Television Time and the Relationship to Obesity in Adults with Visual Impairments

By Elizabeth K. Lenz, Brooke E. Starkoff, John T. Foley, and Lauren J. Lieberman

Dr. Elizabeth K. Lenz, Department of Kinesiology, Sport Studies, and Physical Education, The College at Brockport, State University of New York.

Dr. Brooke E. Starkoff, Department of Kinesiology, Sport Studies, and Physical Education, The College at Brockport, State University of New York.

Dr. John T. Foley, Department of Physical Education, State University of New York, College at Cortland.

Dr. Lauren J. Lieberman, Department of Kinesiology, Sport Studies, and Physical Education, The College at Brockport, State University of New York.

Abstract

Introduction:Television and movie watching (TV time) has been linked to deleterious health outcomes. TV time of individuals with visual impairments (VI) and the relationship between TV time and body mass index was explored. Methods: Participants (N = 140; M = 36, SD = 13.3 years) classified as B1-B4 levels of VI completed the Patient-centered Assessment and Counseling for Exercise Sedentary Behavior Questionnaire. Results: TV time was greater on the weekends, with a larger percentage of individuals watching > 2 hours on weekends compared to weekdays (χ2 (1) = 36.73, p < 0.01). On the weekends, a difference in TV time between visual acuity was noted in males (χ2 (8) = 17.16, p = 0.03). Individuals who engaged in more than 2 hours of TV time during the weekday were 2.89 times more likely to be obese compared to those watching less than 2 hours of TV (p = 0.036). Conclusion: Those spending more than 2 hours watching TV on weekdays were more likely to be obese. Therefore, excessive TV time may play a substantial role in contributing to obesity in individuals with VI.

Keywords

Visual impairment, sedentary behavior, PACE+ SBQ, physical activity, blind, body mass index

Introduction

Television (TV) viewing has been identified as one of the most common sedentary activities among Americans of all ages. Over the last 60 years, Americans have more than doubled the number of hours per day spent viewing TV (Brownson, Boehmer, & Luke, 2005). This could be attributed to the increase in avenues by which TV can be watched via tablets, computers, and smartphones. We are now able to watch TV more frequently and in many more locations than in previous years.the 2013 American Time Use Survey data from the Bureau of Labor Statistics report, Americans 15 years of age and older spend an average of 2.8 hours per day watching TV (U. S. Department of Labor, 2014).

Recent studies have found that the amount of time spent watching television and videos (“TV time”) has been independently linked to increased waist circumference, percent body fat, increased body mass index (BMI), blood pressure, and impaired glucose metabolism in adults (Healy et al., 2008; Hu, Li, Colditz, Willett, & Manson, 2003; Thorp et al., 2009). TV time typically does not contribute to the engagement of significant muscle mass and displaces the opportunity to participate in energy expending activities including light, moderate, and vigorous physical activity. Ultimately, excessive TV time, even 2 hours or more per day may increase the risk for cardiovascular complications, metabolic disease, and even all-cause mortality (Stamatakis, Hamer, & Dunstan, 2011). While no national recommendations have been made regarding TV time for adults, the American Association for Pediatrics recommends limiting TV to 1 – 2 hours per day at most for children (Certain & Kahn, 2002). Furthermore, many studies examining TV time in adults also recommend limiting leisure screen time to 2 hours or less per day, including watching TV/movies, being on the computer, and playing video games (Healy et al., 2008; Stamatakis et al., 2011; Starkoff & Lenz, 2015). 

Individuals with visual impairments (VI) may face even greater risk of acquiring disease as a result of TV time. These individuals, as a result of their condition, have been found to spend significant time participating in TV time. Consequences of VI may include several barriers that prohibit individuals with VI from participating in physical activity and may contribute to increased sedentary behavior, including TV time (Crews & Campbell, 2001; Kirchner, Gerber, & Smith, 2008). Subsequently, this population is at a higher risk for disease associated with excessive sitting time potentially due to TV time.

Nonetheless, there is little research examining TV time among individuals with VI. Therefore, it is of particular importance to identify the trends in the population of individuals with VI, not only to improve health, but also specifically to reduce the onset of secondary conditions, which are common to individuals with disabilities and often a result of prolonged TV time. Therefore, the purpose of our study was to profile the television viewing habits of adult men and women with VI in free-living environments.

Methods

This was a cross-sectional study, designed to examine the magnitude of TV time in adults with varying levels of VI who were participating in the Wellpoint National Fitness Challenge sponsored by the United States Association of Blind Athletes (USABA). During the process of registering online for the Wellpoint National Fitness Challenge, participants were informed about the study. Interested participants read and signed an online informed consent document approved by the University’s Institutional Review Board and the USABA. Eligible participants then completed a demographics questionnaire and the Patient-centered Assessment and Counseling for Exercise (PACE+) Sedentary Behavior Questionnaire (SBQ) for adults (Sallis, n.d.).

Participants

A total of 227 participants were recruited from 35 affiliation sites in 21 states in the United States. One hundred and forty individuals successfully completed the present study (71 males and 69 females) (Table 1). The participants were approximately M = 36, SD = 13.3 years of age and Caucasian (60%), having completed college and/or graduate school (48.6%), a household income of ≤ $49,000 (32.3%), a congenital VI (40.7%), and a visual acuity classification of B3 (30%). Participant VI and acuity characteristics are found in Table 2. Visual Acuity classifications are based on those used by the International Blind Sports Federation (IBSA) and the USABA: B1 = from no light perception in either eye up to light perception, but inability to recognize the shape of a hand at any distance or in any direction; B2 = from ability to recognize the shape of a hand up to visual acuity of 20/600 and/or a visual field of less than five degrees in the better eye with the best practical eye correction; B3 = from visual acuity above 20/600 and up to visual acuity of 20/200 and/or a visual field of less than 20 degrees and more than five degrees in the better eye with the best practical eye correction; B4 = from visual acuity above 20/200 and up to visual acuity of 20/70 and a visual field larger than 20 degrees in the better eye with the best practical eye correction (Lieberman, Ponchillia, & Ponchillia, 2012).

Questionnaires and Anthropometrics

All participants were asked to complete an online demographics questionnaire. This form inquired about age, gender, ethnicity and race, household income, and VI and acuity, as well as self-reported height (inches) and body weight (pounds). The anthropometric information was then used to estimate body size via body mass index (BMI) by dividing body weight (lb)/[height (in)]2 x 703. Participant anthropometric characteristics are found in Tables 1 and 2.

Table 1. Participant Characteristics by Gender and for the Entire Group

 

Males (n = 71)

Females (n = 69)

All (N = 140)

Age (yrs)

36.1 ± 14.2

35.9 ± 12.3

36.03 ± 13.3

Height (in)

69.2 ± 2.7*

64.3 ± 2.7

66.8 ± 3.6

Weight (lbs)

193.3 ± 45.0*

170.1 ± 50.2

181.9 ± 48.9

BMI

28.5 ± 6.7

29 ± 8.3

28.7 ± 7.5

*= p < 0.05
Note: yrs = years; in = inches; lbs = pounds; BMI = Body Mass Index = weight (lb)/[height (in)]2 x 703.

Table 2. Participant Characteristics by Visual Acuity for Males, Females, and Entire Group


 

B1
Males (n=15)

B1 Females (n=17)

B1
All
(N=32)

B2
Males (n=14)

B2 Females (n=16)

B2
All
(N=30)

B3
Males (n=24)

B3 Females (n=18)

B3
All
(N=42)

B4
Males (n=18)

B4 Females (n=18)

B4
All
(N=36)

Age (yrs)

40.5±15.4

39.3±9.3

39.9±12.4

34.2±12.9

28.7±7.9

31.2±10.7

36.8±14.8

36.1±13.1

36.5±14

32.9±13.6

39±14.9

36±14.4

Ht (in)

69.2±2.9*

63.1±2.4

65.9±4.1

69.4±2.6*

65.3±2.3

67.2±3.2

68.5±2.4*

64.6±3.5

66.8±3.5

70±3*

64.5±2.1

67.2±3.8

Wt  (lbs)

194.1±35*

161.8±39.8

176.9±40.5

195.9±34*

179.1±51.6

186.9±44.4

190.5±55.2*

167.6±40.8

180.7±50.3

194.5±48*

172.5±66.3

183.5±58.1

BMI

28.6±4.7

28.8±7.4

28.7±6.2

28.7± 4.9

29.7± 8.8

29.2±7.2

28.7±8.8

28.4±6.9

28.5±7.9

27.9±6.5

29.1±10.3

28.5±8.5


*= p < 0.05
Note: yrs = years; ht = height; in = inches; lbs = pounds; Body Mass Index = BMI = weight (lb)/[height (in)]2 x 703.

Participants were then provided with written instructions for the completion of the PACE+ SBQ survey (Rosenberg et al., 2010; Sallis, n.d.). The PACE+ SBQ is a tool designed to measure nine specific sedentary activities on a typical weekday and weekend day. The survey was originally adapted from a measurement used in children. The SBQ was one of several measures designed for studies of overweight individuals and is based on social cognitive theory and the transtheoretical model of behavior change (Norman, Schmid, Sallis, Calfas, & Patrick, 2005). Previous research has shown the SBQ to be valid and reliable among overweight adults (Rosenberg et al., 2010).

The first section of the survey asked, “On a typical WEEKDAY, how much time do you spend (from when you wake up until you go to bed) doing the following?” The activities listed were: watching television (including videos on VCR/DVD); playing computer or video games; sitting listening to music on the radio, tapes, or CDs; sitting and talking on the phone; doing paperwork or computer work (office work, emails, paying bills, etc.); sitting reading a book or magazine; playing a musical instrument; doing artwork or crafts; and sitting and driving in a car, bus, or train. The second section of the survey asked the same questions, but in reference to weekend days. There were nine time choices per activity that participants could choose, ranging from zero minutes to six or more hours. The present study focused on examining TV time only.

Data Analysis

The Patient-centered Assessment & Counseling for Exercise (PACE+) Sedentary Behavior Questionnaire (SBQ)

All PACE+ SBQ surveys were examined for missing data. All nine time frames were entered into a database and coded as a number (e.g., none = 0, 15 minutes or less = 0.25, 30 minutes = 0.5, 1 hour = 1, etc.) specific to each of the nine sedentary activities on the survey for both the weekday and weekend day. Participants were not included in the study if they answered a question with more than one answer or did not complete the survey.

Statistical Analysis

The statistical analysis was conducted with STATA® V.12 (StataCorp, LP, 2011). The descriptive analysis was presented in the following tables as mean ± standard deviation for demographic and anthropometric information. Frequencies were reported for VI and acuity classifications, income, education, race, and ethnicity. Chi-square tests were conducted to examine weekday and weekend differences in TV time by gender and visual acuity classifications. A logistic regression is used to better understand the relationships between obesity (BMI ≥ 30 kg/m2) and the following variables: TV time during week and weekend days, visual acuity, age, and gender. Significance for all analysis was set a priori at p < 0.05.

Results

Overall, there was a different pattern in TV time between the weekday and weekend. On average individuals in the present study watched TV between 30-120 minutes on a typical weekday with 47.1% of the sample reporting 1-2 hours of TV viewing per day. In regard to watching TV on the weekends, 40% of the sample reported 1-2 hours and 28.6% reported 3-4 hours of TV viewing. During weekdays, 22.86% of the individuals surveyed spent more than 2 hours with TV time, while on the weekend that number significantly increased to 38.57% (χ2 (1) = 36.73, p < 0.01). The number of individuals who reported no TV time was consistent between weekday (10.00%) and weekend days (10.71%).

During a typical weekday, there were no significant differences in TV time for both the males and the females between those with no vision and those with some sight (Table 3). However, for weekend days there were significant differences in TV viewing hours for the males between visual acuity, across TV time (χ2 (8) = 17.16, p = 0.03), but not for the females (Table 4).

Table 3. Weekday TV Time by Gender and Visual Acuity

TV Time

Male
B2-B4

Male
B1

Male Total

Female
B2-B4

Female B1

Female Total

None

4 (7.14%)

3 (20.00%)

7 (9.86%)

5 (9.62%)

2 (11.76%)

7 (10.14%)

< 15 mins

3 (5.36%)

1 (6.67%)

4 (5.63%)

3 (5.77%)

2 (11.76%)

5 (7.25%)

30 mins

5 (8.93%)

3 (20.00%)

8 (11.27%)

10 (19.23%)

1 (5.88%)

11 (15.94%)

1 hr

15 (26.79%)

4 (26.67%)

19 (26.76%)

9 (17.31%)

7 (41.18%)

16 (23.19%)

2 hrs

15 (26.79%)

2 (13.33%)

17 (23.94%)

12 (23.08%)

2 (11.76%)

14 (20.29%)

3 hrs

5 (8.93%)

2 (13.33%)

7 (9.86%)

8 (15.38%)

1 (5.88%)

9 (13.04%)

4 hrs

4 (7.14%)

0 (0%)

4 (5.63%)

2 (3.85%)

1 (5.88%)

3 (4.35%)

5 hrs

3 (5.36%)

0 (0%)

3 (4.23%)

3 (5.77%)

1 (5.88%)

4 (5.8%)

> 6 hrs

2 (3.57%)

0 (0%)

2 (2.82%)

0 (0%)

0 (0%)

0 (0%)

Total

56

15

71

52

17

69

Table 4. Weekend TV Time by Gender and Visual Acuity

TV Time

Male
B2-B4

Male
B1

Male
Total

Female
B2-B4

Female
B1

Female Total

None

4 (7.14%)

5 (33.33%)

9 (12.68%)

3 (5.77%)

3 (17.65%)

6 (8.70%)

< 15 min

2 (3.57%)

1 (6.67%)

3 (4.23%)

2 (3.85%)

1 (5.88%)

3 (4.35%)

30 mins

1 (1.79%)

1 (6.67%)

2 (2.82%)

6 (11.54%)

1 (5.88%)

7 (10.14%)

1 hr

7 (12.50%)

5 (33.33%)

12 (16.9%)

6 (11.54%)

4 (23.53%)

10 (14.49%)

2 hrs

16 (28.57%)

2 (13.33%)

18 (25.35%)

13 (25.00%)

3 (17.65%)

16 (23.19%)

3 hrs

8 (14.29%)

1 (6.67%)

9 (12.68%)

7 (13.46%)

2 (11.76%)

9 (13.04%)

4 hrs

11 (19.64%)

0 (0%)

11 (15.49%)

10 (19.23%)

1 (5.88%)

11 (15.94%)

5 hrs

6 (10.71%)

0 (0%)

6 (8.45%)

1 (1.92%)

1 (5.88%)

2 (2.9%)

> 6 hrs

1 (1.79%)

0 (0%)

1 (1.41%)

4 (7.69%)

1 (5.88%)

5 (7.25%)

Total

56

15

71

52

17

69

There was a significant relationship between watching TV during the weekday and being obese while accounting for age, gender, and visual acuity as seen in Table 5. Those who watched TV for two hours or more during the weekday were 2.89 times more likely to be obese (p = 0.036; 95% confidence interval, 1.07-7.79). Television time of two hours or more during the weekend was not a significant predictor in being obese.

Table 5. The Relationship Between Obesity (BMI ≥ 30 kg/m2) and TV Time During Week and Weekend Days, Visual Acuity, Age, and Gender.

 

OR

SE

Z

p

95% CI

Gender

1.19

0.44

0.47

0.64

0.58-2.46

Age

1.00

0.01

-0.04

0.96

0.97-1.03

Weekday TV

2.89

1.46

2.10

0.04

1.07-7.79

Weekend TV

1.63

0.73

1.09

0.28

0.68-3.93

VA Classification

 

 

 

 

 

B2

1.20

0.66

0.33

0.74

0.41-3.54

B3

0.45

0.25

-1.44

0.15

0.15-1.33

B4

0.90

0.48

-0.20

0.84

0.31-2.57

Reference group = females with B1 visual acuity watching TV less than 2 hours/day
Note: VA = visual acuity

Discussion

In this study, 140 participants with VI completed the PACE+ SBQ and demographic information. The results revealed the most significant differences in TV time were between BMI and visual acuity. In particular, one major finding in our study showed that individuals with obesity spent significantly more time watching TV or videos than those in the healthy weight category, on both weekdays and weekends. Several studies have identified a link between TV time and increased risk of obesity in adults (Heinonen et al., 2013; Hu et al., 2003; Inoue et al., 2012; Maher, Mire, Harrington, Staiano, & Katzmarzyk, 2013; Salmon, Bauman, Crawford, Timperio, & Owen, 2000; Smith, Fisher, & Hamer, 2015; Vioque, Torres, & Quiles, 2000; Williams, Raynor, & Ciccolo, 2008).  

Currently in the United States, 68.7% of adults are classified as overweight or obese as defined by a BMI ≥ 25 kg/m2 (Fryar, Carroll, & Ogden, 2012). Even more alarming is the trend in obesity among individuals with disabilities, specifically those with VI (Holbrook, Caputo, Perry, Fuller, & Morgan, 2009). Some research has even reported that the odds of obesity for persons with blindness or low vision is 1.5 times greater than the general population (Weil et al., 2002). However, our data was not consistent with these findings and revealed a similar prevalence of overweight and obesity (67.9%) to the general population. One reason for the similarities may be due to the fact that our participants may have been more involved with physical activity and wellness compared to other individuals with VI due to the nature of the sample pooled. Yet the average BMI in our study of 28.7 kg/m2 indicates that our participants were still overweight.

A significant contributing factor to overweight and obesity is prolonged time with sedentary activities. Excessive participation with TV time, for example, replaces time where individuals could be physically active and achieve greater energy expenditure. Instead, TV time results in low energy expenditure, and low muscle mass recruitment, ultimately increasing the risk of overweight and obesity along with the potential development of several diseases (Owen, Sparling, Healy, Dunstan, & Matthews, 2010; Starkoff & Lenz, 2015). Our participants demonstrated substantial TV time comparable to the amount attained among their sighted peers.

Not only are there dangers associated with inactivity, but also the passive sedentary activity of watching TV and videos is often further accompanied by increased caloric consumption. This may be of particular importance due to the association of energy intake while watching TV in children (Epstein, Roemmich, Paluch, & Raynor, 2005; Robinson, 1999). However, more active sedentary behaviors, such as reading, have not been linked to increased caloric consumption or cardiometabolic disease. Therefore, compared to other involved sedentary activities, TV time may be a substantial contributor to obesity.  

Our study also identified greater TV time for those with higher acuity levels. We found no significant relationship between BMI and visual acuity, but perhaps those with higher visual acuity may be at a greater risk for overweight and obesity compared to those with lower vision. This may be of particular concern for males who self-reported watching TV for at least one hour more than women during the week and two or more hours more on the weekend (Tables 3 & 4). This difference in TV time may be the reason for the differences between visual acuity in males, rather than a result of the actual visual acuity. However, these results differ from the findings of Ray, Horvat, Williams, and Blasch (2007) who identified a negative correlation between BMI and visual acuity, such that those with higher vision have lower BMI values.

In the current study, it was apparent that having a VI does not prohibit individuals from TV time. However, TV time does not have to remain entirely inactive and can be transformed into more active recreational pursuits with some creativity and proactive thinking. For example, while engaged in TV time, individuals can also participate in a variety of other activities such as household chores including doing laundry, cooking, and cleaning. Furthermore, most individuals can also use this time to participate in some exercises such as wall sits, push-ups, sit-ups, free weights, yoga, jumping jacks, walking around the house, or marching in place. There are also several brands of stationary bikes and treadmills that have TV’s in them that can be utilized so the participant can watch TV and exercise at the same time if desired.

Limitations

One major limitation of the study is that the information collected was self-reported. Therefore, heights and weights may not have been accurate, skewing our BMI values. Furthermore, assessment of time spent on average weekday and weekend day TV time was also self-reported, and may have been under- or over-reported. Specifically, some subjects may not accurately report negative habits, specifically sedentary behaviors. In addition, there may have been some confusion in correctly completing the SBQ in regards to TV time. While the survey directly asks about “Watching television (including videos on VCR/DVD),” the question does not account for the more recent methods of watching TV and movies (tablets, computers, and smartphones). Therefore, participants may have only reported time spent actually in front of a television and not the cumulative amount of time watching TV and videos by other means. Furthermore, watching TV from more mobile devices may allow for concurrent physical activity (walking and watching TV), thereby negating the traditional sedentary connotation associated with TV viewing. Future research should use a multi-method approach, including a combination of objective and subjective assessments of TV time and allowing for a more specific distinction of and definition for TV time. Another limitation of the study is that the participants in this study were a part of a USABA sponsored program so the results may not be representative of all adults with VI. Participant’s involvement with the program potentially implies that they are athletic or are interested in participating in recreational and athletic activities, which may not necessarily be common in all adults with VI. 

In conclusion, our study examined the self-reported TV time of individuals with VI. Individuals with VI frequently engaged in increased TV time of more than two hours per day. Furthermore there was a relationship between BMI and TV time such that greater TV and video watching was identified in those with obesity compared to healthy weight participants. Visual acuity was also related to engagement in TV time. Specifically, individuals with higher visual acuity spent more time watching television and videos. These findings have a substantial impact on the health of individuals with VI. Interventions should be implemented to assist individuals with VI in reducing TV time, potentially by incorporating short bursts of activity during TV time.

Implications for Practitioners and Families

Individuals with VI may engage in greater amounts of TV time than the two hours or less that is recommended. To avoid the subsequent negative impact on overall health, including weight, these individuals should find ways to reduce time spent watching TV and movies. If reducing TV time is initially challenging, this otherwise sedentary activity can be transformed into a more active recreational pursuit with some creativity and proactive thinking. For example, while engaging in TV time, individuals can simultaneously participate in activities such as circuit-type exercises (wall-sits, jumping jacks, walking in place, etc.) or household chores (cleaning, making dinner, etc.). It may also be helpful to limit TV time to one hour by setting a timer for 60 minutes and having the individual get up and move for at least 5 minutes every hour. Rehabilitation professionals may also act as an avenue to assist individuals with VI by incorporating more activity into their daily routine. These professionals can help educate those with VI on the dangers of excessive sitting and can encourage them to swap out sedentary activities with more active ones, including playing games, going for a walk, and even engaging in exergames. In short, excessive time sitting, specifically with activities like watching TV and movies, may contribute to obesity in those with VI. Therefore, it is exceedingly important and highly recommended to implement methods to spend more time moving and less time sitting.

Acknowledgements

Thank you to the Institute on Movement Studies for Individuals with Visual Impairments and Camp Abilities for their generous support for this research study.

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