The Canadian Sedentary Behaviour Guidelines for the Early Years (zero to four years of age) and screen time among children from Kingston, Ontario

Abstract

OBJECTIVES

To assess the proportion of children meeting the new Canadian Sedentary Behaviour Guidelines for the Early Years (zero to four years of age) and to describe parental attitudes toward and barriers to reducing screen time.

METHODS:

Participants included 657 children zero to four years of age from the Kingston, Ontario, area. From May to September 2011, parents completed a questionnaire regarding their child’s screen time and their attitudes toward and barriers to reducing their child’s screen time.

RESULTS AND CONCLUSIONS:

Approximately 32% of children younger than two years of age engaged in no screen time and approximately 46% of children two to four years of age engaged in <1 h per day; thereby, meeting the recommendations of the new guidelines. Most parents believed that their child did not engage in excessive screen time. Physicians and other health professionals should inform parents of these new guidelines and provide strategies to help their children meet targets.

Historically, the terms ‘physically inactive’ and ‘sedentary’ were used interchangeably. However, moderate-to-vigorous intensity physical activity (MVPA) and sedentary behaviour, defined as any waking behaviour characterized by a low energy expenditure (ie, ≤1.5 resting metabolic equivalents) while in a sitting or reclining posture, are now recognized as two distinct behaviours (1). In fact, MVPA and sedentary behaviour are weakly correlated (2) and have independent health effects (3). The negative health effects of excessive sedentary behaviour begin early, particularly for screen-based sedentary behaviours such as watching television and playing video/computer games (4). Among young children, screen time is associated with obesity (5,6), aggressive behaviour (7), attention problems (8,9), impaired language development (9) and lower cognitive development (9). Furthermore, screen time habits formed at an early age may persist over time (10) and predict negative health outcomes in adulthood (11).

In March 2012, the Canadian Society for Exercise Physiology released the Canadian Sedentary Behaviour Guidelines for the Early Years (zero to four years of age) (12). These evidence-based guidelines were created in response to an urgent call from public health, health care and child care practitioners for guidance on reducing sedentary behaviour during the early years. The guidelines set measurable targets for surveillance and provide guidance to physicians and other health professionals. Along with the general recommendation of minimizing the time spent being sedentary during waking hours, the guidelines also include specific recommendations regarding screen time. For children younger than two years of age, screen time is not recommended and for children two to four years of age, screen time should be limited to <1 h per day (12). The Canadian Paediatric Society has recently released a position statement on healthy active living that encourages physicians and health care professionals to promote these guidelines (13).

To appreciate the extent to which excessive screen time is an issue within the early years, surveillance studies need to determine what proportion of children zero to four years of age meet the new guidelines. Furthermore, because parents are an important determinant of young children’s screen time engagement (14), information is also needed on parental attitudes toward and barriers to reducing screen time. This knowledge could be used to help promote healthy screen time habits in the early years. Therefore, the objectives of the present study were to assess the proportion of children zero to four years of age meeting the new Canadian Sedentary Behaviour Guidelines for the Early Years and to describe parental attitudes toward and barriers to reducing screen time.

METHODS

Participants

The present study was based on the Healthy Living Habits in Pre-School Children study. Data were collected between May and September 2011 on children ≤5 years of age from the Kingston, Frontenac, Lennox and Addington Health Region of Ontario. Parents of preschool children were recruited from licensed child care centres (46 of 60 participated) and public health or community programs (14 of 16 participated). Eligible parents received a questionnaire package and approximately 37% of parents returned the brief (15 min) questionnaire, resulting in a total sample of 800 children. Children with missing birth date information (n=41) and children older than four years of age (n=102) were excluded from the study, leaving 657 participants. Ethics approval was obtained from the Queen’s University General Research Ethics Board (Kingston, Ontario). Consent was obtained from participating child care centres, public health and community programs, and parents.

Screen time

Parents were asked two previously developed questions (15) regarding their child’s television and video/computer games use: “On average, how much time per day does your child watch television, videos or DVDs?”, and “On average, how much time per day does your child play video/computer games?”. There were seven response options for weekday and weekend use, ranging from ‘none’ to ‘≥3 h/day’. Weighted means of weekday and weekend use were calculated and total screen time was determined by adding the time spent watching television and playing video/computer games. Parents were also asked questions regarding the age of their child when they first started watching television or playing video/computer games (seven response options ranging from ‘0 – 6 months’ to ‘≥4 years old’)

Parental attitudes and barriers

For parents whose child engaged in screen time, their attitudes toward and barriers to reducing their child’s screen time were assessed using 15 questions developed from previous research (16–18). Four response options existed for each question ranging from ‘strongly disagree’ to ‘strongly agree’. These responses were dichotomized into agree (strongly agree/agree) and disagree (strongly disagree/disagree).

Statistical analysis

Analyses were performed using SAS version 9.2 (SAS Institute Inc, USA). Descriptive statistics including means, SDs and frequencies were calculated. χ² tests were conducted to compare percentage of agreement for attitudes and barriers between parents whose children met and exceeded the guidelines. There were no significant differences (P>0.05) in screen time between sexes; therefore, analyses were only stratified according to age (younger than two years of age, two to four years of age) where applicable. Due to the small sample of children younger than two years of age (n=75) and the consistency of results across age groups, age-stratified analyses were not presented for attitudes and barriers.

RESULTS

Participant characteristics are shown in Table 1. The average age of the sample was 3.1 years, slightly greater than one-half (52.3%) were boys and 80.4% attended a child care centre (71.9 % centre-based and 8.5% home-based daycare). On average, children younger than two years of age watched 31.4 min/day of television and played video/computer games for 0.6 min/day, for a total of 32.0 min/day of screen time. The corresponding screen time values for children two to four years of age were 71.9 min/day of television, 8.4 min/day of video/computer game play and 80.3 min/day of total screen time.

TABLE 1.

Participant characteristics

	Total (n=657)	Age, years
		<2 (n=124)	2–4 (n=533)
Child sex*
Male	52.3	46.3	53.7
Female	47.7	53.7	46.3
Child’s age†, years	3.1±1.1	1.3±0.5	3.5±0.8
Child care*
Centre based	71.9	41.9	78.8
Home based	8.5	12.9	7.5
None	19.6	45.2	13.7
Parental education*
Elementary (grades 1–8)	1.5	2.5	1.3
High school (grades 9–12)	15.6	23.9	13.6
Community/technical college	34.4	24.8	36.6
University	27.6	28.1	27.5
Graduate university	20.9	20.7	21.0
Television†, min/day	64.3±48.7	31.4±43.1	71.9±46.7
Video/computer games†, min/day	7.0±18.6	0.6±2.9	8.4±20.4
Screen time†, min/day	71.3±56.9	32.0±44.1	80.3±55.6

Data presented as % for categorical variables and as mean ± SD for continuous variables.

^*Categorical variable;

^†Continuous variable

For children younger than two years of age, 32.3% did not engage in screen time, 36.3% engaged in 1 min/day to 29 min/day, 16.1% engaged in 30 min/day to 59 min/day, 8.9% engaged in 60 min/day to 119 min/day, 4.0% engaged in 120 min/day to 179 min/day and 2.4% engaged in ≥180 min/day. For children two to four years of age, 2.1% did not engage in screen time, 18.4% engaged in 1 min/day to 29 min/day, 25.3% engaged in 30 min/day to 59 min/day, 34.7% engaged in 60 min/day to 119 min/day, 14.8% engaged in 120 min/day to 179 min/day and 4.7% engaged in ≥180 min/day. Therefore, 32.3% of children younger than two years of age, 45.8% of children two to four years of age and 43.2% of the total sample met the new sedentary behaviour guidelines (Figure 1).

Figure 1).

Proportion of children meeting the new Canadian Sedentary Behaviour Guidelines for the Early Years (12) according to age group

For children two to four years of age, 16.7% watched television and 0.2% used video/computer games within the first six months of life, 44.6% watched television and 0.9% used video/computer games within the first year of life, and 79.7% watched television and 4.0% used video/computer games within the first two years of life.

The three most commonly agreed on attitudes toward screen time were that screen time was enjoyable for their child (95.8%), when their child engages in screen time it gives parents an opportunity to get things done (87.4%) and screen time is a good learning tool (79.4%) (Table 2). The three most commonly agreed on barriers to reducing screen time were that their child does not engage in excessive screen time (74.7%), screen time is enjoyable for their child (69.5%) and parents need time to perform household chores (63.5%). Compared with parents whose children met the guidelines, the percentage of agreement for parents whose children exceeded the guidelines was significantly higher (approximately 10% to 25%) for 13 of the 15 attitudes and barriers, and significantly lower (16.1%) for the barrier that their child does not engage in excessive screen time (Table 2).

TABLE 2.

Attitudes and barriers of all parents whose children engaged in screen time and according to whether their children met or exceeded the guidelines

	Agree or strongly agree*
	Engaged in screen time (n=560)	Met guidelines (n=210)	Exceeded guidelines (n=350)
Attitudes
Good learning tool	73.0	62.8	79.4†
Child enjoyment	95.8	94.1	96.8
Gives parent opportunity to get things done	84.0	78.6	87.4†
Allows parent to cope with busy day/multiple children	51.0	43.1	55.9†
Allows child to relax	53.5	45.6	58.3†
Family, bonding or quality time	47.2	37.6	53.1†
Grabs hold of child’s attention	66.9	58.9	71.9†
It teaches children to get along with others	21.0	14.8	24.9†
Barriers
Pressure from society to purchase media equipment	23.4	18.8	26.3†
Neighbourhood is unsafe	8.8	5.9	10.7†
Poor weather limits time outside	50.7	40.8	56.9†
Parent needs coping-tool for busy day/multiple children	32.5	21.7	39.4†
Parent needs time to do household chores	63.5	53.5	69.6†
Child really enjoys screen time	69.5	54.0	79.3†
Child does not engage in too much screen time	74.7	84.5	68.4†

Data presented as %.

^*Ninety-seven parents did not respond to these attitudes and barriers questions, including 53 parents whose child did not engage in screen time activities;

^†χ² P≤0.05

DISCUSSION

Within this sample of 657 children from the Kingston area, only 43% met the new Canadian Sedentary Behaviour Guidelines for the Early Years (32% for children younger than two years of age, 46% for children two to four years of age). For parents whose children exceeded the guidelines, greater than two-thirds believed their child did not participate in excessive screen time and greater than three-quarters stated that screen time had educational benefits, was an enjoyable activity for their child or provided the parent with an opportunity to get things done.

The present study was the first to examine the proportion of children meeting the new sedentary behaviour guidelines. However, based on the Canadian Paediatric Society’s previous recommendation of limiting television viewing to less than 1 h to 2 h a day (19), only 22% of a sample of approximately 1500 children four to five years of age from Edmonton (Alberta) engaged in ≤1 h of screen time per day or less (20). In addition to Canada, the proportion of children meeting similar screen time recommendations from the United States (21) and Australia (22) has recently been reported. Specifically, only 32% of a representative sample of American zero to two year olds engaged in no screen time (23) and only 22% of a sample of Australian three to five year olds engaged in ≤1 h of screen time per day (24). The different age groups in these studies make cross-national comparisons challenging. Future surveillance research is needed within representative samples of Canadian children to determine the extent to which excessive screen time is problematic at the national level.

Television watching represented the most dominant type of screen time, comprising 98% of total screen time in children younger than two years of age and 90% of total screen time in children two to four years of age. Nonetheless, the availability of video/computer games specifically designed for the early years is on the rise with the advancement and availability of new technology (25), such as tablet computers (eg, iPad [Apple Inc, USA] with hundreds of child-focused applications) and learning laptops (eg, 13 options available at www.Toysrus.ca in January, 2012). In fact, more than 50% of participants in the present study who played video/computer games used this type of technology at least 50% of the time (data not shown). Therefore, future studies involving this age group should continue to consider multiple screen-based activities.

While evidence of excessive screen time engagement and the associated health implications in the early years is accumulating, little is known about appropriate strategies for reducing or eliminating screen time in this age group (26). Emerging research suggests that parents’ cognitions, such as attitudes and perceived barriers, are important determinants of children’s screen time use (14). In terms of parental attitudes, similar descriptive findings were reported by approximately 1000 American parents of two to 24 month olds. More specifically, the three most important reasons for television use were its perceived educational value, child enjoyment and the opportunity for parents to get things done (16). Although young children enjoy screen time activities and screen time allows parents to complete household chores more easily, these reasons should not outweigh the health implications associated with screen time engagement (4). Furthermore, while many parents believe that screen-based activities may provide some learning and educational benefits, the scientific evidence does not support this belief (9). In fact, accumulating evidence suggests that engagement in screen time during the early years is detrimental for language and cognitive development (9). For example, a recent systematic review examining the relationship between sedentary behaviour and health outcomes in children zero to four years of age found moderate quality evidence in infants (one month to one year of age) and low-quality evidence in toddlers (1.1 to three years of age) that increased television viewing was associated with a decrease in cognitive outcomes such as attention, vocalization count, reading recognition, reading comprehension, memory scores, classroom engagement and math scores (4).

To promote healthy screen time habits in the early years, physicians and other health professionals should consider increasing parental awareness of the health benefits of limiting or eliminating screen time (27). This objective may be achieved by discussing the new sedentary behaviour guidelines and their importance with parents. The recent position statement from the Canadian Paediatric Society on healthy active living encourages this dialogue (13). Along with increasing awareness, providing parents with strategies to keep their children occupied and safe while they complete household tasks should also be considered (27). These strategies may include the promotion of nonscreen-based toys, puzzles and games. Furthermore, as screen time habits formed at an early age track over time (28) and because almost one-half of children two to four year of age in the present study started watching television within the first year of life, parents of infants or even expecting parents should be targeted.

As with all studies, the present study was not void of limitations. A key limitation was the use of parental-reported screen time, which is prone to measurement error. However, direct measurements of screen time are not feasible in large samples. Another limitation was the low response rate and the fact that a primary recruitment source was licensed child care centres, which only 15% of preschool children in the health region attend (29). Consequently, the proportion of children meeting the sedentary behaviour guidelines within the entire Canadian population may be lower than reported here due to the relatively high socioeconomic status of our sample. It is also important to note that the data for the present study were collected just before the guidelines were released. Therefore, the present study represents a baseline assessment of the proportion of children meeting the new guidelines.

CONCLUSION

Only 32% of children younger than two years of age and 46% of children two to four years of age met the Canadian Sedentary Behaviour Guidelines for the Early Years. Physicians and other health professionals should inform parents of the health benefits associated with the new sedentary behaviour guidelines and provide them with strategies to help their children meet these recommendations.