Association between television viewing and obesity in Peruvian women

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1 Rev Súde Públic Julio A Poterico I Antonio Bernbé-Ortiz I,II Christin Loret de Mol I,III,IV J Jime Mirnd I,V Assocition between television viewing nd obesity in Peruvin women ABSTRACT I Centro de Excelenci en Enfermeddes Crônics. Universidd Perun Cyetno Heredi. Lim, Perú II Unidd de Epidemiologí, Fcultd de Slud Públic y Administrción, Universidd Perun Cyetno Heredi. Lim, Perú III Progrm de Pós-Grdução em Epidemiologi, Universidde Federl de Pelots. Pelots, RS, Brsil OBJECTIVE: To ssess the ssocition between frequency of television viewing, overweight nd obesity in ntionlly representtive smple of Peruvin women. METHODS: Secondry nlysis of the Demogrphic nd Helth Survey 2008 including women ged from 15 to 49 yers old. The outcome vribles were obesity (body mss index 30 kg/m 2 ) nd overweight (body mss index 25 but < 30 kg/m 2 ) wheres the exposure vrible ws frequency of television viewing (never, occsionlly, lmost every dy). Logistic regression tking into ccount the multistge study design nd djusting for potentil confounders ws used. Results were presented s djusted odds rtios (OR) with 95% confidence intervls (95%CI). RESULTS: A totl of 21,712 women were included in the nlysis. The prevlence of overweight ws 34.7% (95%CI 33.8%;35.7%), nd obesity prevlence ws 14.3% (95%CI 13.6%;15.1%). Compred to women who never wtched television, those who reported wtching television occsionlly nd lmost dily were more likely to be obese: OR 1.7 (95%CI 1.3; 2.3) nd OR 2.6 (95%CI 2.0;3.5), respectively. The mgnitude of this ssocition ws lower for overweight: OR 1.2 (95CI 1.3;2.3) nd OR 1.6 (95%CI 1.1;1.4), respectively. The strength of the ssocition ws greter in urbn res. CONCLUSIONS: Frequency of television viewing ws ssocited with overweight nd obesity in Peruvin women nd the strength of this ssocition vried by re of residence. These findings cn provide input to strtegies for obesity prevention in the Peruvin context. DESCRIPTORS: Women. Obesity, epidemiology. Sedentry Lifestyle. Television, utiliztion. Helth Surveys. IV Grupo Ltinomericno de Investigciones Epidemiológics. Orgnizción Ltinomericn pr el Fomento de l Investigción en Slud. Bucrmng, Colombi V Deprtmento de Medicin. Fcultd de Medicin, Universidd Perun Cyetno Heredi. Lim, Perú Correspondence: Julio A. Poterico Av. Armendriz 497, 2 do piso Mirflores, Lim 18, Perú E-mil: julio.poterico@upch.pe Received: 7/15/2011 Approved: 3/11/2012 Article vilble from: INTRODUCTION Severl chronic conditions including obesity hve significntly incresed in recent yers, especilly in developing countries. 19 At the sme time there hs been n increse in crdiovsculr deths in Peru. 10 Certin ctivities such s television viewing for severl hours my contribute to sedentry lifestyle with incresed cloric intke nd low levels of physicl ctivity predisposing to overweight nd obesity, which in turn contributes to the development of chronic non-communicble diseses (NCDs). 13 The ssocition between frequency of television viewing nd obesity hs been described in previous studies in dults, 9 dolescents, 23 nd children. 7 Moreover, frequent television viewing during childhood nd dolescence predicts the onset of obesity in dulthood. 8,24 This sedentry ctivity is ssocited with crdiovsculr diseses including obesity, metbolic syndrome, nd type 2 dibetes

2 Television viewing nd obesity Poterico JA et l mellitus. 4,9 A prospective study crried out in British dults found n independent ssocition between frequency of television viewing nd mortlity from ll cuses including those from crdiovsculr diseses. 25 In the light of the epidemiologicl 10 nd nutritionl trnsition 17 tht Peruvin society is experiencing, it is crucil to better understnd potentil risk fctors ssocited with high rtes of obesity. Thus, the present study imed to ssess the ssocition between frequency of television viewing nd obesity in women. METHODS Cross-sectionl study tht nlyzed secondry dt from the Peruvin Ntionl Demogrphic nd Helth Survey (DHS) conducted by the Ntionl Institute of Sttistics nd Informtics in 2008 (ENDES Líne de Bse). This survey is regulrly conducted s prt of the DHS globl progrm. It hs multistge, self-weighted design using rndom smpling of res nd representtive popultion t the ntionl level. According to the World Bnk, Peru is n upper-middle income country with n estimted popultion of 29 million people. About 80% of the popultion lives in urbn res, nd bout 30% re below the poverty line. The officil lnguge is Spnish, but there re other ntive lnguges spoken in Peru such s Quechu nd Aymr, mong others, especilly spoken in Anden nd jungle res. The DHS is ntionl survey conducted in urbn nd rurl res of 24 deprtments in Peru. The DHS 2008 comprised women ged between 15 nd 49 yers. A totl of 1,097 clusters were selected comprising 29,196 households. There ws collected sociodemogrphic nd helth informtion, including nthropometric mesurements. In rurl res, primry smpling units were villges with 500 to 2,000 inhbitnts. In urbn res, primry smpling units were blocks or groups of blocks tht together consisted on verge of 120 households. The secondry units of nlysis for both rurl nd urbn res were privte households, which were prt of their corresponding primry smpling units. The study outcomes were obesity nd overweight, evluted using the body mss index (BMI). Both weight nd height were mesured using stndrd techniques. Weight mesures were tken with light clothing nd without shoes, using n electronic blnce with 0.1 kg precision. Height ws mesured using mesuring tpe to the nerest 0.1cm. Obesity nd overweight were defined ccording to interntionl stndrds s BMI 30 kg/m 2 nd BMI 25 but < 30 kg/m 2 ; respectively. Norml weight ws defined s BMI between 18.5 nd 24.9 kg/m 2. 1 The exposure of interest ws self-reported frequency of television viewing. Following the DHS methodology, respondents were sked: Do you wtch television lmost every dy, t lest once week, severl times week or never? Of ll respondents, 2.7% nswered t lest once week. Thus, the exposure vrible nlyzed ws divided into three ctegories: lmost every dy; occsionlly (severl times week nd t lest once week); nd never. The covrites used in the nlysis were: ge (5-yer ge groups); re of residence (urbn or rurl); ssets index (used s proxy for socioeconomic sttus); qurtiles of eduction level (bsed on yers of schooling); nd self-reported current smoking (yes/no). The vribles ssets index nd eduction level were divided into qurtiles seprtely for both rurl nd urbn res. The ssets index, including owing television, nd therefore the frequency of television viewing, vries by re of residence. Moreover, it hs been reported tht the prevlence of obesity in Peru vries by re (urbn or rurl) nd socioeconomic sttus. 20 For sttisticl nlysis we used Stt version 11 (SttCorp LP, College Sttion, TX, U.S.). Weighted estimtes were obtined tking into ccount the complex design of the DHS Thus, both descriptive nlyses, nd univrite nd multivrite models were performed using the svy commnd for complex smple designs. Proportions were compred using the chi-squre test. We used logistic regression nlysis to ssess the ssocition between frequency of television viewing nd obesity nd overweight, using those with norml BMI (BMI kg/m 2 ) ) s reference group. We clculted crude (OR) nd djusted odds rtios (OR) nd their relted 95% confidence intervls (95% CI). The vribles re of residence nd eduction level were nlyzed s potentil effect modifiers bsed on previous finding of our reserch group. 20 Vribles tht showed no significnce were ssessed s potentil confounders. The study ws pproved by the Institutionl Ethics Committee of the Universidd Perun Cyetno Heredi (Protocol number: SIDISI 58833, 2011). RESULTS A totl of 31,911 women were included in the ntionl survey; 10,199 (32.0%) were excluded for the following The World Bnk. Peru: Dt.[cited 2012 My 14] Avilble from:

3 Rev Súde Públic resons: BMI dt not vilble (n = 8,645); pregnncy (n = 1,102); low weight or BMI < 18.5 kg/m 2 (n = 439); nd foreign lnguge spoken t home (n = 13). A totl of 21,712 women were included in the nlysis. The men ge of respondents ws 30.6 yers old (SD ± 10.1). The overll prevlence of overweight ws 34.7% (95%CI 33.8;35.7) while the prevlence of obesity ws 14.3% (95%CI 13.6;15.1). The prevlence of overweight nd obesity ws 32.2% (95%CI 30.7; 33.8) nd 8.5% (95%CI 7.6;9.5) in rurl res nd 35.7% (95%CI 34.5;36.8) nd 16.5% (95%CI 15.6;17.5) in urbn res, respectively. Tble 1 shows the study vribles when BMI dt ws vilble nd when it ws not vilble. Tble 2 shows the demogrphic chrcteristics of the study popultion with overweight nd obesity. Of ll respondents, 92.1% in urbn res nd 41.8% in rurl res reported hving television set t home (p < ). The highest proportions of obesity were found mong women who reported television viewing occsionlly nd lmost every dy. The prevlence of obesity ws lower in those with lower ssets index nd higher in those with lower eduction level (Tble 3). We found n ssocition between frequency of television viewing nd both obesity nd overweight (Tble 3). The mgnitude of this ssocition ws more pronounced in the estimtes of ssocition with obesity nd those who reported greter frequency of television viewing (Tble 3). When we ssessed whether the strength of ssocition vried ccording to re of residence, stronger ssocition with obesity ws found in urbn (OR = 2.2, 95%CI 1.3;3.5) thn rurl re (OR = 1.6, 95%CI 1.1;2.4). Similr results were found with overweight in urbn nd rurl res (OR = 1.8; 95%CI 1.2;2.7 nd OR = 1.3, 95%CI 1.1;1.7, respectively). However, these ssocitions were ttenuted mong the ctegory of those who reported occsionl hbit of wtching television. DISCUSSION This study conducted in Peru, trnsitionl country with specific geogrphicl nd socioeconomic vritions, evidenced strong ssocition between frequency of television viewing nd obesity mong Peruvin women ged 15 to 49. This ssocition remined fter djusting for potentil confounders such s ge, re of residence, eduction level, ssets index nd self-reported current smoking. Also, the ssocition between frequency of television viewing nd obesity ws stronger in women living in urbn res. Obesity is n incresing public helth concern in severl developing countries, 19 including Peru. An nlysis Tble 1. Chrcteristics of respondents ccording to the vilbility of body mss index dt. Peru, Vrible BMI dt BMI dt not vilble % % p-vlue Frequency of television viewing n = 23,264 n = 7,940 Never Occsionlly < Almost every dy Assets index n = 23,252 n=8,199 1 st (lowest) nd rd th (highest) Eduction level n = 23,252 n = 7,930 1 st (lowest) nd rd th (highest) Age (yers) n = 23,252 n = 7, Self-reported current smoking n = 22,164 n = 7,931 No Yes Are of residence n = 23,252 n = 8,635 Urbn Rurl Differences in proportions were determined by the Chisqure test. BMI: body mss index of DHS 1996 showed 9.4% prevlence of obesity in Peruvin women. 15 Dt from the DHS 2008 showed 14.3% prevlence of obesity, which is n increse by 52% in obesity rtes in Peruvin women. Our study explored the ssocition between frequency of television viewing nd obesity, corroborting findings of studies conducted in developed countries. Previous studies hve shown n ssocition between frequency of television viewing nd obesity. Tucker 22 reported in the Nurses Helth Study tht women who wtched television t lest four hours dy were twice

4 Television viewing nd obesity Poterico JA et l Tble 2. Chrcteristics of the study popultion ccording to nutritionl sttus. Peru, Popultion Norml weight Overweight Obesity Vribles n % % % % p-vlue b n = 21,712 n = 11,113 n =7,503 n = 3,096 Frequency of television viewing < Never 2, Occsionlly 7, Almost every dy 12, Assets index < st (lowest) 5, nd 5, rd 5, th (highest) 5, Eduction level < st (lowest) 6, nd 7, rd 4, th (highest) 3, Age (yers) < , , , , , , , Self-reported current smoking 0.83 No 20, Yes 1, Are of residence < Urbn 14, Rurl 7, The results were obtined in the nlysis for complex smple designs nd my not depict the 100% due to missing vlues. b Differences in proportions were determined by chi-squre test for trends. s likely to be obese compred with those who did it less thn n hour dy. In prospective study, Hu et l 9 found tht television viewing ws independently ssocited with obesity nd type 2 dibetes mellitus. This sme study found trend of obesity incresing proportionlly to time (number of hours) spent wtching television. 9 Bowmn 2 reported tht television viewing for more thn two hours dy ws ssocited with incresed BMI in both men nd women. It should be noted tht these dt come from observtionl studies in the United Sttes popultion. An erlier study crried out in six cities in Peru reported positive reltionship between television viewing of four hours or more nd BMI 25 kg/m 2 (overweight) in women. 11 Other countries undergoing epidemiologicl trnsition, like Brzil, 6 hve reported n ssocition between frequency of television viewing nd overweight or obesity in women but not in men. Not ll studies hve found positive ssocition between obesity nd frequency of television viewing. A cross-sectionl study conducted in the Irnin popultion did not find ny reltionship between BMI nd time spent (minutes per week) wtching television. 21 This type of evidence presents chllenge nd points to the need to explore these ssocitions in specific contexts, hence justifying the importnce of conducting the present study. The mechnism by which television viewing is ssocited with obesity is not yet clerly estblished. It might be due to lck of physicl ctivity, 9 nd unhelthy

5 Rev Súde Públic Tble 3. Crude nd djusted models of the ssocition between frequency of television viewing nd obesity/overweight. Peru, Obesity Overweight Frequency of television viewing Crude Adjusted Crude Adjusted n = 14,209 n = 14,207 n = 18,614 n = 18,611 OR 95%CI OR 95%CI OR 95%CI OR 95%CI Never Occsionlly ; ; ; ;1.4 Almost every dy ; ; ; ;1.9 Model djusted for ge, re of residence, qurtiles of eduction level, ssets index nd self-reported current smoking. All estimtes were clculted using logistic regression for complex smple designs. eting (consumption of high sugr-sweetened beverges nd processed foods) while wtching television, 5 or the effect tht television commercils might hve on people s behvior ptterns with incresed consumption of high-energy foods nd consequent weight gin. 14 In ddition, these effects my vry depending on exposure time nd content of television progrms. Longitudinl studies hve found tht television viewing during childhood nd dolescence for long periods of time my hve n impct on BMI in dulthood. 24 On the other hnd, recent study reported tht chnges in television viewing time in dults re independently ssocited with longterm weight gin. 18 One of the strengths of this popultion-bsed study is tht the finl smple comprised more thn 20,000 women ntionwide including urbn nd rurl res, which could provide informtion to better understnd how indirect fctors ffect physicl ctivity mong Peruvin women. However, our study hs certin limittions. First, informtion bout BMI ws not vilble in 27% of respondents, which could potentilly bis the results of our study. The DHS 2008 comprises group of surveys conducted from 2004 to 2008 in ntionlly representtive smple. However, nthropometric mesurements were crried out only in 2005, 2007 nd 2008, thus explining missing dt on the outcome vrible. Although mesures were not tken in ll wves of this survey, the women smple with vilble nthropometric dt ws ntionlly representtive. A comprison of chrcteristics of respondents with nd without BMI dt vilble showed no differences except for the vrible ssessing frequency of television viewing. However, our study showed results tht re consistent with those from other studies. 2,9,11 A second limittion of this study is tht informtion on frequency of television viewing nlyzed in the DHS survey comes from self-reports nd is collected s ctegories, wheres it would hve been more objective to collect informtion on the number of hours tht women spent exclusively wtching television. Another limittion is the cross-sectionl design tht does not llow mking ny inferences on cusl reltionship between the vribles of interest. Other studies with prospective designs hve shown cusl effect of television viewing on obesity in dults. 12 Finlly, becuse the DHS usully does not ssess crdiovsculr risk fctors, we could not explore other vribles ssocited with obesity such s dietry ptterns, 5 clorie intke by frequency of television viewing, 2 lcohol consumption, 3 nd levels of physicl ctivity, 16 mong others. In conclusion, this study showed strong ssocition between frequency of television viewing nd overweight nd obesity mong Peruvin women, especilly in those of urbn res. Findings of the present study re relevnt in ssessing the effect of television viewing, nd indirectly ssessing the sedentry lifestyle, on obesity in the Peruvin context. We found strong evidence of n ssocition tht vries ccording to re of residence, which could impct future intervention strtegies. Further studies re needed to explore the effects of television viewing in mles, to better understnd the mechnisms ssociting this sedentry ctivity with incresed risk of obesity, nd to suggest dequte strtegies tht cn reduce obesity nd physicl inctivity in the Peruvin popultion. REFERENCES 1. Overweight, obesity, nd helth risk. Ntionl Tsk Force on the Prevention nd Tretment of Obesity. Arch Intern Med. 2000;160(7): Bowmn SA. Television-viewing chrcteristics of dults: correltions to eting prctices nd overweight nd helth sttus. Prev Chronic Dis. 2006;3(2):A Breslow RA, Smothers BA. Drinking ptterns nd body mss index in never smokers: Ntionl Helth Interview Survey, Am J Epidemiol. 2005;161(4): DOI: /je/kwi Chng PC, Li TC, Wu MT, Liu CS, Li CI, Chen CC, et l. Assocition between television viewing nd

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