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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

Screen-media use among young children is highly prevalent, disproportionately high among children from lower-income families and racial/ethnic minorities, and may have adverse effects on obesity risk. Few systematic reviews have examined early intervention strategies to limit TV or total screen time; none have examined strategies to discourage parents from putting TVs in their children's bedrooms or remove TVs if they are already there. In order to identify strategies to reduce TV viewing or total screen time among children <12 years of age, we conducted a systematic review of seven electronic databases to June 2011, using the terms “intervention” and “television,” “media,” or “screen time.” Peer-reviewed intervention studies that reported frequencies of TV viewing or screen-media use in children under age 12 were eligible for inclusion. We identified 144 studies; 47 met our inclusion criteria. Twenty-nine achieved significant reductions in TV viewing or screen-media use. Studies utilizing electronic TV monitoring devices, contingent feedback systems, and clinic-based counseling were most effective. While studies have reduced screen-media use in children, there are several research gaps, including a relative paucity of studies targeting young children (n = 13) or minorities (n = 14), limited long-term (>6 month) follow-up data (n = 5), and few (n = 4) targeting removing TVs from children's bedrooms. Attention to these issues may help increase the effectiveness of existing strategies for screen time reduction and extend them to different populations.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

The American Academy of Pediatrics has recommended that children over 2 years of age use screen media for no more than 2 h per day (1), yet US children use screen media (e.g., TV, videos, DVDs, video games, and/or computers) for about 7 h per day, on average (2). Most time with media is spent watching TV, with children watching 4½ h per day, and infants watching 1–2 h per day (2,3). There is substantial tracking of TV viewing over childhood, such that heavy viewing in the preschool age group predicts greater TV viewing in later childhood and adolescence (4,5,6). Additionally, over one-third of children under the age of 6 years (7) and more than half of middle school-age children have TVs in their bedrooms (2). Research indicates that having a TV in the room where a child sleeps predicts greater TV use (8,9,10) and that once TVs are placed in a child's bedroom, they are not often removed (11).

Several studies reveal a dose-response relationship between the average hours of TV young children watch and prevalence of obesity (4,12,13,14,15,16). Children who watch commercial TV are exposed to more food and beverage advertisements, which increase obesity risk (17,18). They are also more likely to eat when the TV is on, and sometimes in larger amounts, because satiety cues are often disregarded while viewing (19,20,21).

Few studies have independently examined relationships between obesity and video game use, computer use, or total screen-media use. Some show an association, while others do not (22,23,24,25,26,27,28). This may be because some video games and Internet sites contain food and beverage advertisements, product placements, or “advergames” (in which an advertised product is embedded in a game (29,30)), but many do not. Video game play has also been associated with both increased calorie consumption after gaming (31) and energy expenditure/calorie burning during gaming, especially when children play active games, like those made for Nintendo's Wii gaming system (32,33).

A major public health problem, obesity puts children at risk for heart disease (34), type 2 diabetes (35), asthma (25,36), and depression (34) and is associated with higher morbidity and mortality in adulthood (37,38). Since it is very challenging to reduce obesity once established, early intervention may prove essential for prevention of childhood obesity and its associated complications (39,40). Intervention strategies could include limiting TV or screen time, discouraging parents from putting TVs in their children's bedrooms, or removing the TVs if they are already there.

Many interventions have aimed to prevent or treat obesity by reducing TV viewing, or total screen time, in children (39,41,42). While some have reduced viewing, others have not been successful. To our knowledge, few systematic reviews have solely examined early intervention strategies to limit TV or total screen time, discourage parents from putting TVs in their children's bedrooms, or remove TVs if they are already there. In addition, although prevention efforts may have the largest impact for children <6 years of age, a paucity of studies summarizes what is known about media reduction programs for infants or preschool-aged children. Hence, the purpose of this review was to identify and summarize studies that reduce TV viewing or screen time in children 6–12 years of age, as well as birth to <6 years of age, in order to identify effective strategies for future interventions with these populations and to develop future research priorities based on gaps in the current literature.

Methods and Procedures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

Literature search

We conducted a systematic review of the published literature on intervention studies to reduce TV viewing in children, from 1947 through June 2011, using the terms “intervention” and “television,” “media,” or “screen time,” to identify relevant studies. Databases searched included MEDLINE/PubMed, Academic Search Premier, RePort, ERIC, NHS EED, the Cochrane Database of Systematic Reviews, and the Cochrane Register of Controlled Trials. We also reviewed reference lists of included papers and other relevant reviews and meta-analyses.

Inclusion criteria

Eligible intervention studies were broadly defined as research studies that aimed to reduce TV viewing, or total screen-media use, in children. Studies that did not directly aim to influence screen-media use but aimed to modify behaviors related to overweight or obesity, physical activity, or nutrition and recorded some measure of frequency of TV viewing/screen-media use, as a primary or secondary outcome were also eligible for inclusion. Eligible studies had to include children under age 12, be peer reviewed, and in English. Case studies and theses were excluded. Studies were not excluded because of their designs, durations, or settings.

One author (M.E.S.) read all the titles and abstracts identified in the initial searches. Since our search criteria were very broad, a large number of studies were excluded because it was obvious from their titles that they did not fit our inclusion criteria. Many studies also repeated across databases. After reviewing all of the study titles, one author (M.E.S.) reviewed all the remaining abstracts, and another author (A.O.) separately reviewed all the abstracts of the papers selected for inclusion by the first author to verify eligibility. Of 144 possible titles, 47 were selected for inclusion. Decisions about excluding studies were based on thorough reading of the selected papers by one author, and, if necessary, discussion among the other authors. Common reasons for exclusion included no intervention component (e.g., correlation studies), results not reported, child TV viewing not a measured outcome, not an original article, case studies, or no participants under age 12.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

Tables 1, 2, and 3 show the characteristics of the 47 intervention studies selected for inclusion, categorized by age group and study setting. Almost all studies included a home component and most took place in more than one setting. For this review, we categorized studies into settings based on where the intervention program was primarily delivered. Settings included schools, homes, community settings, and clinics.

Table 1.  Summary of school-based studies: design, duration, participants, sample, primary exposures/outcomes, intervention, and results
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Table 2.  Summary of home- and community-based studies: design, participants, sample, primary exposures/outcomes, intervention, and results
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Table 3.  Summary of clinic-based studies: design, participants, sample, primary exposures/outcomes, intervention, and results
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Among included studies, a wide variety of strategies were used to reduce children's TV viewing. These included educational sessions, physical activity sessions, resources/curricula for teachers, resource kits for parents, parent newsletters, electronic TV time monitors (e.g., TV Allowance, Mindmaster, Miami, FL), incentives, open- or closed-loop contingent systems, activity programs, and community advertising. Most interventions (35 of 47, or 74%) were randomized controlled trials and lasted less than one year (32 of 47, or 68%). Only 11 (23%) evaluated follow-up effects beyond the end of the intervention period. In all, 29 of 47 studies (62%) reported statistically significant reductions in TV viewing or total screen time after intervention.

In the subheadings below, studies are reviewed in greater detail, within setting categories and age groups. Special attention is given to intervention strategies and their outcomes. Given the many differences across cultures in nutrition, physical activity, and educational systems, results are separated into United States and international studies in the tables; however, all programs that share settings and ages are reviewed together.

Early education and school-based studies

Almost all school-based studies involved some kind of in-class instruction about nutrition, physical activity, and/or media use; some programs also included a physical education program, teacher training, and/or school food service modifications. Only four programs were found for children <6 years of age. Most school-based studies had large sample sizes, with participants 8 years of age or older. The majority of programs lasted between 6 months and 1 year; only three lasted 2 years or longer.

Early education and school-based studies, children under 6 years. As reported in Table 1, four school-based studies with children under 6 years of age were included in our review, and only one of these significantly reduced TV viewing. One additional study reduced total screen time. All took place in the United States and were randomized controlled trials. Three lasted for 14 weeks, and one lasted for 7 weeks; three had sample sizes under 500. Three of the interventions were specifically designed to target racial/ethnic minority children (43,44,45).

Only Dennison et al. significantly reduced TV viewing (∼3 h per week), via a 7-session, weekly TV reduction-focused intervention program, which also provided participants with a variety of materials for parents and children to use at home. Video/computer game play, measured separately, was not reduced (46). Three other school-based studies with preschool-aged participants tested the same intervention program (“Hip Hop to Health”) among Black and Latino children (43,44,45). Although the “Hip Hop to Health” program did not reduce TV viewing in any of the studies, total screen time was reduced, by just under 28 min per day, in one study (45).

The Dennison et al. study specifically targeted reducing TV viewing or promoting alternatives to TV viewing, like reading. Further, the Dennison et al. intervention included two “TV turnoff week” components, and parents were provided with materials and incentives to facilitate achieving their child's TV reduction targets. In contrast, the “Hip Hop to Health” interventions primarily targeted diet and physical activity, and devoted only 1 week of each of the 14-week programs to reducing TV viewing.

School-based studies, 6- to 12-year-old children. Fifteen studies implemented in grade schools were selected for inclusion, as detailed in Table 1. Six took place in the United States, and nine took place internationally. Most school-based studies with 6- to 12-year-old children were randomized controlled trials and had over 500 participants. Almost half lasted for 1 year or longer. Three of 15 studies specifically recruited ethnic minorities (47,48,49); five studies specifically recruited from low socioeconomic status (SES) schools (47,50,52,53,54).

As measured at the end of the intervention programs, eight of 15 school-based intervention programs significantly reduced TV and/or screen-media use. Robinson et al. reported the largest reductions (∼1 h per day) in screen-media use (56), followed by Gortmaker et al. (∼40 min per day (51)) and Muller et al. (20 min per day, TV only) (40). Jones et al. (57), Sprujit-Metz et al. (48), and Salmon et al. (54) all reported reducing screen media by less than 20 min per day. Gentile et al. reported a 2-h per week reduction in screen time, but only according to parent, and not child, report (58). One additional study, by Simon et al., reduced the proportion of children spending >3 h per day in sedentary activity, by 7% in girls and 3% in boys (55).

All but one of these programs specifically focused on screen-media reduction or had content on reducing screen media as a major part of classroom lessons. Like Dennison et al., many also utilized household TV reduction campaigns, e.g., Robinson included a 10-day TV turnoff campaign (56) and Gortmaker et al. included a 2-week “power down” campaign (51). The use of electronic TV time monitors was a unique component of the Robinson trial that reported the largest statistically significant reductions in screen media (56).

Home-based studies

A variety of intervention programs have been tested in homes, including contingent feedback systems, TV time monitors, and parent education programs. Most home-based studies lasted less than 6 months and had less than 50 participants. Unlike school-based programs, most home-based interventions reviewed here specifically recruited obese or overweight participants (59,60,61,62), and/or participants who watched above average amounts of TV (60,62,63,64). No home-based studies specifically recruited ethnic minorities or low-SES participants. Only two home-based interventions included children under 6.

Home-based studies, children under 6 years. As shown in Table 2, two home-based studies included children under age 6. Only Epstein et al. successfully reduced screen-media use by using TV Allowance devices, monetary incentives, and sticker charts to reward children for reducing their TV time to 50% of baseline. After 6 and 24 months, children in the intervention group recorded 17.5 fewer hours of TV and computer use per week (59). In contrast, the second home-based study for children under 6, by Essery et al., utilized weekly newsletters or a 52-page booklet to improve preschoolers' feeding practices and physical activity (65). Reducing TV viewing was recommended in the newsletter/booklet; however, the program did not specify particular goals for reducing TV viewing, nor was TV reduction its primary focus.

Home-based studies, 6- to 12-year-old children. Three of five home-based studies significantly reduced TV viewing, or screen-media use, in 6- to 12-year-old children (see Table 2). Faith et al. employed a “closed-loop” feedback system to reduce TV viewing in school-age children and recorded the largest reductions (∼20 h per week) among home-based studies. Participants could only watch TV while they pedaled a custom-made stationary bicycle, attached to a home TV, at a prescribed level of intensity (60). Goldfield et al. also used a contingent feedback system, albeit an “open-loop” one, in which intervention participants' TV access was made contingent on their level of physical activity—for each 400 counts of physical activity on a pedometer, they could watch 1 h of TV/VCR/DVDs, as managed by an electronic device. Goldfield reduced TV/VCR/DVD/video game playing time by ∼2 h per day (62). Using electronic TV time monitors, TV time budgets, and TV viewing diaries, Todd also reduced screen-media use, by about 1 h per day (64).

Community-based studies

A variety of intervention programs were conducted at the community level, including family workshops, an after-school dance program, and an employee wellness program. Seven interventions were delivered in community settings, and all targeted children over 6 years of age. Five were conducted in the United States, while two occurred in the United Kingdom and in Australia. Most had sample sizes over 100 and lasted less than 1 year. Three studies recruited overweight or obese participants specifically (67,68,69), and three specifically targeted African American or Hispanic children from low-income communities (66,67,68). One additional study, by de Silva-Sanigorski et al., was delivered to all children <5 years in an entire community in Australia (N = 12,000), via preschools, daycares, community health centers, immunization, and civic programs (70).

Three of seven community-based programs significantly reduced TV viewing or screen-media use. Sacher et al. reduced sedentary activity (TV and computer use) by almost 5 h per week, through a family education, physical activity, and provision of a 12-week free swimming pass to families. Participants were all obese at baseline (69). In de Silva-Sanigorski, media use was significantly lower in the intervention as compared to a control community after a community-wide program for children <5 years that trained early childhood workers and provided resources to parents and teachers (70). In Sepulveda et al., 7% more parents who completed an online parent education program offered to employees of a large corporation were more likely, after the program, to report that their children watched <1 h of screen time per day (71).

Clinic- and WIC-based studies

Clinic-based studies relied primarily on parent and child training/counseling (Table 3). Counseling or training was usually offered by health professionals (e.g., doctors, dietitians, Women, Infants, and Children (WIC) staff). Most studies had over 300 participants and lasted less than 1 year. Seven of the 14 clinic-based studies targeted children under 6. Five specifically recruited low-SES, ethnic minority participants (72,73,74,75,76).

Clinic- and WIC-based studies, children under 6 years. Seven of 14 clinic-based studies specifically targeted children <6 years of age. All took place in the United States, and three were part of the Women, Infants, and Children (WIC) program. Half of the studies ranged between 200 and 600 participants; two included over 3,000 participants. Most programs lasted between 6 months and 1 year. Three of seven studies targeted low-SES participants and/or ethnic minorities (72,74,75). Only one targeted overweight or obese participants (77).

All seven clinic-based studies conducted with children <6 years of age reported significant differences in screen-media use or parenting practices around screen-media use. Three were conducted as part of WIC programs. In Johnson et al., Whaley et al., and Davison et al., families received counseling by WIC staff on reducing TV, physical activity, and/or nutrition. In Johnson and Davison, more intervention parents were likely to report that their children watch <2 h of TV per day after the program (6% and 9 % more parents in Johnson and Davison, respectively (72,78)). In Whaley et al., increases in TV viewing at 12 months were ∼6 min less in the intervention group than in the control group (75).

Four studies were based in primary care clinics. In two studies, participants received parenting advice from a program specialist. In Johnston et al., 16% more intervention, compared to control, parents were less likely to allow more than 1 h of TV viewing daily (79). In Mendelsohn et al., media exposure was reduced for children in the intervention group, by about 20 min per day (74). In two other studies, motivational interviewing techniques were used to encourage participants to reduce media use. In Barkin et al., parents received 2–3 min of counseling from a primary care physician, after which media time was reduced by 30 min per day, and parents were more likely to limit media use to <2 h per day (5.7% increase for the intervention group (80)). In Taveras et al., participants received counseling from a nurse practitioner, and there was a decrease in TV or video viewing, of about 22 min per day, in the intervention group (77).

Clinic-based studies, 6- to 12-year-old children. As reported in Table 3, five of seven clinic-based interventions with children over 6 years of age had sample sizes under 50. Four took place in the United States, and three were conducted internationally. Most were of relatively short duration, lasting for 3 months or less. Three programs recruited obese participants (81,82,83), and two targeted low-SES, ethnic minority children (73,76).

Five of seven clinic-based studies reported statistically significant reductions in TV viewing. Two programs by Nemet et al. reduced screen time by about 2 h per day. In both studies, parents and children attended regular meetings with a dietitian, and children participated in regular physical activity sessions. Parents were specifically encouraged to decrease their children's sedentary behavior, including TV viewing (82,83). Deforche et al. also significantly reduced screen time, by approximately 2 h per day, via an inpatient residential obesity treatment program, in which TV viewing was restricted (81). In Stahl et al., pediatric residents received web-based training, about a program to encourage healthy eating, physical activity, and screen-media reduction. Twelve percent more parents in the intervention group than in the control group reported reducing their children's TV viewing after the intervention (84). Perrin increased the percentage of children in the intervention group who used less than 2 h of screen media per day by 22% by briefly training and providing toolkits to pediatric residents (76).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

Reducing TV time is a potential strategy to prevent or treat childhood overweight and obesity. Of the 47 intervention studies we reviewed, 29 (62%) reported statistically significant reductions in children's TV viewing or screen-media use. Of these, 18 measured BMI and 9 reported reductions in BMI. The most effective interventions specifically targeted and set explicit goals for reduced TV viewing or screen-media use, used electronic monitoring devices, contingent feedback systems or clinic-based counseling, had high levels of parental involvement, and/or recruited participants who were already overweight or obese at baseline.

To our knowledge, few published systematic reviews have summarized effective strategies for reducing TV viewing in young children. A recent meta-analysis by Maniccia et al. revealed a small but statistically significant effect of screen-media interventions to reduce children's screen time. Twenty-nine studies were identified as eligible for meta-analysis (85). In a systematic review of interventions to reduce sedentary behavior (defined as recreational screen time) by DeMattia et al., 12 studies were identified to successfully reduce sedentary behavior (86). Similar to the results of our review, DeMattia et al. found that study approaches and settings varied. DeMattia et al. concluded that targeting sedentary behaviors is an effective way to intervene on obesity and overweight outcomes in children and adolescents (86). Our review updates the literature on reducing TV and video viewing since the publication of DeMattia et al. in 2007 and the meta-analysis of Maniccia (which included studies to 2008), and includes older studies not selected by DeMattia et al. or not eligible for inclusion in meta-analysis in Maniccia et al. We report a similar intervention success rate to DeMattia et al., wherein just over 60% of studies successfully reduced TV viewing in children. Our study also extends Maniccia et al.'s and DeMattia et al.'s work by reporting additional strategies to reduce TV viewing and providing added narrative detail about which intervention strategies and settings were most effective.

We identified electronic monitoring systems as one strategy that most effectively reduced TV viewing among children. Intervention programs that used electronic TV monitors reported significant, large decreases in TV viewing, from 1.5 to 3 h per day. However, in two studies included in our review, about half of families offered electronic TV time monitors either did not use them (56) or reported, after using them, that they would not want to use them in the future (63). Thus, while electronic monitors seem to be an effective strategy for TV reduction, further research is needed to understand how to increase their acceptability in households with children. In addition, more research is needed to determine the long-term effectiveness and sustainability of electronic TV time monitors (63).

Another strategy that had considerable effects on the reduction of TV viewing was the use of contingent feedback systems. For example, Faith et al. (60) used a closed-loop feedback system where TV viewing was made contingent on stationery cycling and saw a decrease in TV viewing by 20 h per week, one of the largest reductions reported in this review. Another effective contingent feedback system was an open-loop feedback in which TV viewing was made contingent on physical activity, as recorded by pedometer or accelerometer. Goldfield used this open-loop design and reduced TV by 116 min per day (62).

Counseling by physicians, nurse practitioners, or Women, Infants, and Children (WIC) providers also had measurable effects on TV viewing. Twelve of 14 clinic-based studies in this review reported significant findings. Most of these studies (seven of 14) were with children under 6 years. However, only one clinic-based study with children under 6 measured follow-up outcomes (80), and only one measured BMI (77). Since the primary care setting offers unique access to large numbers of parents of young children, and parents may be especially receptive to messages delivered in this setting, further research should examine the role of the primary care provider in TV reduction counseling, particularly with regard to effects on BMI, or other weight-based outcomes (74,88). Future clinic-based research should also measure long-term outcomes, in order to determine whether early intervention can have beneficial effects on long-term TV viewing trajectories.

In Table 4, we list screen-media reduction strategies, including but not limited to electronic TV time monitors and feedback systems, that reduced TV/screen media viewing by statistically significant amounts, across multiple studies. Among the different settings in our review, we noted that the largest reductions in TV viewing occurred in home- or clinic-based settings. This may be because parents are required to be involved in home- and clinic-based programs; prior research suggests that high levels of parental involvement are very important, if not essential, for intervention success (87,89,90,91). In addition, most of the home- and clinic-based studies in this review specifically targeted overweight or obese children or children who watched large amounts of TV, whereas interventions in other settings were typically delivered to all participants, randomly assigned to intervention groups regardless of weight or TV viewing habits.

Table 4.  TV reduction strategies that should be considered for future interventions
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Table 5 lists priorities for future research. In general, we recommend future studies include greater recruitment of racial/ethnic minority children and children under 6. Although studies suggest that electronic TV monitors and feedback systems are the most effective TV reduction strategies, little is known about their long-term feasibility and effectiveness. Furthermore, to our knowledge, only Epstein et al. (59) has used electronic TV monitors with children under 6, and no published findings report on the use of open or closed-loop feedback systems in preschool-aged children. Finally, while electronic TV monitors can be effective, they may be prohibitively expensive, at $60 to $90 each on average (92), for use in large-scale public health intervention programs.

Table 5.  Research priorities and recommendations for intervention planning based on gaps in the current literature
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Studies have shown that time-use diaries or electronic monitoring systems provide the most accurate data on TV viewing (93), yet most studies in this review used global, retrospective estimates of TV use, e.g., “How many hours, on average, do you watch TV per week?” Future research should employ TV viewing measurement techniques with greater validity, such as electronic monitors, time-use diaries, or momentary sampling (94). An additional limitation to current studies is that only one measured TV content or intervened on specific TV content (74). Since one of the hypothesized mechanisms for associations between TV watching and obesity is increased food intake, either through food and beverage advertising or increased eating during viewing, future research should investigate whether interventions that target specific TV or media content (e.g., food advertising) are effective at reducing TV and/or BMI.

We also were unable to identify any studies that aimed to prevent or treat obesity by specifically reducing computer use or video game use. These kinds of media use have been included in aggregate measures of screen time in intervention studies, but they have not been independently tested as intervention targets. Future research should also explore the potential for interventions targeting specific media, including new media platforms that deliver TV content and advertising (e.g., Internet, mobile “smart” phones). These have not been well studied.

Numerous studies have indicated that children with TV in their bedrooms watch more TV than children without TV in their bedrooms (9) and are at an increased risk for obesity (9,95,96), sleep problems (97,98,99), and other health risk behaviors, e.g., smoking (100) and alcohol use (101). Although two-thirds (68 %) of 8- to 18-year-old children have TV in their bedrooms (2), only 10 studies in this review measured whether children had TV sets in their bedrooms (46,52,56,59,66,68,72,73,77,102) and recommending removal of bedroom TV sets was listed as a component of only four intervention programs (76,77,84,102). We recommend future interventions specifically address the removal of TV from children's bedrooms, both as a behavioral outcome in itself, and in order to reduce overall TV and video viewing.

Limitations

The vast majority of studies in this review were randomized controlled trials. Due to the wide variety of methods, outcomes, and measures reviewed here, a meta-analysis was not possible. Our conclusions are based on qualitative analysis of broad patterns in the body of published literature and are not definite. In particular, the diverse measurement techniques across studies in this review made it very difficult to compare findings. Although research suggests that different kinds of sedentary media behaviors contribute to obesity differently, if at all (25), half of the studies in this review aggregated screen-media use as a single outcome. When intervention programs report aggregate screen-media reductions, it is unclear which specific media are reduced. When BMI is an outcome of interest, aggregate screen-media measures do not distinguish which specific media may be implicated in any BMI changes. Media use or TV viewing also was variously measured by child report, parent report, or both, and sometimes these measures did not agree (59). For all of these reasons, we were able to draw limited conclusions about the comparative effectiveness of different interventions to reduce TV viewing or screen-media use.

Conclusions

Forty-seven studies have been conducted to reduce TV viewing among children <12 years of age, in various settings, using different strategies, and with variable success. Our findings suggest that electronic TV monitors, contingent feedback systems, and clinic-based counseling were three of the most effective strategies for TV reduction. More work is needed to understand the potential for interventions in children <6 years of age and in low-income and ethnic/minority participants. Future research should also further explore the potential for primary care counseling to reduce children's long-term media use. Finally, no published research to date has evaluated whether removing TV sets from children's bedrooms could measurably impact TV viewing. This should be a priority for future research.

ACKNOWLEDGEMENT

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

This work was supported by the National Center for Chronic Disease Prevention and Health Promotion (Prevention Research Centers Grants, 1U48DP00194). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References
  • 1
    American Academy of Pediatrics. Media education. Pediatrics 2010;126(5):16.
  • 2
    Rideout V, Foehr U, Roberts D. Generation M2: Media in the Lives of 8- to 18-Year-Olds. The Henry J. Kaiser Family Foundation: Menlo Park, CA, 2010.
  • 3
    Rideout V, Hamel E. The Media Family: Electronic Media in the Lives of Infants, Toddlers, Preschoolers, and Their Parents. The Henry J. Kaiser Family Foundation: Menlo Park, CA, 2006.
  • 4
    Certain LK, Kahn RS. Prevalence, correlates, and trajectory of television viewing among infants and toddlers. Pediatrics 2002;109:634642.
  • 5
    Anderson DR, Huston AC, Schmitt KL, Linebarger DL, Wright JC. Early childhood television viewing and adolescent behavior: the recontact study. Monogr Soc Res Child Dev 2001;66:IVIII, 1.
  • 6
    Huston A, Wright J, Rice M, Kerkman D, St. Peters M. Development of television viewing patterns in early childhood: a longitudinal investigation. Developmental Psychology 1990;26:409420.
  • 7
    Rideout VJ, Vandewater EA, Wartella EA. Zero to Six: Electronic Media in the Lives of Infants, Toddlers, and Preschoolers. The Henry J. Kaiser Family Foundation: Menlo Park, CA, 2003.
  • 8
    Wiecha J, Sobol A, Peterson K, Gortmaker S. Household television access: associations with screen time, reading, and homework. Ambul Pediatr 2001;1(5):244251.
  • 9
    Dennison BA, Erb TA, Jenkins PL. Television viewing and television in bedroom associated with overweight risk among low-income preschool children. Pediatrics 2002;109:10281035.
  • 10
    Stanger JD. Television in the Home 1998: The Third Annual National Survey of Parents and Children. Annenberg Public Policy Center: Philadelphia, PA, 1998.
  • 11
    Saelens BE, Sallis JF, Nader PR et al. Home environmental influences on children's television watching from early to middle childhood. J Dev Behav Pediatr 2002;23:127132.
  • 12
    Proctor MH, Moore LL, Gao D et al. Television viewing and change in body fat from preschool to early adolescence: The Framingham Children's Study. Int J Obes Relat Metab Disord 2003;27:827833.
  • 13
    Must A, Tybor DJ. Physical activity and sedentary behavior: a review of longitudinal studies of weight and adiposity in youth. Int J Obes (Lond) 2005;29(suppl 2):S84S96.
  • 14
    Gortmaker S, Must A, Sobol A, Peterson K, Colditz G, Dietz W. Television viewing as a cause of increasing obesity among children in the United States, 1986–1990. Arch Pediatr Adolesc Med 1996;150:356362.
  • 15
    Burke V, Beilin LJ, Simmer K et al. Predictors of body mass index and associations with cardiovascular risk factors in Australian children: a prospective cohort study. Int J Obes (Lond) 2005;29:1523.
  • 16
    Andersen RE, Crespo CJ, Bartlett SJ, Cheskin LJ, Pratt M. Relationship of physical activity and television watching with body weight and level of fatness among children: results from the Third National Health and Nutrition Examination Survey. JAMA 1998;279:938942.
  • 17
    Zimmerman FJ, Bell JF. Associations of television content type and obesity in children. Am J Public Health 2010;100:334340.
  • 18
    Borzekowski DL, Robinson TN. The 30-second effect: an experiment revealing the impact of television commercials on food preferences of preschoolers. J Am Diet Assoc 2001;101:4246.
  • 19
    Francis LA, Birch LL. Does eating during television viewing affect preschool children's intake? J Am Diet Assoc 2006;106:598600.
  • 20
    Blass EM, Anderson DR, Kirkorian HL et al. On the road to obesity: Television viewing increases intake of high-density foods. Physiol Behav 2006;88:597604.
  • 21
    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.
  • 22
    Hesketh K, Carlin J, Wake M, Crawford D. Predictors of body mass index change in Australian primary school children. Int J Pediatr Obes 2009;4:4553.
  • 23
    Mendoza J, Zimmerman F, Christakis D. Television viewing, computer use, obesity and adiposity in US preschool children. International Journal of Behavioral Nutrition and Physical Activity 2007;4:44.
  • 24
    Must A, Bandini LG, Tybor DJ et al. Activity, inactivity, and screen time in relation to weight and fatness over adolescence in girls. Obesity (Silver Spring) 2007;15:17741781.
  • 25
    Rey-López JP, Vicente-Rodríguez G, Biosca M, Moreno LA. Sedentary behaviour and obesity development in children and adolescents. Nutr Metab Cardiovasc Dis 2008;18:242251.
  • 26
    Stettler N, Signer TM, Suter PM. Electronic games and environmental factors associated with childhood obesity in Switzerland. Obes Res 2004;12:896903.
  • 27
    Swinburn B, Shelly A. Effects of TV time and other sedentary pursuits. Int J Obes (Lond) 2008;32(suppl 7):S132S136.
  • 28
    Schneider M, Dunton GF, Cooper DM. Media use and obesity in adolescent females. Obesity (Silver Spring) 2007;15:23282335.
  • 29
    Henry AE, Story M. Food and beverage brands that market to children and adolescents on the internet: a content analysis of branded web sites. J Nutr Educ Behav 2009;41:353359.
  • 30
    Jain A. Temptations in cyberspace: new battlefields in childhood obesity. Health Aff (Millwood) 2010;29:425429.
  • 31
    Chaput JP, Visby T, Nyby S et al. Video game playing increases food intake in adolescents: a randomized crossover study. Am J Clin Nutr 2011;93:11961203.
  • 32
    Biddiss E, Irwin J. Active video games to promote physical activity in children and youth: a systematic review. Arch Pediatr Adolesc Med 2010;164:664672.
  • 33
    Lanningham-Foster L, Foster RC, McCrady SK et al. Activity-promoting video games and increased energy expenditure. J Pediatr 2009;154:819823.
  • 34
    Daniels SR, Arnett DK, Eckel RH et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation 2005;111:19992012.
  • 35
    Rocchini AP. Childhood obesity and a diabetes epidemic. N Engl J Med 2002;346:854855.
  • 36
    Luder E, Melnik TA, DiMaio M. Association of being overweight with greater asthma symptoms in inner city black and Hispanic children. J Pediatr 1998;132:699703.
  • 37
    Mossberg HO. 40-year follow-up of overweight children. Lancet 1989;2:491493.
  • 38
    Must A, Jacques P, Dallal G, Bajema C, Dietz W. Long-term morbidity and mortality of overweight adolescents: A follow-up of the Harvard growth study of 1922 to 1935. N Engl J Med 1992;327:13501355.
  • 39
    Bluford D, Sherry B, Scanlon K. Interventions to prevent or treat obesity in preschool children; A review of evaluated programs. Obesity 2007;15:13561372.
  • 40
    Muller M, Asbeck I, Mast M, Langnase K, Grund A. Prevention of obesity-more than an intention. Concept and first results of the Kiel Obesity Prevention Study (KOPS). Int J Obes 2001;25:S66S74.
  • 41
    Doak CM, Visscher TL, Renders CM, Seidell JC. The prevention of overweight and obesity in children and adolescents: a review of interventions and programmes. Obes Rev 2006;7:111136.
  • 42
    Caballero B. Obesity prevention in children: opportunities and challenges. Int J Obes Relat Metab Disord 2004;28 Suppl 3:S90S95.
  • 43
    Fitzgibbon ML, Stolley MR, Schiffer L, Van Horn L, KauferChristoffel K, Dyer A. Two year follow up results for Hip-Hop to Health Jr.: a randomized controlled trial for overweight prevention in preschool minority children. J Pediatr 2005;146:618625.
  • 44
    Fitzgibbon M, Stolley M, Schiffer L, Van Horn L, KauferChristoffel K, Dyer A. Hip Hop to Health Jr. for Latino preschool children. Obesity 2006;14:16161625.
  • 45
    Fitzgibbon ML, Stolley MR, Schiffer LA et al. Hip-Hop to Health Jr. Obesity Prevention Effectiveness Trial: postintervention results. Obesity (Silver Spring) 2011;19:9941003.
  • 46
    Dennison BA, Russo TJ, Burdick PA, Jenkins PL. An intervention to reduce television viewing by preschool children. Arch Pediatr Adolesc Med 2004;158:170176.
  • 47
    Gortmaker SL, Cheung LW, Peterson KE et al. Impact of a school-based interdisciplinary intervention on diet and physical activity among urban primary school children: eat well and keep moving. Arch Pediatr Adolesc Med 1999;153:975983.
  • 48
    Spruijt-Metz D, Nguyen-Michel ST, Goran MI, Chou CP, Huang TT. Reducing sedentary behavior in minority girls via a theory-based, tailored classroom media intervention. Int J Pediatr Obes 2008;3:240248.
  • 49
    Paradis G, Lévesque L, Macaulay AC et al. Impact of a diabetes prevention program on body size, physical activity, and diet among Kanien'keha:ka (Mohawk) children 6 to 11 years old: 8-year results from the Kahnawake Schools Diabetes Prevention Project. Pediatrics 2005;115:333339.
  • 50
    Colín-Ramírez E, Castillo-Martínez L, Orea-Tejeda A et al. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8–10 years. Health Educ Res 2010;25:10421049.
  • 51
    Gortmaker S, Peterson K, Wiecha J et al. Reducing obesity via a school-based interdisciplinary intervention among youth. Arch Pediatr Adolesc Med 1999;153:409418.
  • 52
    Harrison M, Burns C, McGuinness M, Heslin J, Murphy N. Influence of a health education intervention on physical activity and screen time in primary school children: Switch Off—Get Active. J Sci Med Sport 2006;9(5):388394.
  • 53
    Salmon J, Ball K, Hume C, Booth M, Crawford D. Outcomes of a group-randomized trial to prevent excess weight gain, reduce screen behaviors and promote physical activity in 10-year-old children: Switch-Play. Int J Obes (Lond) 2008;32:601612.
  • 54
    Salmon J, Jorna M, Hume C et al. A translational research intervention to reduce screen behaviors and promote physical activity among children: Switch-2-activity. Health Promot Int 2010; Advance Access.
  • 55
    Simon C, Wagner A, DiVita C et al. Intervention centred on adolescents' physical activity and sedentary behavior (ICAPS): concept and 6-month results. Int J Obes 2004;28:S96S103.
  • 56
    Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA 1999;282:15611567.
  • 57
    Jones D, Hoelscher DM, Kelder SH, Hergenroeder A, Sharma SV. Increasing physical activity and decreasing sedentary activity in adolescent girls-the Incorporating More Physical Activity and Calcium in Teens (IMPACT) study. Int J Behav Nutr Phys Act 2008;5:42.
  • 58
    Gentile DA, Welk G, Eisenmann JC et al. Evaluation of a multiple ecological level child obesity prevention program: Switch what you Do, View, and Chew. BMC Med 2009;7:49.
  • 59
    Epstein LH, Roemmich JN, Robinson JL et al. A randomized trial of the effects of reducing television viewing and computer use on body mass index in young children. Arch Pediatr Adolesc Med 2008;162:239245.
  • 60
    Faith MS, Berman N, Heo M et al. Effects of contingent television on physical activity and television viewing in obese children. Pediatrics 2001;107:10431048.
  • 61
    Golan M, Fainaru M, Weizman A. Role of behavior modification in the treatment of child obesity with the parents as the exclusive agents of change. Int J Obes 1998;22(12):12171224.
  • 62
    Goldfield GS, Mallory R, Parker T et al. Effects of open-loop feedback on physical activity and television viewing in overweight and obese children: a randomized, controlled trial. Pediatrics 2006;118:e157e166.
  • 63
    Ni-Mhurchu C, Roberts V, Maddison R et al. Effect of electronic time monitors on children's television watching: pilot trial of a home-based intervention. Prev Med 2009;49:413417.
  • 64
    Todd M, Reis-Bergan M, Sidman C et al. Effect of a family-based intervention on electronic media use and body composition among boys aged 8–11 years: a pilot study. J Child Health Care 2008;12(4):344358.
  • 65
    Essery EV, DiMarco NM, Rich SS, Nichols DL. Mothers of preschoolers report using less pressure in child feeding situations following a newsletter intervention. J Nutr Educ Behav 2008;40:110115.
  • 66
    Robinson TN, Killen JD, Kraemer HC et al. Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study. Ethn Dis 2003;13:S65S77.
  • 67
    Weintraub DL, Tirumalai EC, Haydel KF et al. Team sports for overweight children: the Stanford Sports to Prevent Obesity Randomized Trial (SPORT). Arch Pediatr Adolesc Med 2008;162:232237.
  • 68
    Robinson TN, Matheson DM, Kraemer HC et al. A randomized controlled trial of culturally tailored dance and reducing screen time to prevent weight gain in low-income African American girls: Stanford GEMS. Arch Pediatr Adolesc Med 2010;164:9951004.
  • 69
    Sacher PM, Kolotourou M, Chadwick PM et al. Randomized controlled trial of the MEND program: a family-based community intervention for childhood obesity. Obesity (Silver Spring) 2010;18(suppl 1): S62S68.
  • 70
    de Silva-Sanigorski AM, Bell AC, Kremer P et al. Reducing obesity in early childhood: results from Romp & Chomp, an Australian community-wide intervention program. Am J Clin Nutr 2010;91:831840.
  • 71
    Sepúlveda MJ, Lu C, Sill S, Young JM, Edington DW. An observational study of an employer intervention for children's healthy weight behaviors. Pediatrics 2010;126:e1153e1160.
  • 72
    Davison K, Edmunds L, Wyker B, Young L, Sarfoh V, Sekhobo J. Feasibility of increasing childhood outdoor play and decreasing television viewing through a family-based intervention in WIC, New York state, 2007–2008. Preventing Chronic Disease 2011;8(3):18.
  • 73
    Ford BS, McDonald TE, Owens AS, Robinson TN. Primary care interventions to reduce television viewing in African-American children. Am J Prev Med 2002;22:106109.
  • 74
    Mendelsohn AL, Dreyer BP, Brockmeyer CA et al. Randomized controlled trial of primary care pediatric parenting programs: effect on reduced media exposure in infants, mediated through enhanced parent-child interaction. Arch Pediatr Adolesc Med 2011;165:4248.
  • 75
    Whaley SE, McGregor S, Jiang L et al. A WIC-based intervention to prevent early childhood overweight. J Nutr Educ Behav 2010;42:S47S51.
  • 76
    Perrin EM, Jacobsen-Vann JC, Benjamin JT et al. Use of a pediatrician toolkit to address parental perception of children's weight status, nutrition, and activity behaviors. Acad Pediat 2010;10:274281.
  • 77
    Taveras EM, Gortmaker SL, Hohman KH et al. Randomized controlled trial to improve primary care to prevent and manage childhood obesity: the High Five for Kids study. Arch Pediatr Adolesc Med 2011;165:714722.
  • 78
    Johnson DB, Birkett D, Evens C, Pickering S. Statewide intervention to reduce television viewing in WIC clients and staff. Am J Health Promot 2005;19:418421.
  • 79
    Johnston BD, Huebner CE, Anderson ML, Tyll LT, Thompson RS. Healthy steps in an integrated delivery system: child and parent outcomes at 30 months. Arch Pediatr Adolesc Med 2006;160:793800.
  • 80
    Barkin SL, Finch SA, Ip EH et al. Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics 2008;122:e15e25.
  • 81
    Deforche B, De Bourdeaudhuij I, Tanghe A, Hills AP, De Bode P. Changes in physical activity and psychosocial determinants of physical activity in children and adolescents treated for obesity. Patient Educ Couns 2004;55:407415.
  • 82
    Nemet D, Barkan S, Epstein Y et al. Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics 2005;115:e443e449.
  • 83
    Nemet D, Barzilay-Teeni N, Eliakim A. Treatment of childhood obesity in obese families. J Pediatr Endocrinol Metab 2008;21:461467.
  • 84
    Stahl CE, Necheles JW, Mayefsky JH, Wright LK, Rankin KM. 5-4-3-2-1 go! Coordinating pediatric resident education and community health promotion to address the obesity epidemic in children and youth. Clin Pediatr (Phila) 2011;50:215224.
  • 85
    Maniccia DM, Davison KK, Marshall SJ, Manganello JA, Dennison BA. A meta-analysis of interventions that target children's screen time for reduction. Pediatrics 2011;128:e193e210.
  • 86
    DeMattia L, Lemont L, Meurer L. Do interventions to limit sedentary behaviors change behavior and reduce childhood obesity? A critical review of the literature. Obes Rev 2007;8:6981.
  • 87
    Epstein LH, Paluch RA, Gordy CC, Dorn J. Decreasing sedentary behaviors in treating pediatric obesity. Arch Pediatr Adolesc Med 2000;154:220226.
  • 88
    Perrin EM, Finkle JP, Benjamin JT. Obesity prevention and the primary care pediatrician's office. Curr Opin Pediatr 2007;19:354361.
  • 89
    Golan M, Crow S. Parents are key players in the prevention and treatment of weight-related problems. Nutr Rev 2004;62:3950.
  • 90
    Nader PR, Sellers DE, Johnson CC et al. The effect of adult participation in a school-based family intervention to improve children's diet and physical activity: the Child and Adolescent Trial for Cardiovascular Health. Prev Med 1996;25:455464.
  • 91
    Perry CL, Luepker RV, Murray DM et al. Parent involvement with children's health promotion: a one-year follow-up of the Minnesota home team. Health Educ Q 1989;16:171180.
  • 92
    Family Safe Media. TV, video game, and computer time management tools <http:familysafemedia.comtv_time_management_tools_-_par.html> (2011).
  • 93
    Anderson DR, Field DE, Collins PA, Lorch EP, Nathan JG. Estimates of young children's time with television: a methodological comparison of parent reports with time-lapse video home observation. Child Dev 1985;56:13451357.
  • 94
    Dunton GF, Liao Y, Intille SS, Spruijt-Metz D, Pentz M. Investigating children's physical activity and sedentary behavior using ecological momentary assessment with mobile phones. Obesity (Silver Spring) 2011;19:12051212.
  • 95
    Adachi-Mejia AM, Longacre MR, Gibson JJ et al. Children with a TV in their bedroom at higher risk for being overweight. Int J Obes (Lond) 2007;31:644651.
  • 96
    Morgenstern M, Sargent JD, Hanewinkel R. Relation between socioeconomic status and body mass index: evidence of an indirect path via television use. Arch Pediatr Adolesc Med 2009;163:731738.
  • 97
    Mindell JA, Meltzer LJ, Carskadon MA, Chervin RD. Developmental aspects of sleep hygiene: findings from the 2004 National Sleep Foundation Sleep in America Poll. Sleep Med 2009;10:771779.
  • 98
    Mistry KB, Minkovitz CS, Strobino DM, Borzekowski DL. Children's television exposure and behavioral and social outcomes at 5.5 years: does timing of exposure matter? Pediatrics 2007;120:762769.
  • 99
    Oka Y, Suzuki S, Inoue Y. Bedtime activities, sleep environment, and sleep/wake patterns of Japanese elementary school children. Behav Sleep Med 2008;6:220233.
  • 100
    Jackson C, Brown J, Pardun CJ. A TV in the bedroom: implications for viewing habits and risk behaviors during early adolescence. Journal of Broadcasting and Electronic Media 2008;52(3):349367.
  • 101
    Hanewinkel R, Sargent JD. Longitudinal study of exposure to entertainment media and alcohol use among german adolescents. Pediatrics 2009;123:989995.
  • 102
    Escobar-Chaves SL, Markham CM, Addy RC et al. The Fun Families Study: intervention to reduce children's TV viewing. Obesity (Silver Spring) 2010;18(suppl 1):S99101.
  • 103
    Burke V, Milligan RAK, Thompson C et al. A controlled trial of health promotion programs in 11-year-olds using physical activity “enrichment” for higher risk children. The Journal of Pediatrics 1998;132:840848.
  • 104
    Sahota P, Rudolf MCJ, Dixey R et al. Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. BMJ 2001;323:15.
  • 105
    Roemmich JN, Grugol CM, Epstein LH. Open-loop feedback increases physical activity of youth. Med Sci Sports Exerc 2004;36:668673.