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Obesity Prevention and Control: Behavioral Interventions that Aim to Reduce Recreational Sedentary Screen Time Among Children

Task Force Finding

The Community Preventive Services Task Force recommends behavioral interventions to reduce recreational sedentary screen time among children aged 13 years and younger. This finding is based on strong evidence of effectiveness in reducing recreational sedentary screen time, increasing physical activity, improving diet, and improving or maintaining weight-related outcomes. Evidence includes studies of interventions that focus only on reducing recreational sedentary screen time (screen-time-only) and studies that focus on reducing recreational sedentary screen time and improving physical activity and/or diet (screen-time-plus). Limited evidence was available to assess the effectiveness of these interventions among adults.

Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Intervention Definition

Behavioral interventions that aim to reduce recreational (i.e., neither school-related nor work-related) sedentary screen time teach behavioral self-management skills to initiate or maintain behavior change.

Behavioral screen time interventions are classified into two types:

  1. Screen-time-only interventions only focus on reducing recreational sedentary screen time.
  2. Screen-time-plus interventions focus on reducing recreational sedentary screen time and increasing physical activity and/or improving diet.

Screen-time-only and screen-time-plus interventions teach behavioral self-management skills through one or more of the following components:

  • Classroom-based education
  • Tracking and monitoring
  • Coaching or counseling sessions
  • Family-based or peer social support

Interventions may include one or more additional components: use of an electronic monitoring device to limit screen time; TV Turnoff Challenge; screen time contingent on physical activity; or small media.

Screen-time-only and screen-time-plus interventions are stratified by intensity:

  • High-intensity interventions must include use of an electronic monitoring device to limit screen time or at least 3 personal or computer-tailored interactions. Interactions must focus on screen time and may be in person or by phone or computer.
  • Low-intensity interventions include two or fewer personal or computer-tailored interactions.

Childhood obesity has been positively associated with time spent watching TV (Marshall, et al. 2004, Tremblay, et al. 2011). The American Academy of Pediatrics (AAP) recommends no more than 2 hours per day of screen time for children 2 years and older and none for children younger than 2 years (American Academy of Pediatrics 2001). In the U.S., children aged 8-18 years report an average of 7 hours of screen time per day, of which 4.5 hours are spent watching TV content, that is, TV programs, DVDs, or movies, viewed on a TV, computer, cell phone, or other device (Rideout, et al. 2010). Children aged 5 years and younger spend an average of 2 hours per day with screen media (i.e., TV, DVDs, videos, video/computer games), of which approximately 1.5 hours are spent watching TV or videos (Rideout 2011).

About the Systematic Review

The Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (7 studies with 9 study arms, search period 1966–July 2007) combined with an updated search for evidence in 2013 (42 studies with 52 study arms, search period April 2007–June 2013). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to obesity prevention and control. This finding updates and replaces the 2008 Task Force findings on Behavioral Interventions to Reduce Screen Time and Mass Media Interventions to Reduce Screen Time.

Results

A combined total of 49 studies with 62 study arms qualified for the review.

  • Screen Time Outcomes
    • Duration of composite screen time: median decrease of 26.4 minutes/day (interquartile interval (IQI): ‑74.4 to ‑12.0 minutes/day; 34 study arms)
      • Screen-time-only interventions: median decrease of 82.2 minutes/day (IQI: ‑105.4 to ‑52.1 minutes/day; 11 study arms)
      • Screen-time-plus interventions: median decrease of 21.6 minutes/day (IQI= ‑38.4 to ‑12.9 minutes/day; 23 study arms)
  • Physical Activity Outcomes
    • Accelerometer counts:
      • Screen-time-only interventions: no study arms
      • Screen-time-plus interventions:
        • Screen time contingent on physical activity: median increase of 130.0 counts per day (range: 127.8 to 150.0 counts/day; 3 study arms)
        • Screen time not contingent on physical activity: median increase of 66.0 counts per day (range: 40.8 to 1150.0; 4 study arms)
        • Screen time not contingent on physical activity: median increase of 3.6 counts per minute (range: ‑12.3 to 18.0; 3 study arms)
    • Other physical activity outcomes (e.g., pedometer steps of physical activity, score on a fitness test, and duration of physical activity):
      • The body of evidence for both interventions suggests a positive effect, but the magnitude of effect was small.
  • Dietary Outcomes
    • Total energy intake (kcal/day):
      • Screen-time-only interventions: decrease of 75 kcal/day (1 study arm)
      • Screen-time-plus interventions: decrease of 117.9 kcal/day (IQI: ‑373.1 to 28.5 kcal/day; 5 study arms)
    • Other dietary outcomes (e.g., eating meals or snacking with the TV on, daily snack intake, sugar sweetened beverage intake, and fruit and vegetable intake):
      • The body of evidence for both interventions suggests a positive effect, but the magnitude of effect was small.
  • Weight-Related Outcomes
    • Body mass index (BMI): median decrease of 0.09 (IQI: ‑0.44 to ‑0.04; 15 study arms)
    • BMI Z-score (i.e., a standard deviation score indicating how many units (of the standard deviation) a child's BMI is above or below the average BMI value for their age group and sex): median decrease of 0.13 (IQI: ‑0.23 to ‑0.01; 14 study arms)
  • Obesity Prevalence
    • Proportion of participants obese: median decrease of 2.3 percentage points (IQI: ‑4.5 to ‑1.2 percentage points; 14 study arms)

Study Characteristics

  • Studies were randomized controlled trials (RCT) or group RCTs (37 studies), single group before-after studies (5 studies), before-after with a comparison group (4 studies), and a non-randomized trial (1 study).
  • Included studies were conducted in the United States (30), Australia (6), the United Kingdom (4), Canada (2), France (1), the Netherlands (1), New Zealand (1), Sweden (1), and Switzerland (1).
  • Studies mostly targeted children aged 13 years and younger (46 studies). No studies targeted adolescents aged 14-18 years.
  • Of the 11 screen-time-only studies, 6 were high intensity, 3 were low intensity, and 2 had a high and a low arm. Of the 35 screen-time-plus studies, 22 were high intensity, 11 were low intensity, and 2 had a high and a low arm.
  • Nine studies were conducted in lower economic status populations. Of these, three studies targeted low-income African-American children, two studies targeted Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants, one study targeted Head Start program participants, and three studies targeted disadvantaged children.
  • Six studies targeted overweight or obese populations.
  • Family-based social support was the most common intervention component.
  • Evaluated programs were most commonly implemented in schools (20 studies), and of these 90% were screen-time-plus interventions.

Applicability

Based on results for interventions in different settings and populations, findings are applicable to the following:

  • U.S. or other high- or medium-income countries
  • Children ages 13 years and younger
  • Males and females
  • All racial and ethnic populations studied
  • All socioeconomic levels
  • Normal weight, overweight, and obese populations
  • Urban and suburban settings

Economic Evidence

An economic review is pending.

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.

  • Family-based social support was the most common intervention component. This highlights the importance of family and parental support in changing sedentary screen time behavior among children.
    • Family-based social support, in combination with electronic monitoring devices, was found to be highly effective, especially in screen-time-only studies. Electronic monitoring devices, which allowed users to set time limits for TV, DVD, and/or videogame use, were distributed across all settings and usually installed at home by parents.
  • Availability of electronic monitoring devices for various digital media has increased in recent years. For example, parents can limit screen time through low-cost apps that can be installed on mobile devices, and some cable providers and e-readers offer time controls.
  • Many studies incorporated intervention materials into regular classroom curricula, and most U.S. programs trained existing classroom teachers to deliver the intervention. The review team identified competing demands with other school subjects as a barrier to implementation. Teachers have suggested integrating the intervention into existing curricula (Salmon, et al. 2011).

References

American Academy of Pediatrics. 2001. American Academy of Pediatrics. Children, adolescents, and television. Pediatrics 107: 423-26

Marshall SJ, Biddle SJ, Gorely T, Cameron N, Murdey I. Relationships between media use, body fatness and physical activity in children and youth: a meta-analysis. Int J Obes Relat Metab Disord 2004;28: 1238-46.

Rideout V. Zero to Eight: Children's Media Use in America. Common Sense Media; 2011.

Rideout VJ, Foehr UG, Roberts DF. GENERATION M2: Media in the lives of 8- to 18-Year-Olds. Menlo Park (CA): The Henry J. Kaiser Family Foundation; 2010.

Salmon J, Jorna M, Hume C, Arundell L, Chahine N, Tienstra M, et al. A translational research intervention to reduce screen behaviours and promote physical activity among children: Switch-2-Activity. Health Promotion International 2011;26(3):311-321.

Tremblay MS, LeBlanc AG, Kho ME, Saunders TJ, Larouche R, et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int J Behav Nutr Phys Act 2011;8:98.

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Publication Status

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Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services.  Obesity prevention and control: behavioral interventions that aim to reduce recreational sedentary screen time among children. www.thecommunityguide.org/obesity/behavorial.html. Last updated: MM/DD/YYYY.

Review completed: August 2014