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International Journal of Behavioral Medicine2004, Vol. II, No. 3, 152-163 Copyright 2004 byLawrence Eribaum Associates, Inc.

Couch Kids: Correlates of Television Viewing Among YouthTrish Gorely, Simon J. Marshall, and Stuart J. H. Biddle

The purpose of this study w as to review the published empirical correlates of televi-sion/video viewing among youth (2 to 18 years). A descriptive semi-quantitative re-view was conducted based on 68 primary studies. Variables consistently associatedwith TV/video viewing were ethnicity (non-white +), parent income (-). parent educa-tion (-), body we ight ( + ) , between meal snacking (+), number of parents in the ho use(-), parents TV viewing habits (+), weekend (+ ) and having a TV in the bedroom (+).Variables consistently unrelated to TV/video viewing were sex, other indicators ofsocio-economic status, body fatness, cholesterol levels, aerobic fitness, strength,other indicators of fitness, self-perceptions, emotional support, physical activity,other diet variables, and being an only child. Few modifiable correlates have beenidentified. Further research should aim to iden tify modifiable correlates of TV/videoviewing ifinter\>entions are to be succ essfully tailored to reduce this aspect of inactiv-ity among youth.Keywo rds: television viewing, correlates, determinants, youth.

Physical activity is a key topic in behavioural medi-cine (Sallis & Owen, 1999). Low levels of physical ac-tivity among youtig people have increasingly become asource of public health concern (Biddle, Sallis, &Cav ill, 1998). Rapid increases in juve nile ove rweightand obesity across many industrialised countries(Chinn & Rona, 2001; Flegal. 1999; Troiano, Flegal,Kuczmarski, Campbell, & Johnson, 1995) have beenattributed partly to decreases in habitual physical activ-ity and increases in sedentary behaviour, such as televi-sion (TV) viewing. Despite the public health impor-tance of studying inactivity among young people, verylittle is known about the correlates of highly prevalentsedentary behaviours. This is partly because studies ofyouth inactivity are based on definitions of activity ab-sence (U.S. Department of Health and Human Ser-vices, 1996) or aggregates of multiple behavioursgrouped by energy cost (Maffeis. Zaffanello, &Schutz, 1997). While these measures estimate the

Trish Gorely, Brilish Heart Foundation Nationat Centre for Phys-ical Activity and Health. Loughborough University. Loughborough.United Kingdom: Simon J. Marshail. Department of Exercise andNutritional Sciences. San Diego State University. San Diego. Cali-fornia. USA; Stuart J. H. Biddle. British Heart Foundation Centre forPhysical Activity and Health. Loughborough University.Loughborough. United Kingdom.

This work was supported by a British Heart Foundation grant(PG/20(){)!24}, Trish Gorely and Simon J. Marshall shared lead au-thorship of this work.

Correspondence concerning this article should be addressed toTrish Gorely. British Heart Foundation National Centre for PhysicalActivity and Health, School of Sport and Exercise Sciences.Loughborough University. Loughborough. Leicestershire LEI 13TU, United Kingdom. E-mail: p.j.gorely@lboro,ac.uk

prevalence of inactivity in the population, they preventa clear explication of how inactive youth actuallyspend their time (Marshall, Biddle, Sallis, McKenzie.& Conway, 2002).Studying sedentary behaviour as a concept distinctfrom physical activity has been advocated recently(Owen, Leslie, Salmon, & Fotheringham, 2000). Many

young people find sedentary behaviours m ore reinforc-ing than physically active alternatives and appear morelikely to choose sedentary activities even when physi-cally active alternatives are freely available (Epstein,Smith, Vara, & Rodefen 1991; Vara & E pstein. 1993).Physical inactivity also appears to track better thanphysical activity from childhood to adolescence (Janz,Daw son. & Mahoney, 200 0; Pate et al., 1999; Raitakariet al., 1994; Robinson et al., 1993) suggesting it is amore stable behaviour. Research using behaviouraleconomic theory among samples of youth also demon-strates that reducing sedentary behaviour without spe-cifically targeting active behaviours can increase levelsof physical activity (Epstein & R oemm ich, 2{X)1). Th isis an important finding because reallocating smallamounts of sedentary time in favour of more active be-haviour has shown to significantly impact energy bal-ance and fitness in adults (Blair, Kohl, Gordon, &Paffenbarger, 1992) and it is reasonab le to suggest thatthis would also be true in children and youth.

The most prevalent sedentary behaviour amongyouth is TV viewing. Children and adolescents inmany industrialised countries report watching 2.5 to3.0 hr.dy-' (Gordon-Larsen, McMurray, & Popkin.1999; Roberts, Foehr, Rideout, & Brodie, 1999; WorldHealth Organisation. 2000). Moreover, approximately

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CORRELATES OF TV VIEWING IN YOUTHone third of adolescents watch more than 4 hr daily,which is twice that recommended by the AmericanAcademy of Pediatrics (2001). Because TV viewing isso prevalent and is hypothesised to displace physicalactivity and encourage overeating (French. Story. &Jeffery. 2001), it has been widely implicated in the aeti-ology of pediatric obesity (A ndersen, Crespo, B artlett,Cheskin, & Pratt. 1998; Dietz & Gortmaker, 1985;Gor tmakereta l . 1996) .

To help develop effective interventions to reducetelevision viewing and increase physical activity, con-sistent correlates of TV viewing, need to be identified,Baranowski, Anderson and Carmack (1998) arguedthat focusing interventions on strong and consistentmodifiable correlates of behaviour should be more ef-fective in changing behaviour. To date, no studies haveattempted to review consistent correlates of TV view-ing using a behavioural health perspective. Existing re-views have focused on the behavioural andpsychosocial outcomes of TV viewing (e.g., aggres-sion, academic achievement, cognitive development,prosocial beliefs, etc.), rather than on the modifiableantecedents that may be used as leverage points to re-duce TV viewing and increase physical activity. Thepurpose of this study is to present a descriptivesemiquantitative review of the published empiricalcorrelates of TV/video viewing among youth ages 2 to18 years with a view to better understanding a majorsedentary behaviour.

MethodPublished English-language studies were locatedfrom three sources. Firstly, the computerised data-bases MedLine (PubMed), OCLC FirstSearch andUnCover were searched. The following keywordcombinations were used: physical activity andsedentary behaviour, determinants, correlates,inactivity, television, video, computer games, youthand adolescence. Secondly, reference sections of nar-rative reviews and primary studies located from thefirst method were examined. Finally, a search of per-sonal files was conducted. Studies were limited tosamples comprising participants less than 18 years ofage (or where the majority of participants were lessthan 18 years old). A decision was m ade to not exam-ine correlates separately by developmental group(i,e.. infant, child, adolescent) because limited evi-dence was available to suggest that the number, typeor pattern of correlates is distinct across age groups.However, becau.se age has been studied frequently asa correlate itself, this variable was included in ouranalysis. Only papers, reports or abstracts that hadbeen published in English were included. Using onlypublished data is acknowledged as a limitation of the

review. An independent sample was used as the unit

of analysis. An independent sample was defined asthe smallest independent subsample (based on ageand gender) for which relevant data was reported(Cooper, 1998). For example, if a study reported find-ings separately for boys and girls, these were classedas two independent samples. Baseline data from lon-gitudinal studies and outcome data from experimentalstudies was abstracted.The variety of variables, measures, and samplespresent in the literature precluded a metaanalytic syn-thesis of data and so the review was conducted follow-ing the descriptive, semiquantitative review protocoloutlined by Sallis, Prochaska, and Taylor (2000) intheir examination of correlates of physical activity inyoung people. First, empirical correlates were identi-fied and categorised. Secon d, the direction of associa-tion with TV viewing was coded. Although numerousstatistics were reported in primary studies, coding re-flects whether correlates within independent samplesshowed a positive association (coded -i-), a negative as-sociation (coded - ) , or no association (coded 0) . An in-determinate code (Indeter) was assigned where the na-ture of the association was unclear. Finally, findings foreach variable were summ arised by calculating the per-centage of associations in a given direction (+, - , or 0).The pattern of percentages were examined and a finalsummary code of the association for a correlate derivedaccording to the following, A score of 60% or higher inany one direction was considered evidence for this pos-itive (summary code = +), negative {summary code =-) or nonassociation (summary code = 0). Where fouror more studies supported the summary association,the direction is indicated by a double sign (i.e.. -i-(-, ,00). A mixed pattern of associations below 60% wasconsidered evidence of an inconsistent association(summary code = ?). A summary code of two questionmarks (??) is used to indicate a variable that has beenfrequently studied (i.e., on 10 or more occasions) withconsiderable lack of consistency in the findings. Con-sistent with the recommendations of SalHs et al.(20(M)), final summary codes were computed only forvariables which had been studied on three or more oc-casions. For variables studied on less then three occa-sions, the summary code is denoted not applicable(N/A).

ResultsStudy Characteristics

Sixty-eight studies were located that presented anempirical association between TV viewing and at leastone correlate. Studies which included video/computergame playing in their measure of TV were excluded.The 68 studies presented data on 114 independent sam-ples (the unit of analysis). Table I provides adescription

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GOREI,Y. MARSHALL. BIDDLEof the samples by size, gender, age, data collectionmethod , recall period, units of recall, de sign and countryin which the sample was collecte d. The majority of sam-ples (70.2%) came from studies that were published af-ter 1995 and only 14.9% were published before 1990.The age range of participa nts was 2 to 18 years, Ind e-pendent sample sizes ranged from 22 to 20,766, with amedian of 444. Almost 17% had sample sizes less than100,36% between 100 and 500,11.4% between 500 and1,000, 30.7% between 1,000 and 4,999, and 5.3%greater than 5,000. The majority of samples (92%) as-sessed only TV viewing, with the rem ainder as.sessing acomposite of TV viewing and video viewing. In general,the measures of TV viewing relied on self-report(66.4%) or parental reports (19.5%) of behaviour andmost did not present psychometric data for the mea-sures. Few studies (3.5%) employed direct behaviouralobservation. Most studies employed cross-sectional de-signs (86%) with a few using longitudinal (12.3%),quasi-experimental (0,9%) or randomised controlledtrial (0.9%) designs. The majority of samples wereNorth American (71.9%).

Correlates of TV Viewing in YouthSimilar to Sallis et al, (2000) correlates weregrouped according to demographic variables (n = 7) ,health outcomes (n = 9), psychological factors (n = 4) ,behavioural attributes and skills (n = 5), social and cul-tural factors {n = 4), and physical environment factors(n = 4) . Table 2 presents a summary of the associationsbetween TV viewing and the correlates reviewed.The review identified seven demographic variables,and six were studied three or more times. Age was themost frequently studied (k = 35) although no co nsistentpatterns emerged. However, age-related effects are dif-ficult to identify using our coding protocol because in-dependent samples often cover a narrow age range.From visual inspection samples of children youngerthan 13 years generally showed positive relationshipsand samples involving children older than 13 yearsgenerally showed negative relationships. These dataalso suggest that peak viewing occurs between 9 and13 years of age, implying that the relationship may be

curvilinear. Sex showed no association with TV view-ing. Most studies found young people from ethnic mi-norities to watch more TV than white youth. AfricanAmerican children watched more TV than all otherethnic groups. While parent income and parent educa-tion levels were consistently negatively associatedwith TV viewing, other measures of socio-economicstatus (e.g., attending private school) showed no asso-ciation.Nine health outcome variables were identified ofwhich six had been studied on three or more occasions.The most frequently studied health outcome variable

was body fatness. In 39.5% of samples a positive asso-

ciation was found. However, all other samples revealedno relation, resulting in a nonassociation summarycode. Other health outcome variables to be studied onthree or more occasions were body w eight, cholesterol,aerobic fitness, strength, and other fitness indicators(e.g., flexibility). In three out of four studies, bodyweight showed a positive relationship with TV view-ing. Blood cholesterol levels were unrelated to TVviewing, as were all indicators of fitness.

Three psychological factors (cognitive functioning,self-perceptions and emotional support) had been stud-ied on three or more occasions but all showed an incon-sistent or zero relationship with TV viewing. All fivebehavioural attribute and skill variables had been stud-ied on three or m ore occasions. The most studied vari-able was physical activity. The relationship is best de-scribed as zero with 76% of samples showing noassociation. TV viewing appears to increase be-tween-meal snacking but was inconsistently related tochild prompting for and choosing TV-advertised foods,and actual dietary fat intake. Other dietary behaviourssuch as caloric intake, total energy intake, and food va-riety appear unrelated to TV viewing. Relationshipswith dietary behaviours may be mediated by nutritionknowledge, although only one study (Gracey et al.,1996) has examined this variable.Four social and cultural factors have been studiedon three or more occasions. Young people in sin-gle-parent/guardian families consistently watch moreTV than those from two-parent/guardian families. TVviewing appears unrelated to being an only child andinconsistently related to the mother's employment sta-

tus, however these effects may be confounded bysocioeconomic status. TV viewing in young people ispositively associated with parental viewing habits.Of the physical environment factors, residential lo-cation, day of viewing and availability of TV sets in thehouse have received empirical study on three or moreoccasions. From these studies, it remains equivocalover whether young people in urban areas watch moreor less TV than those in rural areas. However, youngpeople do appear to watch more TV during the week-end than during the week. A small number of studiesshow a positive relationship between having a TV set

in the bedroom and the amount of TV viewed.

DiscussionThe purpose of this study was to review the pub-lished empirical correlates of TV/video viewingamong youth aged 2 to 18 years. Television viewingwas chosen because it is a highly prevalent sedentarybehaviour in young people that has been implicated inthe aetiology of pediatric obesity (Andersen et al.,

1998; Dietz & Gortmaker. 1985; Gortmaker et al.,1996), Understanding the consistent m odifiable corre-

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