Abstract
Introduction
Digitalization of the world is making screen devices such as smart phones, tabs, laptops, etc, a necessity at a household level. Unfortunately, the usage of these screens is not restricted to any particular age group. With the COVID-19 pandemic, the practice of digital media devices has increased not only for leisure or professional work but also for academics. 1 Excessive screen time (ST) negatively impacts physical activity and eating behavior among children. 2
According to the Indian Academy of Pediatrics (2020–2021), screens have become an important part of children’s daily lives. Children under the age of 2 should not exceed any type of ST, except for occasional video calls with relatives. ST for children aged 2 to 5 years should not exceed 1 hour. For children >5 years, it is critical to strike a balance between ST and other activities that are necessary for overall development. If physical activity/playtime, adequate sleep duration, schoolwork time, mealtime, hobbies, and family time are displaced due to the use of screens such as phones, laptops and television, etc, then it is considered excessive ST. 3
Among children, excessive ST is linked to a variety of health risks such as the early onset of hypertension, heart problems, hyperlipidemia, and other health risks, which have direct associations with sedentary ST behavior as a result of lower physical activity and poor sleep quality. 4 The longer the ST, leads to children’s engagement in unhealthy dietary habits such as skipping breakfast, eating fast food and sweets frequently, and less likely to engage in healthy dietary habits such as eating a second fruit every day, eating fresh or cooked vegetables or/and fish regularly. 5 When compared to habits of moderate or vigorous physical exercise, screen-based sedentary behavior developed in childhood are more likely to persist into adulthood. 6 Prolonged leisure ST is associated with greater media accessibility and less presence of parents/others. To avoid prolonged leisure ST, attention should be paid to mobile/small screen-based devices such as cell phones and pads/tablets, especially in boys and/or on weekends. 7
Several studies have been conducted on children aged less than 5 years related to ST and eating habits but there is a lack of scientific evidence on the impact of ST on eating behavior and overall lifestyle among older children.8-11 Considering the importance of establishing appropriate eating behavior among children, which will determine their future health/nutrition status, the present research aimed to study the association of ST on eating behavior among school-going children 8 to 10 years in East Delhi.
Methods
In the present cross-sectional study, the sample of 100 school-going children (8–10 years) of East Delhi was recruited using convenience sampling, after excluding the children having any kind of chronic disease. Four schools in East Delhi, India were approached. After taking due permission from the school authorities. Ethical clearance was obtained from the Institutional Ethics Committee, Lady Irwin College, on November 27, 2021. Since the target group was minors, parents were explained the purpose of the study and their online consent was undertaken. A study information sheet was shared providing detailed information regarding the research and researcher. The subjects were recruited for the study after taking informed consent. Data collection was done between January and March 2022.
The study was conducted using Google Forms. The following information was collected.
General and Anthropometric Information
A questionnaire was prepared to gather information regarding the demographic profile of the child. Anthropometric data like body weight and height of the children were asked and were compared to the WHO BMI cutoff (BMI for Age 5–19 Years, 2007). 12
Screen Time
SCREENS is a questionnaire that covers the six domains that are validated to be important factors of screen media use in children. 13 The six domains include screen media environment, child’s screen media use, context of screen media use, early exposure, parental perception of child’s media use, and parental media use. This questionnaire was adapted according to the Indian setup.
Child Eating Behavior Questionnaire
Child Eating Behavior Questionnaire (CEBQ) is a validated parent-rated instrument to assess 8 dimensions of eating style in children. There are total of 35 questions in CEBQ and each question contains 5 options “Never,” “Rarely,” “Sometimes,” “Often,” and “Always.” Each question relates to a particular dimension; responsiveness to food (FR), enjoyment of food (EF), satiety responsiveness (SR), slowness in eating (SE), fussiness (FF), emotional overeating (EOE), emotional under eating (EUE), and desire for drinks (DD). 14 The above questionnaire was adapted in the present study to analyze children eating behavior.
Physical Activity Questionnaire—Child
Physical Activity Questionnaire (PAQ-C) was adapted according to the Indian setup. The PAQ-C is appropriate for school-aged children (grades 4–8; approximately ages 8–14). This tool was developed to assess general levels of physical activity among children. 15
Pre-testing of the tools was performed; 10 parents of children in the same age group were asked to fill out the questionnaire. Minor changes were made like changing of language of some questions to make them understand easily.
Statistical Analysis
All the data was coded and entered into Microsoft excel sheets. Descriptive statistics of the participants’ baseline characteristics and responses were provided as frequency and percentage for categorical variables that were presented differently for males and females. Continuous variables such as age and BMI were reported as mean and standard deviation (SD).
The association between self-reported nutritional status and various parameters of eating behavior, physical activity, and ST was analyzed using Pearson’s chi-square test. For the association of all other parameters, the Pearson correlation test was performed. For all analyses, a
Results
General Profile of Participants
The demographic profile of participants showed that the majority of the school-going children were girls and belonged to the middle-income group (Table 1).
All children were attending online classes because of the pandemic. The details of children’s online classes are depicted in Table 1. Indian Academy of Pediatrics (Guidelines for Normal Sleep and Physical Activity, 2020–2021) recommended 9 to 11 hours of sleep for 6 to 13 years old children. 16 The majority of the children were having adequate sleep as per the guidelines. The data showed that 29% of the children were overweight and 18% were obese. The present study also showed that 27% of the children were involved in low physical activity (Table 1)
Demographic Profile of the Children.
Screen Time
Table 2 showed that the majority of the children were having 2 to 4 screen media devices in their households. 95% of the parents reported that their child uses screen media daily related to school activities and 85% for playing screen-based games. Parents (52%) reported that their child uses screen media (for YouTube, games, school-related tasks, video calls with relatives, etc) in their leisure time for more than 4 hours. Among 18% of the households, it was reported that television is very often switched on while no one is watching.
More than 90% of the parents agreed that the child must ask for permission to use screen media devices and boundaries should be fixed. The children were more prone to use screen media before half an hour of going to bed than after half an hour of waking up in the morning daily (58%). The parents disclosed that their children (15%) use more than one screen media at the same time (like watching TV and using their phone at the same time). The majority of the children used screen media with their siblings or alone (78%). About 22% of the children used screen media in the presence of an adult. 10% of the parents disagree that if the chance given, their child would spend his/her most of the time on screen media and 90% choose to agree strongly or partly the same (Table 2).
SCREENS Questionnaire.
Eating Behavior
The majority of the children were taking 3 (47%) to 4 (33%) meals a day. According to the Indian Academy of Pediatrics (2021–2022), children of 8 to 10 years should consume 3 meals and at least 2 snacks per day. 3
The eating behavior of children can be broadly divided into 2 subscales. (a) Food Approaching Subscales: These consist of 4 scales—enjoyment of food, food responsiveness, emotional overeating, and desire to drink. (b) Food avoiding subscales: These consists of 4 scales—slowness in eating, satiety responsiveness, food fussiness, and emotional undereating. Data in Table 3 showed that majority of the children sometimes show the parameters of food avoiding and food approaching subscales.
Eating Behavior of School-Going Children.
Association of Screen Time With Various Parameters Among School-Going Children
Screen time and physical activity
Pearson correlation reveals that there was a strong negative correlation between ST and the physical activity of children (
Screen time and parent’s screen time
A strong positive significant difference is also seen between child’s ST and parent’s ST (
However, in the present study, no significant difference was found between gender and ST of children. Similarly, no significant difference was found in the ST of children and qualifications of parents, type of family, number of screens in the house, and socioeconomic status.
Screen time and eating behavior
A strong positive correlation (
Association of Screen Time and Physical Activity.
Eating Behavior and Physical Activity
According to the present results, a negative significant correlation was found between physical activity and 6 subscales of CEBQ, namely food responsiveness, emotional overeating, desire to drink, slowness in eating, satiety responsiveness, and food fussiness as shown in Table 4. It showed that children with higher food responsiveness, emotional eating, desire to drink, slowness in eating, and food fussiness have low physical activity.
Association of Eating Behavior, Screen Time, and Physical Activity With and Body Mass Index for Age
A negative significant difference (
The data also revealed a negative correlation between BMI and physical activity, though the result was not significant.
Discussion
Childhood is a crucial stage for the development of lifestyle practices. It is imperative to monitor children’s daily routines and control unsuitable practices such as improper sleep duration, personal hygiene, physical inactivity, higher ST, and improper eating habits. National and international guidelines have focused on controlling higher ST among children.
Numerous previous studies have focused on ST and its impact on eating behavior below 5 years. There is a dearth of data on older children related to ST and its impact on overall well-being. The present study tried to comprehend the correlation of ST on eating behavior among school-going children aged 8 to 10 years in East Delhi, India. The data showed that majority of participants were girls. All the students were learning through online mode. Table 1 showed that 29% and 18% of the children were overweight and obese, respectively. According to recent NFHS 5 data (2019–2020), the prevalence of overweight/ obesity has increased from 2.1% to 3.4%. The link between screen media exposure and obesity has received a lot of attention. 17 Children with higher ST are generally more likely to overeat and they also learn unhealthy eating habits from advertisements and programs. 18 In the present study over 19% of the parents reported that more than 4 screen devices are accessible to children at home. Around 90% reported regular use of these screen devices by children for school-related and leisure activities. Parents reported (52%) that children spent more than 4 hours in front of the screen in a day (Table 2).
ST and unhealthy eating habits are common in young children, and evidence suggests that they frequently co-occur and are linked. Early recognition of clusters of unhealthy habits and their influences can involve the development of targeted preventive interventions. The risk behavior combination of insufficient fruit and vegetable consumption, excessive ST, and high energy-dense snack consumption occurred more frequently than expected. 19 The present data depicted that 29% and 22% of the children rarely showed food responsiveness and desire to drink. About 19% and 16% of the children showed slowness in eating and food fussiness and 20% of children showed emotional undereating (Table 3).
The present study revealed that ST was negatively associated with physical activity and positively associated with parent’s ST, emotional overeating, satiety responsiveness, food fussiness, and emotional undereating (Table 4). In line with the present findings, several studies have reported adverse consequences of ST on children’s overall development.20–23 The data also revealed an association of eating behavior subscales with physical activity (Table 4), the results depicted a negative correlation of physical activity with food responsiveness, emotional overeating, desire to drink, slowness in eating, and satiety responsiveness. It has been seen that there were significant differences in eating behaviors among children who participated in 60 minutes of daily physical activity and those who are physically inactive. 24 A previous study, 25 also concludes that children who are overweight or obese are engaged in less physical activity. BMI of children was also associated with ST, that is, higher the BMI, higher is the ST of children, but the results were not significant. Some previous studies have also found a positive association between BMI and ST among children.26,27 Table 5 also represented a significant and negative correlation of BMI with physical activity and satiety responsiveness and a positive association with ST. The present study has a few limitations like a smaller sample size and the finding of the study was based on self-reported information. But, the pernicious association of higher ST with eating behavior and physical inactivity among 8 to 10 years is crucial. Even so, the relevancy of the data has an imperative role in the comprehension of higher ST and its impact on children eating behavior, physical activity, and nutrition status which can be the leading factors for detrimental effects on the overall well-being of children.
Association of BMI with Satiety Responsiveness, Physical Activity, and Screen Time.
Hence, this study concludes that excessive ST among school-going children has been associated with physical inactivity and poor eating behavior which could lead to an increased risk of being overweight and obesity.