rogers, Tucker, 2001). Having a TV in the bedroom was more strongly associated with increased risk of child overweight than the child's weekly TV/video viewing hours (Dennison, et al., 2002). Black children/adolescents watch more hours of television than do Hispanics, who, in turn watch more than White children/adolescents, while children in families of lower socioeconomic status watch more hours of TV than those in families of higher socioeconomic status (Woodard, 2000). A number of studies indicate that high-fat or high-sugar foods are frequently advertised on children's television programs (Borzekowski, Robinson, 2001; Gamble, Cotunga, 1999; Kotz, Story, 1994).
Several TV reduction interventions have been reported in the literature. One clinic-based and four school-based interventions have resulted in decreases in reported TV viewing time among children exposed to the interventions. The "Planet Health" intervention in Boston, MA, used an interdisciplinary curriculum addressing TV watching, promoting fruit and vegetable intake, lowering high-fat food intake, and increasing physical activity for use in grades 6 and 7 (Gortmaker, Peterson, Wiecha, 1999). A school-based intervention in San Jose, CA, incorporated lessons on self-monitoring and reducing television, videotape, and video game use into the curriculum for children in grades 3 and 4, distributed newsletters to parents, and provided television monitors to all households in the study (Robinson, 1999). A pilot intervention in an urban community clinic in Atlanta used counseling alone and counseling along with providing a behavioral intervention and TV time manager. Both groups showed a decrease in reported TV viewing time (Ford et al., 2002). The "Eat Well, Keep Moving" program in Baltimore developed materials addressing diet, TV watching, and physical activity to use in classrooms with children in grades 4 and 5 (Ford et al., 2002). "Brocodile the Crocodile," an intervention in 16 rural upstate New York daycare centers, used a curriculum and parental newsletters to reduce television/video viewing by 4.7 hours per week and reduced the percentage of children watching more than 2 hours per day from 33% to 18% (Dennison, Russo, Burdick, Jenkins, 2004).
Several recommendations do exist in an effort to provide guidelines to parents regarding television viewing by children. The 2001 Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity recommended that children watch no more than two hours of television per day (The Surgeon General's Call, 2001). The American Academy of Pediatrics (AAP) recommends that children younger than two years of age be discouraged from viewing television, and that viewing for children two years and older be limited to no more than one to two hours per day of high quality educational shows (American Academy of Pediatrics, 2001).
Data from New York State for 2003 indicates that 45% of students in grades 9 through 12 watched more than two hours per day of TV on an average school day, which is lower than the Healthy People 2010 target of 75% (YRBSS) (Figure 23).
Figure 23:Proportion of adolescents who view television 2 or fewer hours on a school day. (HP Objective 22-11)
Source: YRBSS 2003
A random sample of third grade children surveyed in upstate NYS in 2004 revealed that 18.4% watched more than 2 hours per day. A survey of TV viewing habits was collected from a survey of WIC participants in 2000. Children aged 2 up to 5 years watched an average of 2.3 hours per day of TV. Twenty percent of children and 20% of adults usually or always snacked while watching TV and 38% had a TV in their bedroom (Dennison et al., 2002).
A number of interventions aimed at reducing television viewing and video game use have been successful. The influence of the family and school environments have shown to be powerful factors for both children and adolescents. The evidence is clear that sedentary activities such as television viewing and video game use contribute to childhood obesity.
TV Turnoff Week
Some communities and schools in New York participate in a TV Turnoff Week once a year to encourage families to turn off their televisions and participate in more recreational and physical activities for a week. This event has been shown to change the viewing habits of those who participated not only for seven days, but for much longer, sometimes even permanently, afterwards.
Reducing TV Viewing by Preschoolers
As part of the Department's Obesity Prevention Program, a public health evaluation is being conducted in the Arbor Hill community area in Albany, New York. Known as the Health and Fitness by Age 5 Intervention, this community-based intervention targets pre-school children, their parents and childcare teachers and related caregivers to prevent overweight among preschool and early elementary school children. One of the main goals of the intervention is to reduce TV-viewing time at daycare centers and at home through implementation of the "Fit by 5" curriculum in Centers. Using social marketing techniques, this intervention will also facilitate a community-wide "TV Turnoff Week".
Media and Advertising
New Yorkers are inundated with media messages everyday by their televisions, computers, worksites, schools, buses and even elevators. More often than not, these messages are encouraging the viewer to eat high-fat, high-calorie, energy-dense foods like fast food, candy or soft drinks. The restaurant industry combined with the food and beverage companies represent the second largest advertising group in America (IOM, 2004; Gallo, 1999). To understand the magnitude of this spending power, McDonald's $1 billion promotional costs in 1998 is 1000 times the National Cancer Institute's $1 million annual budget for its of the 5-A-Day Educational Campaign to increase fruit and vegetable consumption (Nestle M, Jacobson MF, 2000). This media force will need to be part of the solution in addressing the epidemic of obesity. Furthermore, evidence suggests that populations with the highest increases in obesity such as children and minorities are those being most heavily targeted for unhealthy foods and beverages by the media (Kaiser Family Foundation, 2004, Williams JD, 2003).
Children learn behaviors, and shape their value systems by the media (IOM, Villani, 2001). A report recently issued by the American Psychological Association (APA) Task Force on Advertising and Children found that children under the age of 8 years are vulnerable to commercial promotion because they do not possess the cognitive skills to understand the difference between information and advertising (IOM, Wilcox et al., 2004). This is disconcerting considering that more than 50% of television advertisements directed at children promote candy, fast food, snack foods, soft drinks, and sweetened breakfast cereals (IOM, Kotz and Story, 1994; Gamble & Cotunga, 1999; Horgen et al., 2001; Hastings et al., 2003). While there is insufficient causal evidence to directly link food advertising with childhood obesity, current research indicates that food choices influenced by exposure to these advertisements contributes to the imbalance of energy and weight gain (IOM, Kaiser Family Foundation, 2004). For example, research has shown that food advertisements promote the purchase of their products by increasing the frequency children request their parents buy these items (in other words, advertising works) (IOM, Hastings et al., 2003). These advertisements not only affect short-term food choice and consumption patterns, but they have also been shown to have long-term effects due to a cumulative effect on children's eating and exercise habits (IOM, Horgen et al., 2001; CSPI, 2003; Hastings et al., 2003; Wilcox et al., 2004).
Research indicates that food companies gear advertising for energy-dense foods such as soda and fast food toward minority populations, and that these populations have shown the greatest inclination toward the consumption of these items (Willett and Domolky, 2004; Williams JD, 2003). A study conducted in 1999 found that television programs targeting Black audiences contained more advertisements for candy and soda than did programs intended for a general audience (Tirodkar MA & Jain A, 2003). Prime time television also contained a significantly greater number of food commercials overall than general prime time television (4.8 per half hour show compared to 2.9).
Mass media health promotion campaigns based on media interventions alone have not sufficiently demonstrated either increases in physical activity or a reduction in unhealthy eating behaviors, but changes in these behaviors have been found within multi-component campaigns where media was one important channel (IOM).
In 1972, Finland had the highest rate of cardiovascular disease (CVD) in the world. The North Karelina Project was initiated to address this health crisis (Willett WC & Domolky S, 2004; Puska P et al., 1981). This project utilized media, schools, worksites, and spokespersons to educate residents about cardiovascular disease. Their evaluation measured risk factors at baseline and at 5-year intervals. By 1992, the CVD rates for men ages 35 through 64 years, had dropped by 57%, and recent data have shown a 75% decrease in total CVD mortality (Pietinen P, et al., 2001).
The Center for Science and the Public Interest's "1% or Less" campaign goal was to encourage adults and children, age 2 years and older to switch from drinking whole milk or 2% milk to 1% milk or skim milk. Paid TV advertising, newspapers and radio, point-of-sale messages, news coverage, community-wide nutrition education programs, and school-based programs were used in several communities. After a few weeks of the campaign, they found a 21% increase in use of low-fat milk and an 11% increase in skim milk after a few weeks of the campaign (Kaiser Family Foundation, 2004).