Systematic Review: TV viewing associated with poor physical, social, and psychological health in preschoolers

the babysitter

Travis’ Note: Today we have a guest post from my colleague Allana Leblanc, reporting on a systematic that she recently published examining the relationship between sedentary behaviour and markers of physical, social, and psychological health.  You can find more on Allana at the bottom of this post.

Background:

In March of this year (March 27th to be exact), the Canadian Society for Exercise Physiology (CSEP) released the first ever Canadian Sedentary Behaviour Guidelines for the Early Years (aged 0-4 years).  These were released at the same time as the Canadian Physical Activity Guidelines for the Early Years (aged 0-4 years) and are the first ever, stand alone, evidence informed guidelines for this age group.

For information on the process and development of the guidelines, you can refer to an earlier post here.  As well as to the published process papers in APNM (see here for the physical activity paper and here for the sedentary behaviour paper).

In brief, back in March 2011, CSEP, in partnership with the Healthy Active Living and Obesity research group (HALO) and ParticipACTION started work to concurrently develop Canadian Physical Activity Guidelines for the Early Years and Canadian Sedentary Behaviour Guidelines for the Early Years. Both of which would be informed by systematic reviews and following rigorous and transparent methods.

The systematic reviews that were used to inform the new guidelines were officially published a couple weeks ago and made available through APNM open access (for the physical activity review see here and for the sedentary behaviour review see here). Today I’m going to provide you with a brief overview of the sedentary behaviour paper.

What we did:

Study inclusion criteria

We searched 5 online databases for studies that looked at the relationship between sedentary behaviour and health in the early years (i.e. 0-4.99 years).  The health indicators we included and their priority can be seen in Table 1.

 

From Leblanc et al., 2012 (APNM)

Only high quality (i.e. RCTs, prospective cohorts, intervention studies) were included. You can see the number of included and excluded studies in the figure below. You can also check out the paper for the full search strategy [Travis' note: the actual figure is too wide for our blog, so just click the figure below to be taken to the full text of the article, which contains the original].

Figure 1 from Leblanc et al., 2012 (APNM)

Data extraction and analysis

We used GRADE methodology (Grading of Recommendations Assessment, Development and Evaluation) to guide our review.  Details on the development, process and framework for GRADE are heavily published and can be found elsewhere (Guyatt et al. 2011a; 2011b; 2011c; 2011d; 2011e; 2011f; 2011g).

In brief, GRADE is an internationally endorsed framework that provides a systematic and transparent methodology for clarifying research questions, determining outcomes of interest, summarizing relevant evidence and presenting recommendations based on the quality of available evidence.  Once you’ve made up a search strategy and determined which articles meet your inclusion criteria, you assess the quality of available evidence.  For this review, included studies were divided by age group and then by health indicator. Quality of evidence for each health indicator was assessed based on study design, risk of bias, consistency of results, directness of the intervention, precision of results, and possible dose-response gradient during data extraction. Randomized control trials begin at the highest quality evidence but may be downgraded as per assessment.  Observational studies begin at the lowest quality evidence but can be upgraded if they score well (usually due to a dose response relationship).

What we found

In the end, we included a total of 21 studies (represented in 23 papers)

-          9 were in infants, 12 in  toddlers, 10 in preschoolers (some overlapped age groups)

-          11 examined the relationship with adiposity

-          8 examined the relationship with cognitive development

-          6 examined the relationship with psychosocial health

-          None examined the relationship with motor development or cardio-metabolic health indicators

-          All studies used parent, caregiver or teacher report to quantify the time children spent watching television.

Overall,

… in infants, there was moderate quality evidence to suggest television viewing elicited no benefits and may be harmful to cognitive development; and low quality evidence to suggest increased television viewing was associated with unfavourable adiposity.  In toddlers, there was moderate evidence suggesting television viewing has a negative impact on adiposity, moderate evidence to suggest it negatively affected psychosocial health and low quality evidence to suggest it has a negative impact on cognitive development.  In preschoolers, there was low to high quality evidence on television’s negative impact on adiposity, moderate quality evidence between increased television and decreased scores on measures of psychosocial health and low quality evidence on the inverse relationship between television viewing and cognitive development.   

What we concluded

Current evidence supports the idea that increased television viewing is associated with unfavourable measures of adiposity, psychosocial health and cognitive development.  Further, no evidence exists to suggest television viewing is beneficial for improved psychosocial or cognitive development.  In several instance, a dose-response relationship existed between increased time spent watching television and decreased psychosocial or cognitive development.

Where we go from here

What was reported in this review is consistent with evidence in older children (i.e. aged 5-17 years) that increased screen time is associated with unfavourable body composition, decreased fitness, lowered scores for self-esteem and pro-social behaviour and decreased academic achievement (Tremblay et al. 2011).  That being said, evidence included in this review did not provide specific information on the dose (i.e. frequencies, interruptions, times, or types) of sedentary behaviour associated with good health, nor did it provide definitive information as to how this relationship differs between boys and girls.  Further, all studies included in this review reported on the relationship between television viewing and a health indicator (i.e. no other types of sedentary behaviour were explored).  But as television viewing is only a crude measure of sedentary behaviour, it’s possible that results may in fact be underestimating its overall impact of television viewing on poor health.

Future work needs to focus on using direct measures (i.e. accelerometers, inclinometers) and standardized cut points within large cohorts of children. This would also help us understand specific times when sedentary behaviour interventions are most needed.

Allana Leblanc, MSc, CEP

About the Author: Allana LeBlanc is a Certified Exercise Physiologist and Research coordinator.  She is a co-author on the process papers outlining the new physical activity guidelines and systematic review, as well as lead author on the systematic review on which the sedentary behaviour guidelines are based.

 

References:

Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, Alderson P, Glasziou P, Falck-Ytter Y and Schunemann HJ.  GRADE guidelines: 2. Framing the question and deciding on important outcomes. Journal of Clinical Epidemiology. 2011a  64(4): 395-400.

Guyatt GH, Oxman AD, Kunz R, Brozek J, onso-Coello P, Rind D, Devereaux PJ, Montori VM, Freyschuss B, Vist G, Jaeschke R, Williams JW Jr., Murad MH, Sinclair D, Falck-Ytter Y, Meerpohl J, Whittington C, Thorlund K, Andrews J & Schunemann HJ.  GRADE guidelines 6. Rating the quality of evidence–imprecision. Journal of Clinical Epidemiology. 2011b.  64(12): 1283-1293.

Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, onso-Coello P, Glasziou P, Jaeschke R, Akl EA, Norris S, Vist G, Dahm P, Shukla VK, Higgins J, Falck-Ytter Y & Schunemann HJ.  GRADE guidelines: 7. Rating the quality of evidence–inconsistency. Journal of Clinical Epidemiology. 2011c.  64(12): 1294-1302.

Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, onso-Coello P, Falck-Ytter Y, Jaeschke R, Vist G, Akl EA, Post PN, Norris S,  Meerpohl J, Shukla VK, Nasser M. & Schunemann HJ.  GRADE guidelines: 8. Rating the quality of evidence–indirectness. Journal of Clinical Epidemiology. 2011. 64(12): 1303-1310.

Guyatt GH, Oxman AD, Montori V, Vist G, Kunz R, Brozek J, onso-Coello P, Djulbegovic B, Atkins D, Falck-Ytter Y, Williams JW Jr., Meerpohl J, Norris SL, Akl EA & Schunemann HJ  GRADE guidelines: 5. Rating the quality of evidence–publication bias. Journal of Clinical Epidemiology. 2011d. 64(12): 1277-1282.

Guyatt GH, Oxman AD, Sultan S, Glasziou P, Akl EA, onso-Coello P, Atkins D, Kunz R, Brozek, J, Montori V, Jaeschke R, Rind D, Dahm P, Meerpohl J, Vist G, Berliner E, Norris S, Falck-Ytter Y, Murad MH & Schunemann HJ. GRADE guidelines: 9. Rating up the quality of evidence. Journal of Clinical Epidemiology. 2011e. 64(12): 1311-1316.

Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, onso-Coello P, Montori V, Akl EA, Djulbegovic B, Falck-Ytter Y, Norris SL, Williams JW Jr., Atkins D, Meerpohl J & Schunemann HJ. GRADE guidelines: 4. Rating the quality of evidence–study limitations (risk of bias). Journal of Clinical Epidemiology. 2011f.  64 (4): 407-415.

Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S , Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke, R, Rind D, Meerpohl J, Dahm P & Schunemann HJ. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. Journal of Clinical Epidemiology. 2011g. 64(4): 383-394.

Timmons BW, LeBlanc AG, Carson V, Connor Gorber S, Dillman C, Janssen I, Kho ME, Stearns J, Spence JC, Tremblay MS.  Systematic review of the relationship between physical activity and health indicators in the early years (aged 0-4 years). Applied Physiology Nutrition and Metabolism. 2012; 37:773-792, 2012.

Tremblay MS, LeBlanc AG, Carson V, Choquette L, Connor Gorber S, Dillman C, Duggan M, Gordon MJ, Hicks A, Janssen I, Kho ME, Latimer-Cheung AE, LeBlanc C, Murumets K, Okely AD, Reilly JJ, Stearns JA, Spence JC, and Timmons BW. Canadian physical activity guidelines for the early years (aged 0-4 years). Applied Physiology Nutrition and Metabolism. 2012; 37(2): 345–356.

Tremblay MS, LeBlanc AG, Carson V, Choquette L, Connor Gorber S, Dillman C, Duggan M, Gordon MJ, Hicks A, Janssen I, Kho ME, Latimer-Cheung AE, LeBlanc C, Murumets K, Okely AD, Reilly JJ, JA Stearns, Timmons BW, and Spence JC. Canadian sedentary behaviour guidelines for the early years (aged 0-4 years). Applied Physiology Nutrition and Metabolism. 2012; 37(2): 370–380.

Tremblay MS, LeBlanc AG, Kho ME, Saunders TJ, Larouche R, Colley RC, Goldfield G. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. International Journal of Behavioural Nutrition and Physical Activity. 2011; 8:98.

ResearchBlogging.orgLeblanc AG, Spence JC, Carson V, Connor Gorber S, Dillman C, Janssen I, Kho ME, Stearns JA, Timmons BW, & Tremblay MS (2012). Systematic review of sedentary behaviour and health indicators in the early years (aged 0-4 years). Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme, 37 (4), 753-72 PMID: 22765839

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9 Responses to Systematic Review: TV viewing associated with poor physical, social, and psychological health in preschoolers

  1. Oliver H says:

    Given the social and psychological factors the study lists as associated with higher TV consumption, the question about what the association actually indicates becomes all the more important: A causative connection from TV consumption to poor social integration and psychological problems? Or the latter leading to kids holing up in their rooms in front of the TV, trying to shut out the world outside? Or, most probably in my eyes, a feedback mechanism between the two? We should be very wary of easy solutions on this issue and simply jump on “sedentary behaviour interventions”. Without keeping a close eye on the socio-psychological environment, such interventions are more likely to breed resentment, and consequentially more problems in the social and psychological field, not less.

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  2. Benoit says:

    We need to act and do more teaching real teaching with no sponsorship and gimmick. If we have to look at the Olympics where the sponsors are the wore in the world to says lie healthy it s normal that normal consumers might be just a little bit confused. Less studies just more action let`s get back to when we were young because things were working back then. Move and eat real food. A bike ride was our way to visit friends not an exercise. It was working. Technologies have a huge impact in our laziness as human and I am including myself in the herd.

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  3. Rob says:

    For the 21 studies that led to the conclusions on infants, toddlers, and pre-schoolers, (eg. “In toddlers, there was moderate evidence suggesting television viewing has a negative impact on adiposity, moderate evidence to suggest it negatively affected psychosocial health and low quality evidence to suggest it has a negative impact on cognitive development.”):
    1. How did they try to isolate the effect of TV watching and rule out confounding factors that could also have contributed to the negative results?
    2. What was the threshold in terms of time spent watching TV at which point the negative results began emerging? I assume there would be a big difference between 1 hour a day and 4 hours a day but this isn’t mentioned.
    3. What kinds of TV shows were watched? Was there an assumption that content made no difference in terms of cognitive and psycho-social health? To me, benefits here would be tied directly to content so just equating all TV content for children as equal would be a huge flaw as far the cognitive and psycho-social side of things. The unfavourable adiposity aspect would ignore content I assume.

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    • Travis says:

      Excellent questions, Rob.

      1. Some studies adjusted for confounders, others did not. Some (but not many) studies also used randomized designs which can also help rule out confounders. The quality of the findings (e.g. moderate in this case) are graded based on the study design, meaning that we can be pretty confident that there is a relationship between TV viewing and these outcomes, but that it’s not an absolute slam dunk. We’d really need a few large randomized studies to get any higher quality evidence on this issue, but that’s going to be difficult (and possibly unethical) on this kind of issue.

      2. For most of these outcomes there was a dose-response, rather than a threshold. Meaning that as TV viewing increased, so did health risk. So you’re right that 4 hours/day is worse than 1 hour, and 8 hours is worse than 4 hours. But there was no clear threshold where risk suddenly increased dramatically, just a gradual increase as TV viewing increased (unfortunately this is the case with most health outcomes, which makes it difficult when it comes to creating guidelines).

      3. As far as I know the studies didn’t try to separate TV based on content, although at least one study did compare “commercial” and “non-commercial” television (the relationship with adiposity seemed primarily due to commercial television, which isn’t a big surprise). It would be very tough to separate the effects of different types of TV shows in any sort of large observational study – it’s tough enough for people to remember how much TV their kids watch in a day, let alone the content of each show and commercial. But as they mention in the paper, there is no evidence that any type of TV exposure is helpful – even “educational” programming isn’t associated with positive outcomes, probably because it takes away from more educational real world experiences.

      It would be fantastic to differentiate

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  4. Rob says:

    Thanks for the extra details Travis. I was asking because I am curious if there are benefits to small doses of specific TV content, especially when viewed as supplemental to “real world” educational experiences.

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  5. Murray says:

    Hi Travis, Peter, I had a question for you unrelated to this post. I came across this paper while trying to find more info on short bouts of cardio versus longer sessions. I thought it was interesting, but I don’t think it’s been published in anything peer-reviewed. Seems like it’s up your alley, in any case.

    http://www.sportnz.org.nz/en-nz/resources-and-publications/Research-grants1/Research-Grants/#march2008

    Stephen Brown
    Massey University – Palmerston North
    ‘Bite-size exercise’ – effectiveness of reducing exercise bout duration
    $25,000
    Bite Size Exercise report (PDF, 151 Kb)

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