Peer Reviewed: Feasibility of Increasing Childhood Outdoor Play and Decreasing Television Viewing Through a Family-Based Intervention in WIC, New York State, 2007-2008

Introduction

Active Families is a program developed to increase outdoor play and decrease television viewing among preschool-aged children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Our objective was to assess its feasibility and efficacy.

Methods

We implemented Active Families in a large WIC clinic in New York State for 1 year. To this end, we incorporated into WIC nutrition counseling sessions a community resource guide with maps showing recreational venues. Outcome measures were children''s television viewing and time playing outdoors and parents'' behaviors (television viewing, physical activity), self-efficacy to influence children''s behaviors, and parenting practices specific to television viewing. We used a nonpaired pretest and posttest design to evaluate the intervention, drawing on comparison data from 3 matched WIC agencies.

Results

Compared with the children at baseline, the children at follow-up were more likely to watch television less than 2 hours per day and play outdoors for at least 60 minutes per day. Additionally, parents reported higher self-efficacy to limit children''s television viewing and were more likely to meet physical activity recommendations and watch television less than 2 hours per day.

Conclusion

Results suggest that it is feasible to foster increased outdoor play and reduced television viewing among WIC-enrolled children by incorporating a community resource guide into WIC nutrition counseling sessions. Future research should test the intervention with a stronger evaluation design in multiple settings, with more diverse WIC populations, and by using more objective outcome measures of child behaviors.     

Television viewing and obesity in adult females.

We measured the relation between time spent watching television per week and obesity in 4,771 adult females. After controlling for age, education, cigarette smoking, length of work week, and weekly duration of exercise, females who reported three to four hours of TV viewing per day showed almost twice the prevalence of obesity (body fat greater than 30 percent), and those who reported more than four hours of TV watching per day showed more than double the prevalence of obesity, compared to the reference group (less than 1 hr/day). Part of the TV/obesity association was a function of differences in exercise duration among the four TV viewing categories.     

Correlates of Television Viewing Among African American and Caucasian Women

This study explores the associations between time spent watching television and physical activity, selected eating behaviors, and quality of life variables among 189 African American and Caucasian women aged 18–60 years. Data were collected via a cross-sectional, random-digit-dialed telephone survey. Seventy-two percent and 46% of women reported to “always, often, or sometimes” eating or overeating while watching television, respectively. Significant associations with television time per week included: eating meals or snacks while watching television, number of days per month feeling depressed, number of days per month feeling anxious, self-rated health, and BMI. Results contribute to recent studies finding associations between television viewing, body mass index, and health; and suggest potential points for intervention.     

Correlates of television viewing among African American and Caucasian women

This study explores the associations between time spent watching television and physical activity, selected eating behaviors, and quality of life variables among 189 African American and Caucasian women aged 18-60 years. Data were collected via a cross-sectional, random-digit-dialed telephone survey. Seventy-two percent and 46% of women reported to "always, often, or sometimes" eating or overeating while watching television, respectively. Significant associations with television time per week included: eating meals or snacks while watching television, number of days per month feeling depressed, number of days per month feeling anxious, self-rated health, and BMI. Results contribute to recent studies finding associations between television viewing, body mass index, and health; and suggest potential points for intervention.     

Impact of the 5As brief counseling on smoking cessation among pregnant clients of Special Supplemental Nutrition Program for Women,Infants, and Children (WIC) clinics in Ohio

ObjectivesWe assessed whether smoking cessation improved among pregnant smokers who attended Women, Infants and Children (WIC) Supplemental Nutrition Program clinics trained to implement a brief smoking cessation counseling intervention, the 5As: ask, advise, assess, assist, arrange.MethodsIn Ohio, staff in 38 WIC clinics were trained to deliver the 5As from 2006 through 2010. Using 2005–2011 Pregnancy Nutrition Surveillance System data, we performed conditional logistic regression, stratified on clinic, to estimate the relationship between women's exposure to the 5As and the odds of self-reported quitting during pregnancy. Reporting bias for quitting was assessed by examining whether differences in infants' birth weight by quit status differed by clinic training status.ResultsOf 71,526 pregnant smokers at WIC enrollment, 23% quit. Odds of quitting were higher among women who attended a clinic after versus before clinic staff was trained (adjusted odds ratio, 1.16; 95% confidence interval, 1.04–1.29). The adjusted mean infant birth weight was, on average, 96 g higher among women who reported quitting (P < 0.0001), regardless of clinic training status.ConclusionsTraining all Ohio WIC clinics to deliver the 5As may promote quitting among pregnant smokers, and thus is an important strategy to improve maternal and child health outcomes.     

Television watching and some eating habits of 6-14-year-old children in Amsterdam, the Netherlands; a cross-sectional study

OBJECTIVE: To describe the time spent by children between the ages of 6-14 years watching television during a weekday and to examine associated factors. DESIGN: Cross-sectional questionnaire study. METHOD: Data were collected during a vaccination campaign against meningococci C in Amsterdam in September 2002. From a sample of 2910 parents of 6-14-year-old children 1775 agreed to participate in the study. Socio-demographic characteristics and data on television viewing the previous day, the presence of a television in the child's bedroom and on eating habits were collected by short interviews. RESULTS: In total 1587 children were included in the analyses, 805 boys and 782 girls. In total 40.1% of the boys and 36.5% of the girls had watched television for > or = 2 h during the previous day. Among the children < or = 10 years 28.7% had a television in their bedroom, among children > 10 years this was 45.7%. Age (> 10 years), ethnicity (notably Surinam origin) and having a television in the bedroom was related to spending more time watching television. Having parents with a high socioeconomic status (SES) was associated with less television viewing than having parents with a lower SES. Children who had not eaten fresh fruit or who had visited a snackbar the previous day had been watching television for > or = 2 h more often than children who had eaten fresh fruit (p < 0.001) or who had not visited a snackbar (p < 0.05). CONCLUSION: Children spent a lot of time watching television. In view of the relation between television viewing and overweight this is an alarming development. Possibilities for the prevention of overweight by reducing television viewing must be investigated.     

Improving the health of infants on Medicaid by collocating special supplemental nutrition clinics with managed care provider sites

OBJECTIVES: This study tested whether collocation of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics at managed care provider sites improved health care for infants enrolled in Medicaid and WIC. METHODS: Weights and immunization rates were studied for the 1997 birth cohort of African American infants enrolled in WIC and Medicaid in Detroit, Mich. Infants using traditional WIC clinics and health services were compared with those enrolled under Medicaid in 2 managed care organizations (MCOs), of whom about half obtained WIC services at MCO provider sites. RESULTS: Compared with other infants, those who used collocated WIC sites either were closer to their age-appropriate weight or had higher immunization rates when recertified by WIC after their first birthday. Specific benefits (weight gain or immunizations) varied according to the priorities at the collocated sites operated by the 2 MCOs. CONCLUSIONS: Collocation of WIC clinics at MCO sites can improve health care of low-income infants. However specific procedures for cooperation between WIC staff and other MCO staff are required to achieve this benefit.     

Primary care interventions to reduce television viewing in African-American children

BACKGROUND: Data are lacking on primary care interventions to reduce children's television viewing. Low-income African-American children watch greater amounts of television than their peers. DESIGN/METHODS: A randomized controlled pilot and feasibility trial was conducted. Twenty-eight families with 7- to 12-year-old African-American children receiving primary care at an urban community clinic serving a low-income population were randomized to receive counseling alone or counseling plus a behavioral intervention that included an electronic television time manager. The main outcome was hours of children's television, videotape, and video game use. Parents/guardians and children completed baseline and 4-week follow-up self-report surveys. Additional outcomes included overall household television use, time spent in organized physical activity and playing outside, and meals eaten by the child while watching television. RESULTS: Both intervention groups reported similar decreases in children's television, videotape, and video game use (mean changes of -13.7, SD=26.1 and -14.1, SD=16.8 hours per week). The behavioral intervention group reported significantly greater increases in organized physical activity (changes of +2.5, SD=5.9 and -3.6, SD=4.7 hours per week; p =0.004) and nearly significant greater increases in playing outside (changes of 1.0, SD=5.9 and -4.7, SD=9.4 hours per week; p <0.06). Changes in overall household television use and meals eaten while watching television also appeared to favor the behavioral intervention, with small to medium effect sizes, but differences were not statistically significant. CONCLUSIONS: This small pilot and feasibility study evaluated two promising primary care-based interventions to reduce television, videotape, and video game use among low-income African-American children. The effects on physical activity suggest that the behavioral intervention may be more effective.     

Watching television: how does it influence the dietary quality of children?

The prevalence of obesity is increasing and continues to be a concern, particularly in children, where the condition may lead to chronic health problems typically seen only in adults. This has prompted researchers to look at the relationships between sedentary behaviours, such as television viewing, diet and obesity in children. Epidemiological studies have shown repeatedly that rates of obesity are associated with both increased media use and poor diet quality in children and adults. Such studies have also shown that hours of television watched are associated with an increased intake of nutrient‐poor, energy dense foods and greater overall energy intake. In children, intervention studies that have imposed reductions in television viewing time have shown that reducing the time spent watching television may decrease energy intake and improve overall diet quality. However, these studies are confounded by the use of self‐reported measures for television viewing time and dietary intake. Despite these limitations, the results are promising and more research could lead to a greater understanding of these relationships. Ultimately, clear and concise public health messages for children and their parents regarding the benefits of television time reduction would assist in the fight against obesity.     

Peer Reviewed: Physical Activity, Watching Television, and the Risk of Obesity in Students, Texas, 2004-2005

Introduction

The epidemic of childhood obesity has been well-documented. Prevalence of obesity among students in Texas is higher than the US prevalence. Our objective was to understand the combined influence of physical activity and television viewing on weight status of students in Texas.

Methods

Students in grades 4, 8, and 11 participated in the School Physical Activity and Nutrition survey during the 2004-2005 academic year. Multinomial logistic regression tested the associations between both being overweight and obese (vs underweight/normal weight) and the combined influence of physical activity and watching television, adjusting for age, grade, race/ethnicity, language spoken at home, and percentage of economically disadvantaged students in the school. We used 5 physical activity indicators to describe students'' physical activity.

Results

Girls who participated in less than 3 days of exercise per week to strengthen or tone muscles and watched 2 hours or less per day of television had increased odds of being obese (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-3.0) compared with girls who participated in 3 or more days per week of exercise to strengthen or tone muscles and watched 2 hours or less per day of television. Boys in our study who watched 3 or more hours per day of television and did not meet physical activity recommendations had increased odds of being obese in all of our 5 physical activity indicators.

Conclusion

Although results varied by physical activity indicator and sex, our findings provide further evidence for the combined effect of high television watching and low physical activity engagement on the risk for obesity in children and adolescents.     

Life without TV? cultivation theory and psychosocial health characteristics of television-free individuals and their television-viewing counterparts

Much attention has been paid to the amount of time Americans spend watching television. Cultivation theory has been important in exploring behavioral effects of television viewing for many years. However, psychosocial health has received much less scrutiny in relation to television viewing time. This investigation examined the hypotheses that television-free individuals and viewers adhering to the American Academy of Pediatrics (AAP) recommendations (up to 2 hr of viewing per day) would display a more positive psychosocial health profile when compared with more frequent television viewers. Results confirmed the hypothesis for women, but not for men. Our analysis showed that moderate television viewing, as defined by the AAP, provides a similar relation with psychosocial health as being television-free. Results are discussed in a cultivation theory framework.     

Improving breastfeeding knowledge,attitudes, and practices of WIC clinic staff

OBJECTIVE: This study was conducted to assess the impact of a breastfeeding promotion clinic environment project implemented by the state of Mississippi on breastfeeding knowledge, attitudes, and practices of WIC clinic staff. METHODS: Thirteen pairs of matched intervention and comparison WIC clinics participated in the study. Clinical and administrative staff completed pre-test and post-test self-administered questionnaires in 1998 and 1999. RESULTS: A total of 397 staff members provided pre-test data, and 277 staff members provided post-test data. Before project implementation, the intervention and comparison groups were similar overall. The majority of staff had positive attitudes/beliefs about breastfeeding, but gaps in knowledge and practices were noted. Post-test data showed that the project improved knowledge, attitudes/beliefs, and confidence/practice of intervention clinic staff. CONCLUSIONS: Clinic environment projects, which combine physical improvements and staff training, are effective in promoting support for breastfeeding among public health clinic staff. Similar interventions may contribute to the overall effectiveness of breastfeeding promotion programs.     

Is aggression in children with behavioural and emotional difficulties associated with television viewing and video game playing? A systematic review

Background Possible associations between television viewing and video game playing and children's aggression have become public health concerns. We did a systematic review of studies that examined such associations, focussing on children and young people with behavioural and emotional difficulties, who are thought to be more susceptible. Methods We did computer‐assisted searches of health and social science databases, gateways, publications from relevant organizations and for grey literature; scanned bibliographies; hand‐searched key journals; and corresponded with authors. We critically appraised all studies. Results A total of 12 studies: three experiments with children with behavioural and emotional difficulties found increased aggression after watching aggressive as opposed to low‐aggressive content television programmes, one found the opposite and two no clear effect, one found such children no more likely than controls to imitate aggressive television characters. One case–control study and one survey found that children and young people with behavioural and emotional difficulties watched more television than controls; another did not. Two studies found that children and young people with behavioural and emotional difficulties viewed more hours of aggressive television programmes than controls. One study on video game use found that young people with behavioural and emotional difficulties viewed more minutes of violence and played longer than controls. In a qualitative study children with behavioural and emotional difficulties, but not their parents, did not associate watching television with aggression. All studies had significant methodological flaws. None was based on power calculations. Conclusion This systematic review found insufficient, contradictory and methodologically flawed evidence on the association between television viewing and video game playing and aggression in children and young people with behavioural and emotional difficulties. If public health advice is to be evidence‐based, good quality research is needed.     

Counseling and motivational videotapes increase duration of breast-feeding in African-American WIC participants who initiate breast-feeding

OBJECTIVE: To evaluate the relative effects introducing motivational videotapes and/or peer counseling in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics serving African-American women have on breast-feeding duration. DESIGN: Experimental intervention study. Pregnant women were enrolled at or before 24 weeks gestation and were followed up until postpartum week 16. Women were interviewed at enrollment, 7 to 10 days, 8 weeks, and 16 weeks postpartum. SUNJECTS/SETTING: One hundred fifteen African-American WIC participants who initiated breast-feeding and who had been enrolled in 1 of 4 clinics. INTERVENTION: Two-by-two factorial design, in which 4 clinics were randomly assigned to receive either no intervention, a motivational video package intervention, a peer-counseling intervention, or both interventions. MAIN OUTCOME MEASURES: Breast-feeding duration in weeks and relative risk ratios for breast-feeding cessation before 16 weeks postpartum. STATISTICAL ANALYSIS PERFORMED: Contingency table analysis, including chi2 tests and log-rank tests; multivariate analysis using Cox proportional hazards regression analysis. RESULTS: A higher proportion of women were breast-feeding at 8 and 16 weeks postpartum in the intervention clinics than in the control clinic. The proportion of women reporting breast-feeding declined at 8 and 16 weeks postpartum, but the rate of decline was slower in the 3 intervention clinics than in the control clinic. Being younger than 19 years of age or older than 25 years of age, having a male infant, and returning to work or school all negatively affected breastfeeding duration, whereas previous breast-feeding experience positively influenced breast-feeding duration. APPLICATIONS/CONCLUSIONS: WIC-based peer counselor support and motivational videos can positively affect the duration of breast-feeding among African-American women. WIC nutritionists and other health professionals in contact with this population should expand their efforts toward promoting increased duration of breast-feeding.     

Effect of television viewing on food and nutrient intake among adolescents

ObjectiveAmong the behaviors associated with food intake, exposure to television is particularly important given the number of adolescents exposed. Also, increased time spent watching television has been associated with physical inactivity and with less desirable dietary intake among adolescents. The aim of this study was to examine the association between television viewing and dietary intake among 13-y-old adolescents.MethodsA cross-sectional evaluation was carried out in the 2003–2004 school year, including adolescents born in 1990 and enrolled in the schools of Porto, Portugal. Time spent watching TV was collected by self-administered questionnaires and dietary intake was evaluated using a food frequency questionnaire. Included in the analysis were 1436 adolescents.ResultsSpending more than 120 min per day watching TV was significantly associated with higher intake of total fat and polyunsaturated fat and with lower intake of magnesium, in both sexes. Additionally, in girls, spending more than 120 min per day watching TV was associated with lower intake of complex carbohydrates, fiber, total vitamin A, folate, vitamin C, calcium, iron, phosphorus, and potassium. In boys, higher intake of saturated fat and cholesterol was found among those spending more time watching TV.ConclusionsWe found that television viewing is associated with higher consumption of foods containing more fats and sugars and a lower consumption of fruits and vegetables. Consequently, adolescents who watched more television had a higher intake of total fat and polyunsaturated fat and a lower intake of minerals and vitamins. This dietary behavior among adolescents may have long-term health implications, not only limited to obesity.     

Altering the perceptions of WIC health professionals about childhood obesity using video with facilitated group discussion

OBJECTIVE: To determine if viewing a documentary video, followed by facilitated group discussion, could alter the perceptions of those providing public health nutrition services about the barriers and solutions to addressing the problem of obesity in low-income preschoolers. DESIGN: Before-after trial to determine how often study participants could identify any of the 17 barriers and seven solutions targeted in the video and during the facilitated group discussion. SUBJECTS/SETTING: One hundred fifty-five attendees of the 2001 Kentucky Maternal and Child Health Conference participated in the study. Sixty percent were nurses, 24% were dietitians or nutritionists, and 64% had Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) counseling experience. INTERVENTION: Participants first viewed a 20-minute documentary video about three families enrolled in WIC. A 40-minute facilitated group discussion followed to highlight the 17 barriers (eg, WIC families are struggling with many demands in their lives that make nutrition a low priority and WIC health professionals "lecture" clients on what they "need to know") and seven solutions (eg, adjusting WIC counseling to assess parenting skills and to increase sensitivity to clients' life context and stresses). MAIN OUTCOME MEASURES/ANALYSES: Participants responded before and after the intervention to the same two open-ended questions, one about barriers and one about solutions. Participant responses were coded to count instances of identifying any of the 17 barriers and seven solutions. RESULTS: At baseline, 51% of participants were unable to record any of the barriers, and 91% could not identify any of the solutions. After the intervention, 37% could identify at least one more of the target barriers than they did at baseline, and 24% could identify at least one more of the target solutions. CONCLUSIONS: A documentary-style video, used with facilitated group discussion, can produce a short-term change in the perceptions of those providing public health nutrition services about addressing the problem of obesity in low-income preschool children.     

Walking the talk: Fit WIC wellness programs improve self-efficacy in pediatric obesity prevention counseling

Six sites of the California Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participated in a staff wellness pilot intervention designed to improve staff self-efficacy in counseling WIC clients about childhood overweight. A pre-post test design with intervention and control groups was used; outcome measures included staff perceptions of the intervention's effects on the workplace environment, their personal habits and health beliefs, and their counseling self-efficacy. Intervention site staff were more likely to report that the workplace environment supported their efforts to make healthy food choices (P <.001), be physically active (P <.01), make positive changes in counseling parents about their children's weight (P <.01), and feel more comfortable in encouraging WIC clients to do physical activities with their children (P <.05).     

Television viewing and smoking volume in adolescent smokers: a cross-sectional study

BACKGROUND: Previous research has shown a relationship between television viewing and smoking initiation. The relationship between television viewing and the amount of cigarettes consumed by adolescent smokers per time unit (day, week, month...) has not yet been studied. METHODS: A cross-sectional sample of children by means of self-reports administered by research assistants in schools was obtained. Participants were 421 smokers in a random sample of 4th year students in 15 secondary schools in Flanders, Belgium. Main outcome measures were quantifiable, closed survey questions about smoking volume, whether or not parents and friends smoked, frequency of going out and average weekly TV viewing volume. RESULTS: Television viewing was a significant predictor of smoking volume. Smokers who watch more TV smoke more. The relationship was curvilinear (quadratic). The relationship becomes stronger (curves upward) for higher levels of viewing. Those who watch 5 or more hours a day smoke between 60 and 147 cigarettes more per week than those who watch 1 h or less. CONCLUSIONS: Television viewing is significantly related to smoking volume. The content of television may glamorize smoking. Children may learn to associate smoking with viewing regardless of content. It is also possible that heavier smoking leads to more viewing or that a third variable influences both smoking volume and viewing. Regardless of the causal direction of the relationship television viewing appears to be an indicator or predictor of smoking volume. The curvilinear nature of the relationship deserves further attention.     

Increased risk of exceeding entertainment-media guidelines in preschool children from low socioeconomic background: The Generation R Study

ObjectiveTo describe and explain the association between maternal educational level and television viewing time among preschool children.MethodWe analyzed data from 2786 preschoolers enrolled in a birth cohort study in Rotterdam, The Netherlands, between 2002 and 2006. Odds ratios of watching television ≥ 2 hours/day and ≥ 1 hour/day were calculated for children of mothers with low, mid-low, and mid-high educational level (reference group: high educational level), before and after adjustment for mediators.ResultsChildren of low, mid-low, and mid-high educated mothers were more likely to watch television ≥ 2 hours/day compared to children of high educated mothers, with children of low educated mother showing the highest risk (OR: 11.32; 95% CI: 6.58, 19.46). Adjustment for mediators (i.e. maternal body mass index, parental television viewing, presence of a television set in the child's bedroom, and financial difficulties) led to a nearly 50% reduction in odds ratio for the lowest educational group (OR: 6.61; 95% CI: 3.69, 11.84). A similar educational gradient was found for watching television ≥ 1 hour/day, although effect estimates were smaller.ConclusionMaternal education is inversely associated with preschoolers' television viewing time. This association was partly explained by known correlates of children's television viewing.     

Sedentary behavior in adolescents: the 11-year follow-up of the 1993 Pelotas (Brazil) birth cohort study

The aim of this study was to estimate the prevalence of sedentary behavior and investigate associated factors in adolescents 11 years of age from the 1993 birth cohort in Pelotas, Rio Grande do Sul State, Brazil. Sedentary behavior was investigated with a questionnaire, and was defined as spending more than two hours per day watching television, playing videogames, or using the computer. Of the 4,452 adolescents interviewed, 98% reported watching television, 44% playing videogames, and 22% using the computer. The average time spent on each of these electronic media was 197, 36, and 17 minutes per day, respectively. Prevalence of sedentary behavior was 79.7% (95%CI: 78.6; 80.9) and showed a positive association with socioeconomic level and nutritional status and a negative association with well-being. These 11-year-olds spent extensive time at TV viewing, videogames, and the computer. Special attention should be given to the most exposed groups of adolescents, including the more affluent, overweight, and those with limited schooling.