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1.  Diet, Activity, and Overweight Among Preschool-Age Children Enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 
Preventing Chronic Disease  2006;3(2):A49.
Overweight is affecting children at younger ages and in increasing numbers, putting them at risk for a lifetime of chronic disease. Consumption of unhealthy foods and time spent watching television have increased concurrently.
Parents of 526 children aged 2 to 4 years old enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) answered questions about their children's food and beverage consumption, television-viewing and computer time, and physical activity. The children's height and weight measurements were collected from administrative records. Crude and adjusted odds ratios were calculated to test for associations between demographic, consumption, and activity variables and overweight or at risk of overweight (body mass index ≥85th percentile for age and sex).
Of the participants, 38% of the children were overweight or at risk of overweight. Hispanic and white children were twice as likely as black children to be overweight or at risk of overweight. Fifty-eight percent of the children drank more than one and 30% drank more than two 8-oz servings of fruit juice per day. The children who drank more than one serving of nonjuice fruit drink per day (30%) had increased odds of being overweight or at risk of overweight. On average, the children spent more than twice as much time watching television and using computers as they did engaging in physical activity. In multivariate analyses, race and ethnicity as well as physical activity were associated with being overweight or at risk of overweight.
Efforts to improve nutrition and prevent overweight in children should focus on the parents of infants and toddlers and provide them with anticipatory guidance on physical activity for young children and nutrition and food transitions.
PMCID: PMC1563967  PMID: 16539790
2.  Family and home correlates of television viewing in 12–13 year old adolescents: The Nepean Study 
Few young people meet television viewing guidelines.
To determine the association between factors in the family and home environment and watching television, including videos and DVDs, in early adolescence.
Cross-sectional, self-report survey of 343 adolescents aged 12–13 years (173 girls), and their parents (338 mothers, 293 fathers). Main measures were factors in the family and home environment potentially associated with adolescents spending ≥ 2 hours per day in front of the television. Factors examined included family structure, opportunities to watch television/video/DVDs, perceptions of rules and regulations on television viewing, and television viewing practices.
Two-thirds of adolescents watched ≥ 2 hours television per day. Factors in the family and home environment associated with adolescents watching television ≥ 2 hours per day include adolescents who have siblings (Adjusted Odds Ratio [95%CI] AOR = 3.0 [1.2, 7.8]); access to pay television (AOR = 2.0 [1.1, 3.7]); ate snacks while watching television (AOR = 3.1 [1.8, 5.4]); co-viewed television with parents (AOR = 2.3 [1.3, 4.2]); and had mothers who watched ≥ 2 hours television per day (AOR = 2.4 [1.3, 4.6]).
There are factors in the family and home environment that influence the volume of television viewed by 12–13 year olds. Television plays a central role in the family environment, potentially providing a means of recreation among families of young adolescents for little cost. Interventions which target family television viewing practices and those of parents, in particular, are more likely to be effective than interventions which directly target adolescent viewing times.
PMCID: PMC1594572  PMID: 16961929
3.  Young children in urban areas: Links among neighborhood characteristics, weight status, outdoor play, and television watching 
Social science & medicine (1982)  2011;72(5):668-676.
Although research consistently demonstrates a link between residential context and physical activity for adults and adolescents, less is known about young children’s physical activity. Using data from the U.S. Fragile Families and Child Wellbeing Study (N=1822, 51% male), we explored whether outdoor play and television watching were associated with children’s body mass indexes (BMIs) at age five using OLS regression models, controlling for a wide array of potential confounders, including maternal BMI. We also tested whether subjective and objective neighborhood measures - socioeconomic status (from U.S. Census tract data), type of dwelling, perceived collective efficacy, and interviewer-assessed physical disorder of the immediate environment outside the home -were associated with children’s activities, using negative binomial regression models. Overall, 19% of the sample were overweight (between the 85th and 95th percentiles), and 16% were obese (≥95th percentile). Hours of outdoor play were negatively associated with BMI, and hours of television were positively associated with BMI. Moreover, a ratio of outdoor play to television time was a significant predictor of BMI. Higher maternal perceptions of neighborhood collective efficacy were associated with more hours of outdoor play, fewer hours of television viewing, and more trips to a park or playground. In addition, we found that neighborhood physical disorder was associated with both more outdoor play and more television watching. Finally, contrary to expectations, we found that children living in public housing had significantly more hours of outdoor play and watched more television, than other children. We hypothesize that poorer children may have more unstructured time, which they fill with television time but also with outdoor play time; and that children in public housing may be likely to have access to play areas on the grounds of their housing facilities.
PMCID: PMC3058513  PMID: 21324574
4.  Referrals of participants in an urban WIC program to health and welfare services. 
Public Health Reports  1992;107(2):173-178.
The Special Supplemental Food Program for Women, Infants, and Children (WIC) provides supplemental food, nutrition education, and referrals to available health and welfare services. Recipients are income-eligible pregnant and postpartum women, their infants, and their children who are younger than 5 years of age. Although studies have documented the nutritional benefits of the program, the extent to which WIC nutritionists help eligible women to obtain available health and welfare services, and the degree to which this referral activity promotes health, is largely unknown. The researchers examined the referral activity at one urban WIC clinic, but did not evaluate the outcomes. Of 1,850 persons seen, there were 762 referrals by WIC nutritionists for 597 persons at the Lawrence, MA, clinic during a 2-month period. Of the 597 persons, 494 (83 percent) were WIC participants and 103 (17 percent) were nonparticipants. The rate of referrals for WIC participants was 27 percent. Multiple referrals were common, with 127 people receiving more than one referral. WIC nutritionists at this site offered a variety of referrals to their clients. The majority of referrals (61.7 percent) were for supplemented food. Nonnutrition-related referrals were to medical and dental services (20.5 percent), developmental and educational services (12.5 percent), and social services (5.4 percent). Nonnutrition-related referrals for women included referrals for family planning, substance abuse, job training, teenaged parenting, and high school equivalency programs. Infants and children were referred for dental care, growth failure, the Head Start Program, kindergarten enrollment, early intervention, and protective services.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1403627  PMID: 1561299
5.  Neighborhood Disparities in Prevalence of Childhood Obesity Among Low-Income Children Before and After Implementation of New York City Child Care Regulations 
New York City Article 47 regulations, implemented in 2007, require licensed child care centers to improve the nutrition, physical activity, and television-viewing behaviors of enrolled children. To supplement an evaluation of the Article 47 regulations, we conducted an exploratory ecologic study to examine changes in childhood obesity prevalence among low-income preschool children enrolled in the Nutrition Program for Women, Infants, and Children (WIC) in New York City neighborhoods with or without a district public health office. We conducted the study 3 years before (from 2004 through 2006) and after (from 2008 through 2010) the implementation of the regulations in 2007.
We used an ecologic, time-trend analysis to compare 3-year cumulative obesity prevalence among WIC-enrolled preschool children during 2004 to 2006 and 2008 to 2010. Outcome data were obtained from the New York State component of the Centers for Disease Control and Prevention’s Pediatric Nutrition Surveillance System.
Early childhood obesity prevalence declined in all study neighborhoods from 2004–2006 to 2008–2010. The greatest decline occurred in Manhattan high-risk neighborhoods where obesity prevalence decreased from 18.6% in 2004–2006 to 15.3% in 2008–2010. The results showed a narrowing of the gap in obesity prevalence between high-risk and low-risk neighborhoods in Manhattan and the Bronx, but not in Brooklyn.
The reductions in early childhood obesity prevalence in some high-risk and low-risk neighborhoods in New York City suggest that progress was made in reducing health disparities during the years just before and after implementation of the 2007 regulations. Future research should consider the built environment and markers of differential exposure to known interventions and policies related to childhood obesity prevention.
PMCID: PMC4208999  PMID: 25321632
6.  Are parental concerns for child TV viewing associated with child TV viewing and the home sedentary environment? 
Time spent watching television affects multiple aspects of child and adolescent health. Although a diverse range of factors have been found to be associated with young people's television viewing, parents and the home environment are particularly influential. However, little is known about whether parents, particularly those who are concerned about their child's television viewing habits, translate their concern into action by providing supportive home environments (e.g. rules restricting screen-time behaviours, limited access to screen-based media). The aim of this study was to examine associations between parental concerns for child television viewing and child television viewing and the home sedentary environment.
Parents of children aged 5-6 years ('younger' children, n = 430) and 10-12 years ('older children', n = 640) reported usual duration of their child's television (TV) viewing, their concerns regarding the amount of time their child spends watching TV, and on aspects of the home environment. Regression analyses examined associations between parental concern and child TV viewing, and between parental concern and aspects of the home environment. Analyses were stratified by age group.
Children of concerned parents watched more TV than those whose parents were not concerned (B = 9.63, 95% CI = 1.58-17.68, p = 0.02 and B = 15.82, 95% CI = 8.85-22.80, p < 0.01, for younger and older children respectively). Parental concern was positively associated with younger children eating dinner in front of the television, and with parental restriction of sedentary behaviours and offering sedentary activities (i.e. TV viewing or computer use) as a reward for good behaviour among older and young children. Furthermore, parents of older children who were concerned had fewer televisions in the home and a lower count of sedentary equipment in the home.
Children of concerned parents watched more TV than those whose parents who were not concerned. Parents appear to recognise excessive television viewing in their children and these parents appear to engage in conflicting parental approaches despite these concerns. Interventions targeting concerned parents may be an innovative way of reaching children most in need of strategies to reduce their television viewing and harnessing this parental concern may offer considerable opportunity to change the family and home environment.
PMCID: PMC3195694  PMID: 21951470
Parents; Children; Television viewing; Sedentary behaviour; Home environment
7.  Use of television, videogames, and computer among children and adolescents in Italy 
BMC Public Health  2009;9:139.
This survey determined the practices about television (video inclusive), videogames, and computer use in children and adolescents in Italy.
A self-administered anonymous questionnaire covered socio-demographics; behaviour about television, videogames, computer, and sports; parental control over television, videogames, and computer.
Overall, 54.1% and 61% always ate lunch or dinner in front of the television, 89.5% had a television in the bedroom while 52.5% of them always watched television there, and 49% indicated that parents controlled the content of what was watched on television. The overall mean length of time daily spent on television viewing (2.8 hours) and the frequency of watching for at least two hours per day (74.9%) were significantly associated with older age, always ate lunch or dinner while watching television, spent more time playing videogames and using computer. Those with parents from a lower socio-economic level were also more likely to spend more minutes viewing television. Two-thirds played videogames for 1.6 daily hours and more time was spent by those younger, males, with parents that do not control them, who watched more television, and who spent more time at the computer. The computer was used by 85% of the sample for 1.6 daily hours and those older, with a computer in the bedroom, with a higher number of computers in home, who view more television and play videogames were more likely to use the computer.
Immediate and comprehensive actions are needed in order to diminish time spent at the television, videogames, and computer.
PMCID: PMC2696431  PMID: 19439070
8.  Television viewing in Thai infants and toddlers: impacts to language development and parental perceptions 
BMC Pediatrics  2009;9:34.
Effects of television to language development in infants and toddlers, especially in the Asian children, are inconclusive. This study aimed to (a) study time spent on television in Thai infants and toddlers (age < 2 years), (b) investigate the association between time spent on television (as recommended by the American Academy of Paediatrics (AAP), < 2 hours per day) and language development in Thai 2-year-old children, and (c) explore parental perceptions on television toward their child's development.
Two hundred and sixty children and their parents were recruited into the study. Time spent on television and parental perceptions on television viewing toward their child's development were recorded during face-to-face and telephone interviews. Language development was assessed at the age of 2 years using the Clinical Linguistic Auditory Milestone Scale (CLAMS), and parents' report. Association between delayed language development and time spent on television viewing, as well as other various parameters such as gender, maternal education and family income, were analysed using a multivariate logistic regression model.
Most Thai infants and toddlers watched television at the age of 6 months, 1 year and 2 years old (98.0, 95.3 and 96.7%, respectively). On average, 1-year-old children watched television 1.23 ± 1.42 hours per day. This increased to 1.69 ± 1.56 hours per day when they were 2 years old. However, watching television longer than 2 hours per day did not associate with delayed language development. On multivariate logistic regression analysis, gender (male) was the only significant factor associated with delayed language development (OR = 6.9, 95% CI = 1.5–31.3). Moreover, 75%, 71%, and 66% of Thai parents believed that television viewing yielded benefits to children's developments.
Thai children commenced watching television at an early age and the amount of television viewing time increased by age. Most parents had positive perceptions to television viewing. The study found no association between time spent on television viewing (≥ 2 hours per day) and delayed language development at the age of 2 years.
Gender (male) was the only variable associated with delayed language development.
PMCID: PMC2694174  PMID: 19460170
9.  Associations between factors within the home setting and screen time among children aged 0–5 years: a cross-sectional study 
BMC Public Health  2012;12:539.
Excessive engagement in screen time has several immediate and long-term health implications among pre-school children. However, little is known about the factors that influence screen time in this age group. Therefore, the purpose of this study was to use the Ecologic Model of Sedentary Behavior as a guide to examine associations between intrapersonal, interpersonal, and physical environment factors within the home setting and screen time among pre-school children.
Participants were 746 pre-school children (≤ 5 years old) from the Kingston, Ontario, Canada area. From May to September, 2011, parents completed a questionnaire regarding several intrapersonal (child demographics), interpersonal (family demographics, parental cognitions, parental behavior), and physical environment (television, computer, or video games in the bedroom) factors within the home setting. Parents also reported the average amount of time per day their child spent watching television and playing video/computer games. Associations were examined using linear and logistic regression models.
Most participants (93.7%) watched television and 37.9% played video/computer games. Several intrapersonal, interpersonal, and physical environment factors within the home setting were associated with screen time. More specifically, age, parental attitudes, parental barriers, parental descriptive norms, parental screen time, and having a television in the bedroom were positive predictors of screen time; whereas, parental education, parental income, and parental self-efficacy were negative predictors of screen time in the linear regression analysis. Collectively these variables explained 64.2% of the variance in screen time. Parental cognitive factors (self-efficacy, attitudes, barriers, descriptive norms) at the interpersonal level explained a large portion (37.9%) of this variance.
A large proportion of screen time in pre-school children was explained by factors within the home setting. Parental cognitive factors at the interpersonal level were of particular relevance. These findings suggest that interventions aiming to foster appropriate screen time habits in pre-school children may be most effective if they target parents for behavioral change.
PMCID: PMC3439297  PMID: 22823887
Child; Pre-school; Television; Parents
10.  Time Well Spent? Relating Television Use to Children’s Free-Time Activities 
Pediatrics  2006;117(2):e181-e191.
This study assessed the claim that children’s television use interferes with time spent in more developmentally appropriate activities.
Data came from the first wave of the Child Development Supplement, a nationally representative sample of children aged 0 to 12 in 1997 (N = 1712). Twenty-four-hour time-use diaries from 1 randomly chosen weekday and 1 randomly chosen weekend day were used to assess children’s time spent watching television, time spent with parents, time spent with siblings, time spent reading (or being read to), time spent doing homework, time spent in creative play, and time spent in active play. Ordinary least squares multiple regression was used to assess the relationship between children’s television use and time spent pursuing other activities.
Results indicated that time spent watching television both with and without parents or siblings was negatively related to time spent with parents or siblings, respectively, in other activities. Television viewing also was negatively related to time spent doing homework for 7- to 12-year-olds and negatively related to creative play, especially among very young children (younger than 5 years). There was no relationship between time spent watching television and time spent reading (or being read to) or to time spent in active play.
The results of this study are among the first to provide empirical support for the assumptions made by the American Academy of Pediatrics in their screen time recommendations. Time spent viewing television both with and without parents and siblings present was strongly negatively related to time spent interacting with parents or siblings. Television viewing was associated with decreased homework time and decreased time in creative play. Conversely, there was no support for the widespread belief that television interferes with time spent reading or in active play.
PMCID: PMC2862999  PMID: 16452327
child development; children; media; television
11.  A community based prevention of weight gain intervention (Mothers In Motion) among young low-income overweight and obese mothers: design and rationale 
BMC Public Health  2014;14:280.
Over 45% of American women 20–39 years old are at risk for type 2 diabetes, cardiovascular disease, and other health conditions because they are overweight or obese. The prevalence of overweight and obesity is disproportionately high among low-income women. This paper describes the study design and rationale of a community based intervention (Mothers In Motion, MIM) aimed to prevent weight gain among low-income overweight and obese mothers18-39 years old by promoting stress management, healthy eating, and physical activity.
Peer recruiters approach participants from 5 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Michigan. The MIM delivers theory-based, culturally-sensitive intervention messages via a combination of DVDs and peer support group teleconferences (PSGTs). The DVD features African American and white overweight and obese WIC mothers who participated in a healthy lifestyle intervention patterned after MIM. The PSGTs are led by paraprofessionals from Michigan State University Extension and WIC providers in Michigan who are trained in motivational interviewing and group facilitation skills. Participants are randomly assigned to an intervention (n = 350) or comparison group (n = 175). The intervention group receives a 16-week intervention on a weekly or bi-weekly basis. Participants are asked to watch 10 MIM DVD chapters at home and join 10 PSGT sessions by phone. The comparison group receives printed educational materials. The primary outcome is body weight. Secondary outcomes include dietary fat, fruit, and vegetable intake; physical activity; stress, and affect. Mediators are self-efficacy, emotional coping response, social support, and autonomous motivation. Telephone interviews and in-person data collection at WIC offices occur at 3 time points: baseline, immediately, and 3 months after the 16-week intervention.
If MIM shows effectiveness, it could have a favorable impact on public health and community programs. The DVDs and PSGTs will be disseminated in WIC, Extension, clinical practice that promote healthy lifestyles for similar target audiences to make a broad contribution to the prevention of weight gain in low-income mothers. Also, our methodology can be adapted by researchers and community stakeholders to help other low-income populations prevent weight gain.
Trial registration
Clinical Trials Number: NCT01839708.
PMCID: PMC3987655  PMID: 24666633
Obesity prevention; Stress management; Healthy eating; Physical activity; Low-income women
12.  Dietary Intakes and Physical Activity among Preschool Aged Children living in Rural American Indian Communities Prior to a Family-based Healthy Lifestyle Intervention 
To report dietary intake and physical activity among preschool-aged children living in rural American Indian (AI) communities prior to a family-based healthy lifestyle intervention and to compare data to current age-specific recommendations.
One hundred thirty-five preschool-aged children, living in rural AI communities, provided diet and physical activity data, prior to a two-year randomized healthy lifestyle intervention. Three 24-hour dietary recalls assessed nutrient and food and added sugar intake, which were compared to the National Academy of Science's Daily Reference Intakes, the United States Department of Agriculture's (USDA) MyPyramid, and the American Heart Association recommendations. Time watching television and moderate plus vigorous activity (MVA) was compared to the MyPyramid and the American Academy of Pediatrics recommendations.
Statistical analysis
Nutrient, food group, added sugar intake and time watching television and in MVA were compared to recommendations by computing the percent of recommendations met. Nonparametric tests identified differences in diet and physical activity among age groups and normal and overweight children (body mass index < 85th and ≥ 85th percentile).
Average nutrient intakes met recommendations whereas food group intakes did not. Mean fruit and vegetable intakes for two to three year-olds were 0.36 cups/day fruit and 0.45 cups/day vegetables and, for four to five year-olds, 0.33 cups/day fruit and 0.48 cups/day vegetables. Both age groups reported consuming more than 50 grams of added sugar, exceeding the recommendation of 16 grams. Overweight versus normal weight children reported significantly more sweetened beverage intake (8.0 ± 0.10 vs. 5.28 ± 0.08 ounces/day, p < 0.01) On average, all children reported watching television 2.0 hours/day and significant differences were observed for total television viewing and non-viewing time between overweight and normal weight children (8.52 ± 0.6 vs. 6.54 ± 0.6 hours/day, p < 0.01). All children engaged in less than 20 minutes/day of MVA.
Overall, children in this sample did not meet MyPyramid recommendations for fruits or vegetables and exceed added sugar intake recommendations. Viewing and non-viewing television time was highly prevalent along with low levels of MVA. The HCSF intervention has the potential for improving nutrition and physical activity among preschool children living in rural AI communities.
PMCID: PMC2946329  PMID: 20630162
dietary intake; physical activity; preschool-aged American Indian children; USDA's MyPyramid
13.  Television viewing and its association with overweight in Colombian children: results from the 2005 National Nutrition Survey: A cross sectional study 
There has been an ongoing discussion about the relationship between time spent watching television and childhood obesity. This debate has special relevance in the Latin American region were the globalization process has increased the availability of screen-based entertainment at home. The aim of this study is to examine the association between television viewing and weight status in Colombian children.
This cross sectional investigation included children aged 5 to12 yrs from the National Nutrition Survey in Colombia (ENSIN 2005). Weight and height were measured in 11,137 children in order to calculate body mass index. Overweight was defined by international standards. Time spent viewing television was determined for these children through parental reports. Multiple logistic regression analyses were conducted for different subgroups and adjusted for potential confounders in order to study the association between television viewing and weight status in this population.
Among the surveyed children, 41.5% viewed television less than two hours/day; 36.8% between two and 3.9 hours/day and 21.7% four or more hours/day. The prevalence of overweight (obesity inclusive) in this population was 11.1%. Children who were classified as excessive television viewers (between two and 3.9 hours/day or 4 or more hours/day) were more likely to be overweight (OR: 1.44 95% CI: 1.41–1.47 and OR: 1.32 95% CI: 1.30–1.34, respectively) than children who reported to watch television less than 2 hours/day. Stratified analyses by age, gender and urbanization levels showed similar results.
Television viewing was positively associated with the presence of overweight in Colombian children. A positive association between urbanization level and television viewing was detected. Considering that the majority of Colombian children lives in densely populated cities and appear to engage in excessive television viewing these findings are of public health relevance for the prevention of childhood obesity.
PMCID: PMC2048503  PMID: 17880726
14.  Television Viewing and Snacking Behaviors of Fourth- and Eighth-Grade Schoolchildren in Texas 
Preventing Chronic Disease  2009;6(3):A89.
Child and adolescent overweight is a serious health issue. Both snacking and television watching have been associated with childhood overweight, but the relationships have not been well examined in a multiethnic population. The aim of this study was to examine relationships between weekday television viewing, snack consumption, consumption of foods advertised on television, and overweight status of a multiethnic sample of fourth- and eighth-grade schoolchildren in Texas.
This study is a secondary analysis of data from the School Physical Activity and Nutrition monitoring system, a validated survey with objective measures of height and weight. The sample of 11,594 children in the fourth and eighth grades was weighted to provide data representative of children in Texas public schools. Children were categorized on the basis of self-reported daily television viewing, snack consumption, and consumption of foods advertised on television. Multiple logistic regression was used to analyze, by grade level, the differences in the prevalence of overweight by category.
Television viewing, frequency of snack consumption, and consumption of foods advertised on television were all positively related to one another. In general, both consuming more snacks and foods advertised on television were associated with reduced odds of overweight regardless of the amount of television watched.
The results suggest that the relationships between weekday snacking behaviors and television viewing in a multiethnic population are complicated. When these behaviors are clustered, overweight status may be related more to the number of snacks consumed than to the amount of television watched. To determine the exact relationship, additional research, especially among Hispanic children, is warranted.
PMCID: PMC2722406  PMID: 19527590
15.  Canadian children's and youth's pedometer-determined steps/day, parent-reported TV watching time, and overweight/obesity: The CANPLAY Surveillance Study 
This study examines associations between pedometer-determined steps/day and parent-reported child's Body Mass Index (BMI) and time typically spent watching television between school and dinner.
Young people (aged 5-19 years) were recruited through their parents by random digit dialling and mailed a data collection package. Information on height and weight and time spent watching television between school and dinner on a typical school day was collected from parents. In total, 5949 boys and 5709 girls reported daily steps. BMI was categorized as overweight or obese using Cole's cut points. Participants wore pedometers for 7 days and logged daily steps. The odds of being overweight and obese by steps/day and parent-reported time spent television watching were estimated using logistic regression for complex samples.
Girls had a lower median steps/day (10682 versus 11059 for boys) and also a narrower variation in steps/day (interquartile range, 4410 versus 5309 for boys). 11% of children aged 5-19 years were classified as obese; 17% of boys and girls were overweight. Both boys and girls watched, on average, < 40 minutes of television between school and dinner on school days. Adjusting for child's age and sex and parental education, the odds of a child being obese decreased by 20% for every extra 3000 steps/day and increased by 21% for every 30 minutes of television watching. There was no association of being overweight with steps/day, however the odds of being overweight increased by 8% for every 30 minutes of additional time spent watching television between school and dinner on a typical school day.
Television viewing is the more prominent factor in terms of predicting overweight, and it contributes to obesity, but steps/day attenuates the association between television viewing and obesity, and therefore can be considered protective against obesity. In addition to replacing opportunities for active alternative behaviours, exposure to television might also impact body weight by promoting excess energy intake.
In this large nationally representative sample, pedometer-determined steps/day was associated with reduced odds of being obese (but not overweight) whereas each parent-reported hour spent watching television between school and dinner increased the odds of both overweight and obesity.
PMCID: PMC3141616  PMID: 21702982
16.  Children's television viewing and objectively measured physical activity: associations with family circumstance 
The contribution of family circumstance to physical activity and television viewing has not been widely investigated in pre-adolescents, and available information is inconsistent. This study examines whether television viewing and objectively measured physical activity vary by different indicators of family circumstance.
Data from the 2001 Children's Leisure Activity Study and the 2002/3 Health, Eating and Play Study, involving Australian children in Grades Prep (mean age 6y) and 5–6 (mean age 11y), were combined. Children wore accelerometers for six consecutive 24 hour periods. Average min/day in low-intensity activity (1.0–1.9 METs) and moderate-to-vigorous-intensity activity (≥3 METs) were calculated. Parents reported children's television viewing and family circumstance. Linear regression analyses were conducted separately for young girls, young boys, older girls and older boys.
Complete data were available for 2458 children. Parental education and, to a lesser extent, employment level were inversely associated with television viewing. Children in single-parent families, those whose fathers were not in paid employment, and those without siblings tended to spend more time in low-intensity activity than their peers. Children with siblings spent more time in moderate-to-vigorous-intensity activity; associations were stronger for girls. Maternal education was positively associated with moderate-to-vigorous-intensity activity for younger children. Maternal employment was positively associated with moderate-to-vigorous-intensity activity for older children. Multivariable models did not demonstrate a cumulative explanatory effect.
Individual measures of family circumstance were differentially associated with television, low-intensity activity and moderate-to-vigorous-intensity activity and associations were often not consistent across age-by-gender groups. Interventions may need to be tailored accordingly.
PMCID: PMC1636654  PMID: 17062166
17.  Insights in Public Health 
The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a proven, cost-effective investment in strengthening families. As part of the United States Department of Agriculture's (USDA) 15 federal nutrition assistance programs for the past 40 years, WIC has grown to be the nation's leading public health nutrition program. WIC serves as an important first access point to health care and social service systems for many limited resource families, serving approximately half the births in the nation as well as locally. By providing nutrition education, breastfeeding promotion and foods in addition to referrals, WIC plays a crucial role in promoting lifetime health for women, infants and children. WIC helps achieve national public health goals such as reducing premature births and infant mortality, increasing breastfeeding, and reducing maternal and childhood overweight. Though individuals and families can self-refer into WIC, physicians and allied health professionals have the opportunity and are encouraged to promote awareness of WIC and refer families in their care.
PMCID: PMC4174695  PMID: 25285258
18.  Physical Activity, Watching Television, and the Risk of Obesity in Students, Texas, 2004-2005 
Preventing Chronic Disease  2011;8(3):A61.
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.
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.
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.
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.
PMCID: PMC3103566  PMID: 21477501
19.  Influence of Social Context on Eating, Physical Activity and Sedentary Behaviors of Latina Mothers’ and Their Preschool-Aged Children 
As more U.S. children grow up in Latino families, understanding how social class, culture and environment influence feeding practices is key to preventing obesity. We conducted six focus groups and 20 in-depth interviews among immigrant, low-income Latina mothers in the Northeast U.S. and classified 17 emergent themes from content analysis according to ecologic frameworks for behavior change. Respondents related environmental influences to child feeding, diet and activity, i.e., supermarket proximity, food cost, access to recreational facilities, neighborhood safety and weather. Television watching was seen as integral to family life, including watching TV during meals and using TV as a babysitter and tool to learn English. Participation in the WIC Program helped families address food insecurity and child care provided healthy eating and physical activity opportunities. Health promotion efforts addressing obesity trends in Latino children must account for organizational and environmental influences on the day-to-day social context of young immigrant families.
PMCID: PMC3089594  PMID: 18689491
social ecological model; obesity; Latino; maternal; children; cultural context
20.  Savings achieved by giving WIC benefits to women prenatally. 
Public Health Reports  1995;110(1):27-34.
The Special Supplemental Food Program for Women, Infants, and Children (WIC) provides supplemental food, nutrition and health education, and social services referral to pregnant, breastfeeding, and post-partum women, and their infants and young children who are both low-income and at nutritional risk. A number of statistically controlled evaluations that compared prenatal women who received WIC services with demographically similar women who did not receive WIC services have found WIC enrollment associated with decreased levels of low birth weight among enrolled women's infants. Several also have found lower overall maternal and infant hospital costs among women who had received prenatal WIC services compared with similar women who did not receive prenatal WIC services. A meta-analysis of the studies shows that providing WIC benefits to pregnant women is estimated to reduce low birth weight rates 25 percent and reduce very low birth weight births by 44 percent. Using these data to estimate costs, prenatal WIC enrollment is estimated to have reduced first year medical costs for U.S. infants by $1.19 billion in 1992. Savings from a reduction in estimated Medicaid expenditures in the first year post-partum more than offset the cost of the Federal prenatal WIC Program. Even using more conservative assumptions, providing prenatal WIC benefits was cost-beneficial. Because of the estimated program cost-savings, the U.S. General Accounting Office has recommended that all pregnant women at or below 185 percent of Federal poverty level be eligible for the program.
PMCID: PMC1382070  PMID: 7838940
21.  Television Viewing Practices and Obesity Among Women Veterans 
Journal of General Internal Medicine  2006;21(Suppl 3):S76-S81.
Obesity is epidemic in the U.S. and has been associated with television viewing.
To describe the association between obesity and television viewing practices among women veterans.
Cross-sectional, mailed survey completed by 1,555 female veterans enrolled at the VA Puget Sound Health Care System in 2000.
We used bivariate and multivariate analyses to assess the association of obesity (body mass index >30 kg/m2 based on self-reported height and weight) with self-reported number of hours of television or videos viewed per day, and frequency of eating meals or snacking while watching television, controlling for other covariates.
Watching television >2 hours per typical day on week days and/or weekends was associated with obesity (P<.001), as was eating or snacking while watching television (P=.003). In multivariate logistic regression analyses, watching television >2 hours per day and eating or snacking while watching television were each associated with obesity (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.1 to 1.8; and OR 1.3, 95% CI 1.0 to 1.7, respectively), after adjusting for demographic variables, smoking, physical activity, and depression. Results were similar when posttraumatic stress disorder was included in the model instead of depression. Women who both watched >2 hours of television per day and ate or snacked while viewing were almost twice as likely to be obese (OR 1.9, 95% CI 1.4 to 2.6).
Watching television over 2 hours per day and eating while watching television were each associated with obesity among female VA patients and may be modifiable risk factors for obesity.
PMCID: PMC1513172  PMID: 16637951
obesity; television; women veterans
22.  Adolescent Sedentary Behaviors: Correlates Differ for Television Viewing and Computer Use 
Sedentary behavior is associated with obesity in youth. Understanding correlates of specific sedentary behaviors can inform the development of interventions to reduce sedentary time. The current research examines correlates of leisure computer use and television viewing among California adolescents.
Using data from the 2005 California Health Interview Survey (CHIS), we examined individual, family and environmental correlates of two sedentary behaviors among 4,029 adolescents: leisure computer use and television watching.
Linear regression analyses adjusting for a range of factors indicated several differences in the correlates of television watching and computer use. Correlates of additional time spent watching television included male sex, American Indian and African American race, lower household income, lower levels of physical activity, lower parent educational attainment, and additional hours worked by parents. Correlates of a greater amount of time spent using the computer for fun included older age, Asian race, higher household income, lower levels of physical activity, less parental knowledge of free time activities, and living in neighborhoods with higher proportions of non-white residents and higher proportions of low-income residents. Only physical activity was associated similarly with both watching television and computer use.
These results suggest that correlates of time spent on television watching and leisure computer use are different. Reducing screen time is a potentially successful strategy in combating childhood obesity, and understanding differences in the correlates of different screen time behaviors can inform the development of more effective interventions to reduce sedentary time.
PMCID: PMC3786734  PMID: 23260837
sedentary behavior; correlates; adolescent health; screen time
23.  Television-Viewing Characteristics of Adults: Correlations to Eating Practices and Overweight and Health Status 
Preventing Chronic Disease  2006;3(2):A38.
The purpose of this study was to examine the associations among television viewing, eating practices, and overweight and health status of a nationally representative sample of adults in the United States.
Data on adults aged 20 years or older from the U.S. Department of Agriculture's Continuing Survey of Food Intakes by Individuals 1994–1996 were used for the study. Participants' socioeconomic and demographic characteristics, macronutrient intakes, weight status, prevalence of health conditions, television viewing, and overweight status were analyzed. Survey design effects were used in the analyses.
More than 2 hours of television viewing per day was associated with a high mean body mass index and overweight or obesity in both men and women. Other characteristics associated with watching more than 2 hours of television per day were being 50 years of age or older, having a high school education or less, living in a household with income below 131% of the federal poverty level, and not being employed. Adults who watched more than 2 hours of television per day had high intakes of energy and macronutrients and were more likely to be overweight. They also obtained more energy from snacks and supper. A higher percentage of adults with health conditions watched more than 2 hours of television per day compared with adults without health conditions.
Obesity intervention programs, especially those aimed at adults who are retired or not employed, should emphasize reducing time spent viewing television or videos or participating in similar sedentary activities and discourage snacking or eating while watching television.
PMCID: PMC1563980  PMID: 16539779
24.  Does television viewing predict dietary intake five years later in high school students and young adults? 
Prior research has found that television viewing is associated with poor diet quality, though little is known about its long-term impact on diet, particularly during adolescence. This study examined the associations between television viewing behavior with dietary intake five years later.
Survey data, which included television viewing time and food frequency questionnaires, were analyzed for 564 middle school students (younger cohort) and 1366 high school students (older cohort) who had complete data available at Time 1 (1998–1999) and five years later at Time 2 (mean age at Time 2, 17.2 ± 0.6 and 20.5 ± 0.8 years, respectively). Regression models examined longitudinal associations between Time 1 television viewing behavior and Time 2 dietary intake adjusting for sociodemographic characteristics, Time 1 dietary intake, and Time 2 total daily energy intake.
Respondents were categorized as limited television users (<2 hours/daily), moderately high television viewers (2–5 hours/daily), and heavy television viewers (≥5 hours/daily). Among the younger cohort, Time 1 heavy television viewers reported lower fruit intake and higher sugar-sweetened beverage consumption than the other two groups. Among the older cohort, watching five or more hours of television per day at Time 1, predicted lower intakes of fruits, vegetables, whole grain and calcium-rich foods, and higher intakes of trans fat, fried foods, fast food menu items, snack products, and sugar-sweetened beverages (products commonly advertised on television) five years later.
Television viewing in middle and high school predicted poorer dietary intake five years later. Adolescents are primary targets of advertising for fast food restaurants, snack foods, and sugar-sweetened beverages, which may influence their food choices. Television viewing, especially during high school, may have long-term effects on eating choices and contribute to poor eating habits in young adulthood.
PMCID: PMC2643350  PMID: 19183442
25.  Promotion of a healthy lifestyle among 5-year-old overweight children: health behavior outcomes of the 'Be active, eat right’ study 
BMC Public Health  2014;14:59.
This study evaluates the effects of an intervention performed by youth health care professionals on child health behaviors. The intervention consisted of offering healthy lifestyle counseling to parents of overweight (not obese) 5-year-old children. Effects of the intervention on the child having breakfast, drinking sweet beverages, watching television and playing outside were evaluated.
Data were collected with the 'Be active, eat right’ study, a cluster randomized controlled trial among nine youth health care centers in the Netherlands. Parents of overweight children received lifestyle counseling according to the intervention protocol in the intervention condition (n = 349) and usual care in the control condition (n = 288). Parents completed questionnaires regarding demographic characteristics, health behaviors and the home environment at baseline and at 2-year follow-up. Cluster adjusted regression models were applied; interaction terms were explored.
The population for analysis consisted of 38.1% boys; mean age 5.8 [sd 0.4] years; mean BMI SDS 1.9 [sd 0.4]. There were no significant differences in the number of minutes of outside play or television viewing a day between children in the intervention and the control condition. Also, the odds ratio for having breakfast daily or drinking two or less glasses of sweet beverages a day showed no significant differences between the two conditions. Additional analyses showed that the odds ratio for drinking less than two glasses of sweet beverages at follow-up compared with baseline was significantly higher for children in both the intervention (p < 0.001) and the control condition (p = 0.029).
Comparison of the children in the two conditions showed that the intervention does not contribute to a change in health behaviors. Further studies are needed to investigate opportunities to adjust the intervention protocol, such as integration of elements in the regular well-child visit. The intervention protocol for youth health care may become part of a broader approach to tackle childhood overweight and obesity.
Trial registration
Current Controlled Trials ISRCTN04965410
PMCID: PMC3911965  PMID: 24447459
Obesity; Overweight; Prevention; Intervention; Elementary school; Preschool; Children; RCT; Youth health care

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