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J Gen Intern Med. Mar 2006; 21(Suppl 3): S76–S81.
PMCID: PMC1513172

Television Viewing Practices and Obesity Among Women Veterans

Kay M Johnson, MD, MPH,1,2 Karin M Nelson, MD, MSHS,1,2,3 and Katharine A Bradley, MD, MPH1,2,3

Abstract

BACKGROUND

Obesity is epidemic in the U.S. and has been associated with television viewing.

OBJECTIVE

To describe the association between obesity and television viewing practices among women veterans.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional, mailed survey completed by 1,555 female veterans enrolled at the VA Puget Sound Health Care System in 2000.

MEASUREMENTS AND METHODS

We used bivariate and multivariate analyses to assess the association of obesity (body mass index >30 kg/m2 based on self-reported height and weight) with self-reported number of hours of television or videos viewed per day, and frequency of eating meals or snacking while watching television, controlling for other covariates.

RESULTS

Watching television >2 hours per typical day on week days and/or weekends was associated with obesity (P<.001), as was eating or snacking while watching television (P=.003). In multivariate logistic regression analyses, watching television >2 hours per day and eating or snacking while watching television were each associated with obesity (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.1 to 1.8; and OR 1.3, 95% CI 1.0 to 1.7, respectively), after adjusting for demographic variables, smoking, physical activity, and depression. Results were similar when posttraumatic stress disorder was included in the model instead of depression. Women who both watched >2 hours of television per day and ate or snacked while viewing were almost twice as likely to be obese (OR 1.9, 95% CI 1.4 to 2.6).

CONCLUSION

Watching television over 2 hours per day and eating while watching television were each associated with obesity among female VA patients and may be modifiable risk factors for obesity.

Keywords: obesity, television, women veterans

Obesity is epidemic in the United States1 and is a major threat to public health given its association with diabetes, hypertension, heart disease, and other serious conditions.2, 3 Because it is extremely difficult to treat,4 innovative and effective approaches to prevent obesity are needed. The association between inadequate physical activity and obesity is well documented, yet most Americans do not engage in regular exercise.57 Although many people report lack of time as a major barrier to regular exercise, the average American adult spends over 4 hours per day watching television.8, 9

Investigators have demonstrated an association between the amount of time spent watching television and obesity in adults,1014 and limiting the hours of television viewing can prevent obesity among children.15 Television viewing could contribute to obesity because of changes in both sides of the energy homeostatic equation: decreased energy expenditure and increased energy intake. Television viewing may “displace” exercise from one's daily routine, thereby reducing energy expenditure16 and it may lower the metabolic rate more than other sedentary activities.17 Television viewing may also lead to increased caloric intake because of less mindful eating while watching television18 or exposure to advertising of high-calorie foods.16, 19 Alternatively, obesity could lead to decreased mobility or poor health, which in turn could lead to increased television viewing. Finally, some of the association between obesity and television viewing could reflect confounding. For example, patients with mental health symptoms may spend more time watching television12, 20, 21 and are at increased risk for obesity.2224

Obesity is a major health problem among women who receive care through the Department of Veterans Affairs (VA) and affects approximately 30%.24, 25 Women veterans may be at high risk for inactivity and excessive television viewing because of physical and/or psychologic disabilities.26 Posttraumatic stress disorder (PTSD) is common among women veterans, and has been associated with increased prevalence of obesity.27 Avoidance of stressful stimuli is a symptom of PTSD, so veteran women with PTSD might spend more time than other women at home in sedentary activities. No prior research has addressed whether mental health symptoms account for some of the association between obesity and television viewing.

The objective of this study was to explore the relationship between television viewing practices and obesity in female VA patients. First, we determined the association of self-reported television viewing practices, including time spent watching television and time spent eating while watching television, with being overweight or obese. Second, we determined whether maintaining adequate physical activity levels affected the association between television viewing practices and obesity. Finally, to address the possibility that mental health symptoms could account for some of the observed association between obesity and television viewing, we determined whether screening positive for depression or PTSD altered the strength of the association between obesity and television viewing.

METHODS

Study Setting and Population

The Women's Health Survey was mailed annually from 1998 to 2000 to all women veterans living in the Puget Sound area and receiving care at the VA Puget Sound Health Care System. Of 3,308 eligible women, 1,811 (55%) women returned the survey in 2000. Of these, 1,555 (86% of respondents and 47% of total surveyed population) completed questions about television viewing practices and reported their height and weight needed to calculate the body mass index (BMI). This study was approved by the University of Washington Human Subjects Committee.

Measures

Obesity

Survey participants reported their height (feet and inches) and weight (pounds), which we converted into BMI: weight in kilograms/(height in meters)2. Individuals were considered overweight if their BMI was 25.1 to 30 kg/m2 and obese if their BMI was >30 kg/m2, consistent with National Institutes of Health guidelines.28 Previous research has shown that self-report of weight and height results in slight underestimates of BMI, which are, however, highly correlated with true BMIs.29 For this study, outliers with regard to BMI (low or high) were compared with the VA computerized medical record, and self-report was found to be an accurate reflection of documented weight and height.

Television Viewing Practices

Questions about television or video viewing (Table 1) were developed based on prior published reports at the time of the survey.1012, 15 Hours of television viewing on weekdays or weekends were asked separately. A question about eating or snacking while watching television (Table 1) was also developed for this study and included on the survey.

Table 1
Questions Used in This Study Regarding Television Viewing Practices and Physical Activity

Physical Activity

At the time of this study, guidelines recommended engaging in at least 30 minutes of moderate physical activity most days of the week, or at least 20 minutes of vigorous-intensity physical activity 3 or more days per week.30 For the purpose of this paper, individuals were considered to engage in adequate physical activity if they reported at least 3 30-minute episodes of moderate physical activity in the past week (Table 1). To assess physical disability, which could confound the relationship between television viewing and obesity, women were also asked if they could walk at least 100 ft without the assistance of another person.

Depression and PTSD

Depression was assessed using a validated screening questionnaire, the 5-item Mental Health Inventory (MHI-5). Scores over 16 are considered a positive screen for depression.31 The 17-item PTSD Checklist-Civilian (PCL-C) version identified women screening positive for PTSD using the optimal cut point (≥38) validated in this population.32

Other Factors Associated with Obesity

Sociodemographic factors associated with obesity are low education and socioeconomic status,33 and black race.34 Demographic characteristics used in this study were based on self-report on the Women's Health Survey and included age, race, and highest education level achieved. Smoking, which is associated with a lower risk of obesity, may also be positively associated with television viewing,35 potentially counteracting any positive association between television viewing and obesity.36 Smoking status was determined based on self-report of current, previous, or never smoking.

Statistical Analysis

All statistical analyses were performed using STATA 8 Special Edition (College Station, TX). We performed bivariate analyses to assess the demographic and clinical characteristics of women classified as: (1) not overweight, (2) overweight, or (3) obese based on BMIs. We also performed bivariate analyses to examine the association between these 3 BMI groups and self-reported hours of television viewing, and other covariates hypothesized to be associated with obesity, television viewing, or both (eating while watching television, physical activity, smoking, depression, PTSD, race, and income). To compare the 3 BMI groups, we used the χ2 test.

Multivariate analyses used logistic regression to assess the odds of obesity (BMI>30) being associated with self-report of viewing more than 2 hours of television per day, adjusting for other characteristics associated with obesity in previous studies. We selected obesity as our main outcome for multivariate analyses, rather than overweight, as individuals who are obese are at high risk of adverse health outcomes related to weight.2 For multivariate analyses, we collapsed categories of television viewing and snacking while viewing to make the results more interpretable to both patients and providers. We generated a composite variable, “Typically views >2 hours of television per day,” on weekdays, weekends, or both, for our main measure of time spent viewing television. This cutoff was selected based on the distribution of the data and to allow comparison of findings with previous studies using a 2-hour cutoff. Women were also divided into 2 groups with regard to snacking during television viewing based on the distribution of responses to the question: those who reported never or very rarely eating while viewing television and those who reported doing so about one fourth of the time or more.

We used a stepped approach to modeling the association between obesity and television viewing practices. Several important covariates (e.g., physical activity, mental health symptoms) could confound and/or mediate an association between television viewing and obesity, and it is beyond the scope of this cross-sectional study to determine which. However, a stepped approach to multivariate modeling allows the reader to evaluate the effect of adding each important covariate to the model. First, we created a model that included demographic and socioeconomic variables associated with obesity (age, race, and education), current smoking, and typically watching more than 2 hours of television on weekdays and/or weekend days (model 1). Second, we added physical activity to the above model (model 2). Third, to determine whether self-report of eating or snacking while watching television was associated with increased risk of obesity after adjusting for watching television more than 2 hours per day, we added this variable to the model above (model 3). Next, we performed the same analysis including either a positive depression screen or positive PTSD screen to the model (model 4). Depression and PTSD were not included simultaneously because of the significant overlap between them (70% of women screening positive for PTSD also screened positive for depression).

To detect whether the observed associations were modified by physical disability (inability to walk), we repeated the bivariate and multivariate analyses after excluding women (n=81) who reported they were unable to walk at least 100 feet without the assistance of another person.

RESULTS

The 1,555 respondents ranged in age from 22 to 96 years old (mean 47). Table 2 displays demographic characteristics of the study population as a whole and by BMI group. Respondents were well educated, with 88% having at least some college education. Although half the women were employed, one third of the study sample reported an annual household income of less than $20,000. Twenty-nine percent screened positive for symptoms of depression, and 34% screened positive for PTSD.

Table 2
Characteristics of Patients by Weight Categories

Most of the women were overweight (33%) or obese (36%), including 21% with class 1 obesity (BMI 30.1 to 35 kg/m2), 10% with class 2 obesity (BMI 35.1 to 40 kg/m2), and 5% with class 3 obesity (BMI >40 kg/m2). Overweight and obese women were more likely to self-identify as black than women who were not overweight (Table 2). Women who were overweight or obese were less likely to report current smoking, and obese women were more likely to screen positive for depression or PTSD (Table 2). Age, education, income, employment outside the home, and marital status were not significantly associated with overweight or obesity in this sample.

Table 3 displays women's self-reported television viewing practices and physical activity levels, and the relationship of these practices to being overweight or obese. The number of hours of television viewed per day varied widely. Over half of the study population reported that they typically watched television more than 2 hours per day on weekdays and/or weekends, which was strongly associated with being overweight or obese (P<.001). The fraction of time spent eating meals or snacking while viewing television was also higher among overweight and obese women (P=.003). Among women who viewed 2 or more hours per day, 75% reported eating or snacking while watching television more often than “rarely” (data not shown). Less than one third of the women reported 3 or more episodes of aerobic activity per week, and physical activity levels were lower among overweight and obese women (P=.002).

Table 3
Self-Reported Television Viewing Practices and Physical Activity in Women by Weight Categories

In multivariate analyses, viewing over 2 hours of television per day was significantly associated with obesity (OR 1.5, 95% CI 1.2 to 1.9) after adjusting for age, race, education, and smoking (Table 4; model 1). When physical activity was added to the model, this association was unchanged (Table 4, model 2). When report of eating meals or snacking (more than very rarely) while viewing television was added to the multivariate model, this was also associated with obesity (OR 1.4, 95% CI 1.1 to 1.8), and the significant association between viewing television more than 2 hours per day and obesity persisted (Table 4; model 3). When depression (Table 4, model 4) or PTSD (data not shown) were added to the model, the observed relationships between television viewing practices and obesity remained unchanged.

Table 4
Association Between Obesity (BMI>30) and Television Viewing, Adjusted for Other Risk Factors

To evaluate the odds of obesity for women who both watched over 2 hours a day of television and ate while viewing, we repeated model 4 above, replacing the separate television viewing and eating variables with a composite variable with 3 values: (1) both views television over 2 hours per day and eats while viewing, (2) views television over 2 hours per day or eats while viewing but not both, and (3) neither views television over 2 hours per day nor eats while viewing. The odds of obesity among women who reported viewing television over 2 hours per day as well as eating while viewing was OR 1.9 (95% CI 1.4 to 2.6), compared with those who viewed 2 hours or less television per day and rarely ate while viewing.

In the secondary analyses, after excluding the 81 women who reported they were unable to walk at least 100 ft without the assistance of another person, the results of bivariate and multivariate analyses were unchanged (data not shown).

DISCUSSION

In this study of women veterans, those who typically view television or videos more than 2 hours per day were 40% more likely to be obese than women viewing 2 hours or less per day. Women who both viewed over 2 hours daily and ate or snacked while viewing television were almost twice as likely to be obese. While physical activity and screening positive for depression or PTSD were also associated with obesity, adjusting for these factors did not account for the observed association between television viewing practices and obesity.

These findings are consistent with previous studies, but extend prior studies' findings in several ways. Previous studies have demonstrated an association between hours of television viewing and obesity among adult women.13, 14 Although mental health symptoms have been associated with obesity2224 and with increased television viewing,12, 20, 21 no previous study of the association between television viewing and obesity has adjusted for potential confounding because of mental health symptoms. The present study uses validated measures to screen for depression and PTSD and adjust for mental health symptoms that might have confounded previous studies of the association of television viewing and obesity. Our findings suggest that confounding because of depression or PTSD does not account for the observed association between television viewing and obesity in this population.

In addition, the present study is the first, to our knowledge, to evaluate an association between obesity and eating while viewing television after adjusting for hours of television viewed. Eating while viewing television could contribute to obesity by causing patients to overeat, even if they were not hungry, or to lose track of portion sizes while their minds were occupied by a television program or video. In addition, viewing of advertisements for high-calorie foods might account for some of the observed association.16, 19

Limitations of our study include the relatively low response rate, self-report measures, and the cross-sectional design of the study. Only about half of the eligible women reported their television viewing practices, height, and weight. A previous analysis of response bias in the first year of this 3-year study revealed that respondents were older (P=.001) and more likely to be white (P=.01) and to report ever being married (P=.03) than nonrespondents. No significant differences were observed with regard to period of military service or service connected disability.37 More active women, those employed outside the home, and women who were less disabled physically or mentally, may have been underrepresented in this study, potentially resulting in overestimation of obesity and television watching and underestimation of activity levels. However, women in the sample spanned a broad range of television viewing and activity levels and we do not expect the relationship between obesity and television viewing to be affected by nonresponse. Additionally, this study likely underestimated obesity, inactivity, and television viewing as all were measured using self-report. However, if obese people were more likely to underreport their weight, overreport their activity levels, and underreport their television viewing time compared with nonobese women, this would obscure any association between obesity and television viewing or activity level. Therefore estimates of the association of obesity and television watching in this study are likely conservative. Finally, this study has the limitations of all cross-sectional, observational studies: observed associations could reflect unmeasured confounding, and no conclusions can be drawn regarding causality. For instance, it is possible that obesity leads to increased television viewing because of decreased mobility or poor health, leading to further weight gain. Prospective studies are needed to further evaluate the association between obesity and television viewing, with further consideration given to other forms of “screen time,” such as internet usage or video games. In addition, randomized trials are needed to determine whether obesity can be prevented and physical activity increased by interventions aimed at decreasing television viewing.

Nevertheless, our results are of interest to VA and non-VA researchers and clinicians. A randomized trial of obese children showed that limiting television viewing decreased the prevalence of obesity.15 Although this intervention trial needs to be replicated in adults, as noted above, primary care providers should be aware that some women view television excessively; providers may want to suggest that patients try modifying television viewing practices. For women veterans who have usually maintained a healthy weight while in the military, early post-discharge education about the importance of maintaining physical activity and the potential benefits of limiting television viewing may be helpful.

In conclusion, this study found that female veterans were almost twice as likely to be obese if they reported watching over 2 hours of television per day and eating or snacking while watching television after adjusting for physical activity and mental health symptoms. The treatment of obesity is extremely difficult, and obesity prevention is vitally important for every patient. There are many barriers for patients to comply with exercise and diet guidelines. Decreasing the time spent watching television and avoiding eating while watching television may represent achievable first steps toward lifestyle change.

Acknowledgments

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the University of Washington, the NIAAA, or the RWJ Foundation. This project was supported by the Department of Veterans Affairs, Veterans Health Administration, and the Health Services Research and Development Service (SDR GEN 97-022). Dr. Bradley was supported by National Institute on Alcohol Abuse and Alcoholism (NIAAA #K23AA00313) and was a Robert Wood Johnson (R.W.J.) Foundation Generalist Physician Faculty Scholar at the time this work was completed. We thank all the women veterans who participated in this study. We also thank Marguerite McNeely, MD, MPH, for her help with development of our survey questions, Kristin R. Bush, MPH, Jennifer L. Sporleder, and Amee J. Epler for assistance with data collection and management, Karen Foster, MD, for review of the manuscript, and Jackie Kimball and Scott Campbell for assistance with manuscript preparation.

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