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5 Marketing and Screen Time GOALS: • imit young children’s screen time and exposure to food L and beverage marketing. • se social marketing to provide consistent information and U strategies for the prevention of childhood obesity in infancy and early childhood. T he lives of young children are permeated by media (e.g., television, video games, mobile media, the Internet) (Harris et al., 2009a; IOM, 2006; Story et al., 2008; Vandewater et al., 2006, 2007). Preschool-age children, for example, watch 1 to 3 hours of television per day (Christakis and Garrison, 2009). For young children, decades of research provides strong evidence that “marketing works” to establish their food preferences, purchase requests, and (at least) short- term consumption (IOM, 2006). Substantial exposure to television (including any advertising) is associated with greater risk of overweight and later obesity, inactivity, decreased metabolic rate, and increased snacking (IOM, 2006; Jago et al., 2005; Kaphingst and Story, 2009; Story et al., 2008; Thompson et al., 2008). Limiting total screen time and improving content across the multiple environments where young children spend their time will reduce both their exposure to food 119

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and beverage marketing and their risk of early childhood obesity (Moore, 2006; Pempek and Calvert, 2009; Swinburn and Shelly, 2008). Accordingly, this chapter is focused on two goals. The first is to limit the exposure of young children to media and food marketing, as well as to improve voluntary standards for marketing foods and beverages to young children. The second is to provide consistent information and strategies to parents and other caregivers on how to prevent childhood obesity and promote healthy child devel- opment through a long-term, robust program of social marketing. In 2001, the American Academy of Pediatrics (AAP) issued a statement regarding media use and children, as well as a guideline recommending no television viewing for chil- dren under 2 years of age (AAP, 2001). This age recommendation is consistent with neurodevelopmental research showing that significant brain development is completed in response to environmental stimuli over the first 18–24 months of life (Christakis, 2009). Yet despite these recommendations, there has been an explo- sion of television programming geared specifically toward infants and preschool- ers, generating sales of nearly $100 million in 2004 (Anderson and Pempek, 2005; Khermouch, 2004; Mendelsohn et al., 2008; Wartella et al., 2005). In fact, a recent Kaiser Family Foundation report showed that 61 percent of children young- er than 2 years of age are exposed to television and spend approximately 1 hour 20 minutes daily in this activity (Rideout and Hamel, 2006). Further, a reported 30 percent of children aged 0–3 and 43 percent of those aged 4–6 have a televi- sion in their bedroom (Kaiser Family Foundation, 2005). Research is limited on the impact of media exposure on very young children. Several factors account for the dearth of research, including methodological chal- lenges specific to this age group, a lack of federal funding priority, and difficulty in defining and assessing attention to content (Anderson and Pempek, 2005; Christakis et al., 2004; Kaiser Family Foundation, 2005). Evidence is limited in particular for children aged 0–2 and for “new” media, such as social networking media and the Internet. GOAL: LIMIT YOUNG CHILDREN’S SCREEN TIME AND EXPOSURE TO FOOD AND BEVERAGE MARKETING Recommendation 5-1: Adults working with children should limit screen time, including television, cell phones, or digital media, to less than 2 hours per day for children aged 2-5. Early Childhood Obesity Prevention Policies 120

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Potential actions include • child care settings limiting screen time, including television, cell phones, or digital media, for preschoolers (aged 2–5) to less than 30 minutes per day for children in half-day programs or less than 1 hour per day for those in full-day programs; • health care providers counseling parents and children’s caregivers to permit no more than a total of 2 hours per day of screen time, including television, cell phones, or digital media, for preschoolers, including time spent in child care settings and early childhood education programs; • health care providers counseling parents to coordinate with child care pro- viders and early childhood education programs to ensure that total screen time limits are not exceeded between at-home and child care or early educa- tion settings; and • state and local government agencies providing training, tools, and techni- cal assistance for child care providers, early childhood education program teachers and assistants, health care providers, and community service agency personnel in how to provide effective counseling of parents regarding the importance of reducing screen time for young children. Rationale The recommended limitation on screen time for children aged 2–5 is related to two different factors, both of which have the potential to contribute to childhood obesity: the food and beverage marketing the child may experience when watching television or interacting with other media, and the amount of screen time to which a child is exposed. Young children are exposed to high levels of food marketing and advertising designed to foster brand loyalty and influence purchasing behavior (Elliott, 2008; Harris et al., 2009a,b; IOM, 2006; Kovacic et al., 2008). Television advertising influences children to prefer and request high-calorie and low-nutrient foods and beverages (IOM, 2006). Conservative estimates suggest that U.S. expen- ditures for food marketing to children aged 2–17 through television, the Internet, radio, packaging, in-store promotions, video games, and text messages reach $1.6 billion per year (Kovacic et al., 2008). According to a Federal Trade Commission (FTC) Bureau of Economics Report, children aged 2–5 are exposed to approxi- mately 25,000 advertisements annually, about 5,400 of which are for food (FTC, 2007). 121 Marketing and Screen Time

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There have been industry efforts to address this issue. A self-regulatory advertising initiative by 17 major food and beverage companies has set company- specific standards for products marketed to children younger than age 12 (CBBB, 2010). Their reports show good compliance with individual company standards, significant product reformulation (e.g., less sugar added to cereals), and a reduc- tion in initiativewide food advertising to children since 2006 (CBBB, 2008, 2009). At the same time, other researchers, using common nutrition standards for all foods, report that overall food marketing on television continues to be mainly for products high in calories, added sugars, and fat (Kunkel, 2009; Yale Rudd Center for Food Policy and Obesity, 2010). Children below the age of 5 and probably up to age 8 do not recognize the persuasive intent of commercial advertising or even understand what advertis- ing is; they tend to interpret advertising claims as accurate (Harris et al., 2009b). They also are attracted to brands they associate with media characters, products, and brand logos (Elliott, 2008; Schor and Ford, 2007; Stitt and Kunkel, 2008). Marketing on television influences their food beliefs and preferences, purchase requests to parents, short-term consumption, and usual dietary intake (IOM, 2006; Story et al., 2008). Moreover, according to the Institute of Medicine (IOM) report Food Marketing to Children and Youth: Threat or Opportunity (IOM, 2006), there is strong evidence that exposure to television advertising is associated with adiposity in children aged 2–11. Young children spend a large portion of their day in child care settings, and their environment should not promote televi- sion viewing or marketing of calorie-dense, nutrient-poor foods, beverages, and brands. The amount of time young children are exposed to media also is important. Children experience the cumulative effects of various forms of screen time across settings of care (Kaiser Family Foundation, 2003; Miller et al., 2008; Swinburn and Shelly, 2008; Viner and Cole, 2005; Zimmerman et al., 2007). In the typical American home, the television is on approximately 6 hours per day (Vandewater et al., 2005). Moreover, Christakis and Garrison (2009) found that children in home-based child care settings are exposed to 1.84 more hours of television than those in center-based programs (infants: 0.2 versus 0 hours; toddlers: 1.6 versus 0.1 hours) (Christakis and Garrison, 2009). Young children’s screen time expo- sure may be underestimated across settings of care (Lee et al., 2009; Vandewater et al., 2006, 2007). Accordingly, child care providers should include the amount of screen time to which a child was exposed during the day in their daily activity reports to the child’s parents. Early Childhood Obesity Prevention Policies 122

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Substantial television viewing (more than 2 hours per day) has been shown to be significantly associated with increased body mass index (BMI) (Jago et al., 2005; Proctor et al., 2003) and body fatness (Jackson et al., 2009; Janz et al., 2002; Proctor et al., 2003) in young children. Research has found that children aged 2–5 who watch more than 2 hours per day of television/videos are signifi- cantly more likely to be overweight or obese than those who do not (Mendoza et al., 2007). Likewise, in a longitudinal study of preschool-age children who were fol- lowed for 8 years, Proctor and colleagues (2003) found that young children who watched television 3 or more hours per day had significantly higher BMI, triceps skinfold, and sum of five skinfolds than children who watched television less than 1.75 hours per day. Jackson and colleagues (2009) found that each extra hour of television viewing was associated with an extra 1 kg of body fat. Major federal government initiatives have concluded that screen time is related to weight outcomes and to adequacy of physical activity, but their defi- nition of screen time is not limited to media that contain food advertising. The Centers for Disease Control and Prevention’s (CDC’s) Task Force on Community Preventive Services recommends behavioral interventions aimed at reducing screen time based on “sufficient evidence of effectiveness for reducing measured screen time and improving weight-related outcomes.” Screen time is defined as “time spent watching TV, videotapes, or DVDs; playing video or computer games; and surfing the internet.” In identifying research gaps, the task force points out that important research issues remain, including that “additional research is needed to identify how screen time affects health outcomes.” One of the task force’s research questions is: “What is the mechanism for screen time being associated with weight-related outcomes?” (Community Guide, 2010). Healthy People 2020 (HHS, 2010) positions screen time as a direct com- petitor with adequate physical activity in children from birth to 12th grade. Key physical activity objectives recommended by Healthy People 2020 include increas- ing the proportion of children aged 0 to 2 years who view no television or videos on an average weekday; increasing the proportion of children and adolescents aged 2 through 12th grade who view television and videos or play videogames for less than 2 hours a day; and increasing the proportion of children and adolescents aged 2 through 12th grade who use a computer or play computer games outside of school (or for nonschool work) for less than 2 hours a day, The AAP (2001) recommends limiting children’s total media time to no more than 1 to 2 hours of quality programming per day and discouraging televi- sion viewing for children younger than 2 years of age. Yet a recent study suggests 123 Marketing and Screen Time

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that more than a third of health care providers fail to discuss television guidelines with parents (Spivack et al., 2010). Health care providers are important sources of information for parents. They should consistently recommend limitations on young children’s screen time exposure and encourage parents to ask child care providers about the amount of screen time that occurred during the day for their child. Although the committee thought it reasonable to assume that the relation- ship between screen time and obesity among children aged 2–5 is similar to that among children aged 0–2, the evidence about this relationship was insufficient for the committee to make an obesity prevention recommendation for the latter age group. The committee notes, however, that evidence unrelated to obesity (e.g., about cognitive development) has led others to raise concern about any screen time in this age group. Thus the committee believes that discouraging screen time in this age group may be important for other reasons, as noted by the AAP (2001). Recommendation 5-2: Health care providers should counsel parents and chil- dren’s caregivers not to permit televisions, computers, or other digital media devices in children’s bedrooms or other sleeping areas. Rationale The presence of a television in a child’s bedroom that is on for more than 2 hours per day is a risk factor for becoming overweight by age 3 (Swinburn and Shelly, 2008). As noted earlier, televisions in the bedrooms of young children are com- mon. Parents should receive consistent counseling regarding the impact of screen time on their children’s sedentary behavior, dietary intake, and risk for obesity and the pediatric media recommendations of the AAP (Gentile et al., 2004; Taveras et al., 2010). Among one diverse sample, 67 percent of all children had a television in the room where they slept, including 70 percent of black, 74 percent of Hispanic, and 22 percent of white children. Parents place a television in their child’s bedroom to keep the child occupied, to help the child sleep, and to free up other televisions for use by family members (Taveras et al., 2009). Young children with a television in their bedroom are more likely to experience higher levels of television viewing with an increased risk of unsupervised screen time (Kumanyika and Grier, 2006; Swinburn and Shelly, 2008). As discussed under the previous recommendation, substantial television viewing is associated with increased BMI in young children. Early Childhood Obesity Prevention Policies 124

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Recommendation 5-3: The Federal Trade Commission, the U.S. Department of Agriculture, the Centers for Disease Control and Prevention, and the Food and Drug Administration should continue their work to establish and moni- tor the implementation of uniform voluntary national nutrition and market- ing standards for food and beverage products marketed to children. Rationale As previously discussed in this chapter, television advertising has been shown to influence children to prefer and request high-calorie and low-nutrient foods and beverages, and there is strong evidence that exposure to television advertising is associated with adiposity in children aged 2–11. The food and beverage industry at best has used a variety of differing nutri- tion standards in marketing products and brands targeting children, including cur- rent self-regulatory systems (CBBB, 2010). Such varying standards, or the absence of any marketing standards, create a confusing food marketing environment for parents and children and make it difficult for parents to rely on marketing claims or make healthy product choices for their children, even with some improvements in product formulation (CBBB, 2010; Kunkel, 2009; Yale Rudd Center for Food Policy and Obesity, 2010). Because “marketing works” to impact the food prefer- ences, purchase requests, and consumption of parents and children (IOM, 2006), uniform voluntary standards for nutrition and marketing of products targeting children could help them make better choices. An evaluation of stakeholders’ progress in achieving the recommendations in the IOM report Food Marketing to Children and Youth: Threat or Opportunity (IOM, 2006), however, shows little progress (Wartella, 2011). The Interagency Working Group on Food Marketed to Children (2011), which includes representa- tives from the FTC, CDC, the Food and Drug Administration (FDA), and the U.S. Department of Agriculture (USDA), has released “Preliminary Proposed Nutrition Principles to Guide Industry Self-Regulatory Efforts” and requested public com- ment from stakeholders. Such standards will provide clear guidance for industry and consumers about foods and beverages marketed to children. In addition, once the voluntary standards have been established, the FTC should launch an ongo- ing annual monitoring program to assess voluntary and uniform compliance with the standards and their effectiveness in improving food and beverage marketing to children. Embedded in this recommendation is the committee’s expectation that the food industry will adopt the voluntary standards quickly and uniformly. 125 Marketing and Screen Time

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GOAL: USE SOCIAL MARKETING TO PROVIDE CONSISTENT INFORMATION AND STRATEGIES FOR THE PREVENTION OF CHILDHOOD OBESITY IN INFANCY AND EARLY CHILDHOOD Recommendation 5-4: The Secretary of Health and Human Services, in coop- eration with state and local government agencies and interested private enti- ties, should establish a sustained social marketing program to provide preg- nant women and caregivers of children from birth to age 5 with consistent, practical information on the risk factors for obesity in young children and strategies for preventing overweight and obesity in this population. Rationale Parents’ and other caregivers’ work is hard and constant—never more so than during pregnancy and children’s early years. A large-scale social marketing pro- gram, sustained over time and offering consistent and practical guidance, could help parents undertake actions, behaviors, and ongoing parenting practices that can help prevent obesity and support healthy development in their children. Such a program also could direct parents to complementary and reinforcing informa- tion and guidance provided in health care settings and community service agencies (Asbury et al., 2008; IOM, 2006). Some examples of potential core messages for such a campaign are listed in Box 5-1. Social marketing is defined as using commercial marketing principles (such as the four “Ps” of place, price, product, and promotion) to benefit society and the target audience (Evans et al., 2010). Effective social marketing includes sequenced action steps that demonstrate benefits and reduce barriers for specific audiences through consumer decision making, leading to increased societal benefit (Smith, 2006). Social marketing interventions may be able to impact a variety of health and risk behaviors through one campaign; for example, a campaign may target increasing fruit and vegetable consumption at the same time that it targets behaviors to decrease fat intake (Stead et al., 2007). Social marketing interventions can produce changes across a relatively broad spectrum of behaviors. Successful social marketing programs include those target- ing oral health, reduced alcohol use, smoking cessation, and seat belt use (Smith, 2006; Snyder et al., 2004). Key elements of the most successful campaigns include specific behavioral goals of the intervention, target populations, communication activities and channels, message content and presentation, and techniques for feed- back and evaluation (Smith, 2006). Early Childhood Obesity Prevention Policies 126

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Box 5-1 Examples of Potential Core Messages for a Social Marketing Program on Preventing Obesity in Young Children • Set healthy routines for your family (offer healthy foods and diet, eat together, promote physical activity, set regular sleep times, limit screen time). • Establish healthy places for your child at home or away (make healthy food and physical activity choices the easy choices in these environments). • Move with your child (encourage, model, and join in physical activity). • Eat with your child (model healthy eating, and encourage the child to respond to hunger and full- ness cues). • Get everybody on the same page (talk to your family members, child care provider, health care pro- vider, early childhood education program, and community service agencies about how to prevent childhood obesity). Because overweight and obesity are now prevalent throughout society and because concern about overweight status can be culturally counterintuitive, an effective social marketing program should be long term as well as robust and accessible. Examples of long-term social marketing campaigns aimed at adults that have proven effective over time include smoking cessation and seat belt use (Smith, 2006). Of course, unlike tobacco and seat belt use, obesity presents the additional challenge of maintaining balance between the need to eat and overeating. Costs associated with an effective long-term social marketing program will be significant. As an example, CDC’s VERB campaign1 had average annual fund- ing of about $60 million, starting with $125 million the first year and decreasing each year thereafter. The VERB campaign provided evidence that the development of a national media campaign with social marketing messages for children can have a demonstrable impact on physical activity (Asbury et al., 2008; Banspach, 2008; Huhman et al., 2010). VERB was successful in part because resources were 1See http://www.cdc.gov/youthcampaign/index.htm. 127 Marketing and Screen Time

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allocated up front for planning a successful campaign by developing a brand that resonated with the target market, children aged 9–13. Although less money was available the following years, the campaign was able to continue being effec- tive because it was built on what had been done in the first year (Wong, 2011). Moreover, when trying to reach large numbers of people, media campaigns are more cost-effective than interpersonal communication methods, such as clinic- based education (Snyder, 2007; Snyder et al., 2004). The use of lower-cost digital media as an important part of the program can help limit costs and make the program more effective and responsive to individual parental requests for information. Coordination of the social marketing efforts with health care providers and community service agencies can add substantially to cost-effectiveness (Snyder et al., 2004). It is important to emphasize that the cost of a successful social marketing campaign may represent only a small fraction of the increasing health care costs associated with obesity each year. The value in human terms of preventing overweight and obesity in childhood is incalculable. Social marketing programs can be effective for disseminating information that can help parents and caregivers who directly influence the health of young children (Grier and Kumanyika, 2010; Kumanyika and Grier, 2006). Yet research conducted over the past two decades indicates that today’s health information is not presented in a usable, understandable format for most people (White House Task Force on Childhood Obesity, 2010). Caregivers in particular lack accurate information about nutrition and physical activity for young children that is com- municated consistently in a clear and actionable way (HHS, 2010). The 1% Or Less Milk campaign (Reger et al., 1998), CDC’s VERB cam- paign, and the 5-4-3-2-1 Go! campaign2 in Chicago are examples of social market- ing programs that have been used to promote good nutrition and increased physi- cal activity levels. These programs targeted parents, in addition to children, to encourage them to have a healthier family and home environment. Programs such as these often use a combination of approaches involving community outreach and mass media (Evans et al., 2010). Messages aimed at parents can address risk factors such as television watching, interactions with children that can alter prefer- ences, and patterns of behavior consistent with healthy child development (Evans et al., 2008, 2010). Caregivers also can be reached with targeted social marketing messages about food preferences and choices, exercise, and healthy weight. 2See http://www.clocc.net/partners/54321Go/index.html. Early Childhood Obesity Prevention Policies 128

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