Obesity and Media

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Author(s):

	Artur Mazur
	Medical Faculty University of Rzeszów 35-205 Rzeszów ul. Warszawska 26a Poland.
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	Igor Radziewicz-Winnicki
	Undersecretary of State, Ministry of Health of the Republic of Poland
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	Edyta Łuszczki
	Dean of the Faculty of Health Sciences and Psychology Medical College, University of Rzeszów, Poland.
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Introduction 

The concept of mass media refers collectively to all media technologies used for mass communication and to all social organizations that control these technologies. Mass-media technologies may be divided into two major groups: traditional media: newspapers, books, magazines, and radio, and television which are characterized as providing one-way transmission of messages from sender to audience, and so-called “new media”, providing interactive cooperation between two or more people transferring and receiving messages simultaneously. Historically mass communication originated when humankind developed their communicational skills. But the real communication revolution occurred approximately 90000-40000 B.P. when humankind invented language and this fact, according to anthropologists, meant transforming Homo sapiens into Homo loquens – the language-skilled humankind. The next milestone was reached when about 5000 years ago an alphabet was invented in ancient Mesopotamia and the Script epoch commenced. Barely 500 years ago in 1455, Johannes Gutenberg designed the printing press which started a real informational revolution. Since then, humankind has irreversibly been living in the epoch of mass communication, which has continuously influenced our lives’ religious, political, scientific, social, cultural, and health aspects. The invention of interactive mass media started in 1832 when Baron Schilling von Cannstatt designed the telegraph, opening the gate to successive development of new inventions that widely extended into the 20th century . The rise in popularity of the Internet and the development of smartphones have greatly impacted society, particularly young users of various electronic devices . A research study carried out at the University of Colorado has identified factors that contribute to sleep disturbances in children, such as heightened sensitivity of a child’s eyes, which can disrupt sleep patterns by reducing melatonin levels . Short-term effects linked to sleep issues in children and teenagers include behavioral problems, increased risk of injury, parental stress, and sleep deprivation . Potential long-term consequences may involve obesity, delayed onset of mental health conditions, and academic underachievement . 

Epidemiology  

The duration of screen time is steadily increasing, and the age of users is decreasing. Mobile devices are becoming an integral part of a child’s developmental environment. Despite their risks, they are often regarded as attractive educational tools . An analysis of more than 60 studies of children and adolescents between 5 and 17 years of age found that the more screen time they spend, the greater the risk of falling asleep later, fewer hours of sleep, and worse sleep quality . Scientists emphasize removing digital devices from children’s and adolescent bedrooms. As per the guidance of the Canadian Paediatric Society and the Canadian Society for Exercise Physiology, the recommended daily screen time for children is determined by their age . Children under the age of two should have no exposure to screens or monitors of electronic devices. For children aged 2–4, it is advisable to limit screen time to less than one hour per day, while children and teenagers aged 5–17 should not exceed two hours per day for activities such as watching TV, playing computer games, or engaging in digital communication with friends . Nevertheless, research conducted in the United States indicates that school children and adolescents typically spend around 7 hours per day in front of screens .  

According to the 2019 Business Fiber Report, the Philippines tops the list as the country where people spend more than 10 hours online each day. In contrast, individuals in Brazil, Colombia, and Thailand spend approximately 9 hours online, while those in European countries average between 5 and 6 hours. Interestingly, despite 94% of the Japanese population having access to the Internet, they only spend 3 hours and 45 minutes on mobile devices. These findings suggest that it is predominantly children and adolescents who are engaging with various types of technological devices . The consequences of the above-mentioned behavior include, inter alia, a disorder called the vibrating telephone syndrome; which is constant checking whether the telephone rings or nomophobia (no mobile phone phobia), resulting from the fear of functioning without a telephone . Prolonged screen time often leads to uncontrolled consumption of calorie-dense snacks and sweetened beverages, accompanied by reduced physical activity (PA) . Consequently, both sedentary behavior and increased food intake contribute to the prevalence of overweight and obesity in children . Multiple studies have established a direct link between screen time and elevated body mass index (BMI) or obesity in children and adolescents, identifying it as a risk factor for obesity development . Previous research by scientists has shown a clear association between time spent in front of a TV screen and the occurrence of overweight and obesity in children . The issue at hand pertains to an increasing number of children and adolescents, posing a burden that impacts their future functioning and health . A recent study has revealed a correlation between the amount of time 10-year-old girls spend on social media and their self-reported well-being, indicating a negative relationship . 

In the United States, 80% of adolescents possess at least one modern mass-media device, such as a cell phone, tablet, and/or computer. With 75% of American households having a minimum of three televisions, it is estimated that televisions are situated in the bedrooms of 19% of infants, 29% of children aged 2-3 years, 43% of children aged 4-6 years, and 68% of those aged 8 years and older. The well-known UNESCO multicultural study of 5,000 12-year-old adolescents from 23 countries representing different world regions varying in social development stages, cultures, and economic and social conditions has revealed, that the pattern of children’s exposure to mass media is similar globally. This survey found that 91% of sampled children had access to a television set at home and spent a daily average of three hours in front of the TV set, which was at least 50% longer than those dedicated to any other out-of-school activity, including homework . The average estimated media exposure for children aged 8-18 in the United States in 2010 was reported to be 10 hours and 45 minutes per day, with television being the dominant media platform. There has been a consistent and significant increase in media exposure over the past decade. Media usage is notably higher in single-parent households and in families with lower levels of education and/or income . 

TV Watching and Childhood Obesity 

The impact of mass media on children’s health is well-documented, with a notable consequence being an elevated risk of overweight and obesity . Over the past few decades, there has been a significant increase in the prevalence of obesity among children and adolescents, resulting in a substantial public health concern . Many studies have shown a positive correlation between time spent by children watching television, BMI increase, and unhealthy nutritional behavior. Some well-designed longitudinal studies such as the Framingham Children Study, provided evidence that the increase in time spent by children viewing television is an independent risk factor that predicts an increase in BMI . Other authors suggested that children who saw a videotape with embedded food commercials were significantly more likely to select the advertised product than children who had not seen the commercials. Several research studies have indicated that children have a preference for the taste of food and beverages presented in McDonald’s branded packaging over identical items in unbranded packaging . The viewing habits of television have been linked to increased adiposity in the long term, implying a causal relationship. This association, however, is partially influenced by physical activity and is linked to specific variations in dietary intake. Heightened television viewing among children and adolescents is correlated with decreased consumption of fruits and vegetables, increased snacking, and a rise in the consumption of unhealthy foods along with a decrease in the intake of healthy foods. Consequently, television viewing is linked to both the nature and quantity of food consumed. Multiple studies have indicated that obese children exhibit a higher capacity to recognize TV food advertisements in comparison to non-food TV ads. Additionally, they demonstrate a greater awareness of TV food ads compared to their normal-weight counterparts . Increased caloric intake associated with television viewing primarily stems from the consumption of energy-dense, nutrient-poor foods. Consequently, television viewing is linked to poor overall diet quality. Furthermore, research has revealed an inverse relationship between television viewing and fruit and vegetable intake. Particularly concerning is the finding that children derive a significant proportion of their daily energy intake from television viewing, accounting for up to 20% and 25% during weekdays and weekends, respectively . It is evident that television viewing significantly impacts overall energy consumption, particularly among children and adolescents. This influence is not solely attributed to the time spent engaging with media, but also to the content of the programs. Notably, children who listen to music tend to consume less than those who watch television . 

In a cross-sectional study conducted by Aurore et al. , a significant correlation was observed between the utilization of computers before bedtime and an escalation in BMI among the evaluated adolescents . Consequently, the American Academy of Pediatrics (AAP) advocates for parental vigilance in regulating their children’s screen time, particularly in minimizing exposure to games and programs featuring excessive distracting stimuli or violence. The AAP underscores the significance of parental oversight during screen time, advising on content selection, and consistently implementing the practice of zero screen time one hour before bedtime . The gravity of this issue is underscored by various initiatives undertaken by scientific and medical communities, presenting guidelines for families and healthcare practitioners on mitigating the adverse effects stemming from children and adolescents’ excessive use of electronic devices. 

The World Health Organization (WHO) suggests that children and teenagers should engage in at least one hour of moderate to vigorous physical activity each day and vigorous-intensity physical activity at least three times a week . However, nowadays, active time is being increasingly substituted by screen-based media, and screen time has risen among both children and adolescents, playing a significant role in promoting obesity worldwide . In a study of Health Behavior in School-aged Children (HBSC), it was found that frequent use of social media is linked to an increased likelihood of meeting physical activity guidelines. However, both inactive and problematic social media use were connected to a decreased likelihood of engaging in physical activity . 

TV Food Marketing 

The promotion of foods and food products targeted at children in Europe and the USA predominantly consists of energy-dense items that are high in fat, sugar, and/or salt, which contradicts both national and international dietary guidelines. This type of targeting is driven by the substantial $250 billion annual advertising industry, which represents 900,000 brands vying for consumer attention. Children and adolescents are particularly coveted consumers, with teenagers spending $155 billion annually, children under 12 spending an additional $25 billion, and both groups potentially influencing an estimated $200 billion of their parents’ annual expenditure . Before the age of 7 or 8, children typically perceive advertising as enjoyable, entertaining, and impartial information. Around 8 to 10 years of age, children may start to develop the cognitive capability to comprehend advertisements, although this is not consistently the case. As early adolescence sets in (around 11-12 years), children’s thinking becomes more multifaceted, encompassing both abstract and concrete thought processes . 

Studies have demonstrated that exposure to food commercials embedded within videotapes significantly influences children’s product preferences, leading to a higher likelihood of selecting the advertised items. This effect is particularly notable among children aged 2 to 11, indicating a clear impact on their short-term consumption. Moreover, there is moderate evidence suggesting that advertising also influences the regular dietary choices of children aged 2 to 5, as well as older children aged 6 to 11. Furthermore, research has compellingly linked exposure to advertising with increased adiposity in children aged 2 to 11, extending into the teenage years from 12 to 18. Despite growing societal and institutional awareness, there continues to be a prevalence of advertisements targeting children, capitalizing on their vulnerability and lack of experience. This underscores the need for legislative measures to protect the younger generation from excessive influence on their food consumption behaviors. Furthermore, to enhance the impact of sales campaigns, manufacturers provide various appealing incentives such as stickers and toys and promote their product lines through the inclusion of branded items in purchases, such as cereal boxes, confectionery, or fast food packaging. It has been observed that children may be exposed to as many as 11 advertisements per hour during Saturday morning television programming . Unsurprisingly, there exists a notable correlation between the duration of children’s television viewing and the frequency of parental attempts to influence the purchase of certain products. Television viewing not only influences increased energy intake due to snacking while watching programs and the desire for certain foods but also shapes attitudes and enduring beliefs regarding normative nutritional standards . The rapid delivery of information through electronic media, particularly television, often precludes critical analysis of content and the formation of individual attitudes. Several studies suggest that the frequency of advertisements seen by children significantly influences their requests for purchases. A study revealed that up to three out of four requests made by children are for food products seen on television . 

Internet and New Media 

Computer-mediated communication has recently emerged as an effective method for both gathering and disseminating medical information. Advertisers and marketers have begun to focus on the rapidly growing number of children online, employing various interactive advertising and marketing strategies. Many major companies targeting children have developed their own websites, designed as “branded environments” tailored to children. These websites offer a range of activities including games, word-find puzzles, contests, quizzes, riddles, music, email cards, clips of commercials, sweepstakes, downloadable recipes, desktop wallpaper, screensavers featuring their products, and online stores selling licensed merchandise. In 2009, approximately 1.2 million children aged 6–11 visited food company–sponsored advertising game sites every month, spending up to 63 minutes per month on a single site. Numerous commercial sites directed at children feature targeted food product advertisements. Food companies utilize social media to directly promote marketing messages to young people, including the 12 largest fast-food restaurants and 33 brands of sugary drinks. One of the latest forms of marketing allows food companies to reach young people on their mobile devices (cell phones, tablets) through text messages, emails, social networks, and mobile apps, including advertising games. Fast food, soda, energy drinks, snack food, and candy companies are early adopters of mobile marketing to appeal to youth.   The emergence of new media has the potential to serve as a valuable tool in assisting individuals with obesity. Internet-based programs and mobile accessibility can address traditional barriers to weight loss treatment by offering round-the-clock availability, cost-effectiveness, and the option of anonymity for those who may otherwise refrain from seeking treatment due to feelings of embarrassment or other inhibiting factors. These media platforms create a space for social support through various means such as email, bulletin boards, chat rooms, group forums, and web-hosted meetings. Furthermore, new media can alleviate the inconveniences associated with physical visits to clinics, saving time and resources, and can be used across a wide spectrum of settings to optimize weight-related outcomes . 

Regulations on Advertising to Children 

The susceptibility of children to advertising has been a topic of social and political discourse for an extended period. In addition to concerns about the adverse impact of advertising on children’s well-being, there are ongoing deliberations regarding the ethical dimensions of advertising directed at this demographic. In recent years, there has been a growing acknowledgment among policymakers and health professionals regarding the significant impact of unhealthy food marketing on children’s rights, which, in turn, implicates governments’ responsibility to ensure the realization of these rights. The UN Convention on the Rights of the Child, which upholds the right of the child to the highest attainable standard of health, stands as the most extensively ratified human rights treaty in history. The 2018 EU Council Conclusions on healthy nutrition for children underscore the relevance of this convention, urging Member States and the Commission to endorse policies on nutrition, food, and physical activity that prioritize children’s rights. Nonetheless, it is evident that signatories, including the EU and its Member States, must take further measures to effectively fulfill their obligations to safeguard children. 

The 2018 revision of the EU Audiovisual Media Services Directive (AVMSD), which governs commercial communications in the audiovisual realm, missed a significant opportunity for EU policymakers to prioritize the protection of children’s interests regarding unhealthy food marketing . Instead of introducing strict new EU-wide regulations to address the impact of high-fat, high-salt, and high-sugar (HFSS) foods on childhood obesity, the Directive simply mandates EU Member States to promote the use of self-regulatory or co-regulatory codes by audiovisual media service providers, either independently or in collaboration with other sectors (e.g. food, advertising industry). This has led to ubiquitous exposure to unhealthy food marketing for children growing up across Europe due to the rise in powerful and persuasive advertising techniques.  

There is evidence to suggest that voluntary approaches have not been effective so far . Unfortunately, the EU Strategy on the Rights of the Child, released in March 2021, continues in this direction by committing the European Commission to “develop best practices and a voluntary code of conduct to reduce online marketing of high-sugar, high-fat, and high-salt products to children .” Although the AVMSD did not establish strict harmonized EU regulations on unhealthy food marketing, it does state that Member States should ensure that even self-regulatory codes “effectively reduce children’s exposure” to the marketing of high-fat, high-sugar, and high-salt foods.  

Considerations for health care systems 

Healthcare professionals hold a unique role in educating parents and children about the complex social and health-related aspects of both digital and traditional media. They should advise parents not only to monitor the amount of time their children spend consuming media but also to oversee the content they are exposed to. Integrating media literacy into standard health promotion services offered to families by healthcare workers is imperative. Encouraging parents and children to engage in media consumption together and assisting children in developing skills to sift through the overwhelming amount of information, analyze it critically, and discuss its significance are essential components of this initiative.   

Parents are strongly advised against permitting their children to have mass media devices, particularly televisions and unrestricted internet access, in their bedrooms. Pediatricians should promote comprehensive family discussions regarding internet usage and the supervision of online activities, rather than relying on electronic restrictions or surveillance applications, which are less effective and may lead to deteriorating communication within families. Efforts should be made to implement preventive and educational programs aimed at enhancing children’s cognitive abilities and increasing their awareness of mass media usage at the community level. These programs should ideally establish partnerships with kindergartens, schools, and even incorporate parental education into childbirth preparation classes. 

Communities should be equipped with the skills and knowledge to seek professional health information in mass media and to avoid misleading myths and distorting advertisements. At the state level, it is essential to raise awareness among society and stakeholders about the negative impact of uncontrolled exposure of children to the harmful influence of mass media, which constitutes a form of emotional abuse and neglect. Awareness and advocacy for the implementation of children’s protection regulations should align with the European policy statement “Health in all policies,” encompassing all significant mass media. The emergence and advancement of new communication technologies necessitate that states devote special attention to integrating health-promoting programs into the World Wide Web. Health protection policies should also disseminate scientific information regarding potential health hazards associated with mass media exposure and assess the potential benefits of implementing health protection regulations, with a focus on the internet, particularly through blogs and social media content. 

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