Association of Television Watching Practices of Mothers on Overweight and Obesity of Their Under-5 Offspring in Urban Bangladesh

Childhood overweight and obesity, is an emerging public health concern in developing countries like Bangladesh. However, regular television watching by child’s mother and its impact on excess weight gain or overweight and obesity to their offspring is not reported elsewhere. The aim of the present analysis was to determine the socio-demographic characteristics among overweight and obese children based on those mothers who watch television regularly and compare this finding with malnourished and well-nourished under-5 children. A total of 20,800 under-5 children were enrolled during 1996 to 2012 in the Diarrheal Disease Surveillance System (DDSS) of Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Mean weight-for-age z-score (−1.61 vs. −2.30; mean difference: −0.69; p < 0.001), height-for-age z-score (−1.42 vs. −1.99; −0.57; <0.001), weight-for-height z-score (−1.59 vs. −1.07; −0.53; <0.001), BMI-for-age z-score (−1.09 vs. −1.61, −0.52; <0.001) differed significantly between the children whose mother did and did not watch television regularly. Under-5 children whose mother watched television regularly (2%) compared to those who did not (1%), had 2.28 [(95%


Introduction
The double burden of under nutrition and over nutrition has already been determined as global health concern [1] [2].Prevalence of childhood obesity has been increased sharply during the past few decades [3] [4].This number has become double in the last two or three decades in the developed as well as developing region [5].
Overweight and obesity, an emerging childhood malnutrition, is a growing public health concern in developing countries like Bangladesh affecting all age groups as well [6] [7].Obesity and its consequences are among the leading causes of deaths and it has been increasing sharply during the past few decades [4] [7].Several socio-economic and behavioural factors which are associated with childhood overweight and obesity include the relentless access to mass media especially watching television [8] [9].
Researcher had found that watching television has direct relation with childhood overweight and obesity [10]- [13]; however, most of them were from developing context with few exceptions, and there is lack of evidence based information especially among Bangladeshi children [14].The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) maintains a round the clock Diarrheal Disease Surveillance System (DDSS) where children under-5 year with diarrhea were enrolled irrespective of sex and socio-economic status [15].Information on watching television regularly was collected as a part of socio-demographic indicators.Taking the advantage of this long standing data-base, the present sub-group analysis aimed to determine the socio-demographic characteristics among overweight and obese children whose mother watched television regularly and compare this findings with that of well-nourished and malnourished under-5 children.

Study Population, Site and Source of Data
The study was conducted among under five children visiting the Dhaka Hospital of icddr,b, located in Dhaka, the capital city of Bangladesh which provides cost free care and treatment to about 140,000 patients each year.The DDSS of icddr,b has been established since 1979, to collect longitudinal data on the hospital's patient populations.The DDSS currently collects information on clinical, epidemiological and demographic characteristics including watching television, nutritional status of infants and young children.A trained research assistant interviewed care givers of children.
The DDSS recently explored a dramatic increase in overweight and obese under-5 children [7] [15].Due to limitation of data on impact of regular watching of television by mother on childhood overweight and obesity, we evaluated the same from 1996-2012 by observing 20,800 under-5 children.
Detailed socio-demographic information including mother's television practice (watching television regularly or not) were also collected.Child's nutritional indices (weight and height) were measured following standard guideline [16]; and overweight and obesity were defined according to WHO guidelines using BMI-for-age zscore (≥+2.00SD) [17].

Data Analysis and Sampling Frame
Data analysis was done using Statistical Package for Social Sciences (SPSS) for Windows (Version 15.2; Chicago, IL) and Epi Info (Version 6.0, USD, Stone Mountain, GA).Data were first categorized into two groups 1) watched TV (=1); 2) did not watch TV (=0) and compared their socio-demographic information, clinical char-acteristic and pathogen responsible for diarrhea by Chi-square test and a probability of <0.05 (Type I error) was considered as statistically significant.Proportion of mother watched TV was analyzed by nutritional status (overweight and obese, well-nourished, and malnourished).Then in-depth analysis was performed assuming the proportion of overweight and obese was higher among children whose mother watched TV regularly.Here data was categorized into 3 quarters among TV watching group as 1) overweight and obese, 2) well-nourished, and 3) malnourished and compared by applying both descriptive and analytical methods.Overweight and obese was considered as risk group while well-nourished and malnourished as referral categories to determine the predictors of overweight and obese among children whose mother watched TV on regular basis.

Ethical Consideration
This activity was approved by the Research and Ethical Review Committees of icddr,b and the detail has been reported elsewhere [18].
Among under-5 children whose mother watched television regularly; higher proportion of those mothers were literate, had smaller family size, living in a non slum residential area, had higher monthly family income (>100 USD), used sanitary toilet, used boiled water for drinking compared to non-watching group (Table 2).While we compared within the TV watching groups, overweight and obese were different in socio-economic aspects from their counterpart.For example, higher proportion of mothers belonging to overweight and obese children were literate, had higher monthly income (>100 USD), used sanitary toilet, and boiled drinking water compared to well-nourished and malnourished children (Table 3).
In multivariate analysis, children aged 24 -59 months, male children, literate mother and higher monthly family income (>100 USD) were significantly associated with overweight and obese children whose mother watched TV regularly when well-nourished was considered as referral group (Table 4(a)).On the other hand, considering malnourished as referral group, overweight and obese was significantly associated with maternal literacy and higher monthly family income (Table 4(b)).

Discussion
Watching television by the mothers of young children has strong association with excess weight gain with subsequent ramification to overweight and obesity in late childhood [12], and persists till their adolescent age and adulthood.However, watching of television regularly by mothers also has significant impact on excess weight gain or overweight and obesity to their offspring-that is an interesting finding and was not reported elsewhere.It is difficult to explain such association with childhood overweight and obesity based on the present cross-sectional surveillance system and therefore does not allow for any causal inference of children with diarrhea due to lack of life-style and behavioural information.Rapid and unplanned urbanization drastically reduces open room for playing condition which divert them towards idle indoor games especially video games or watching television, resulting in their less catabolic activities.Mothers, those who watch television during leisure time, their kids potentially accompany them probably with changes in their feeding practices that may include highly dense fatty meal.Most of the cases, household with television is from well-off socio-economic status in whom childhood overweight and obesity has been reported [19] [20].Our present finding, urges further exploration of public health interest to determine comprehensive impact of the life style and behaviour of mothers on overweight and obesity of their offspring's.

Limitations
This study was conducted among children attending a large diarrheal disease health facility and may not be representative of for general population.Strengths of our study include long time period for data collection, and use of large, systematic sample and unbiased sampling of the surveillance system.

Conclusion
Our study demonstrated that, mothers' television watching is associated with childhood overweight and obesity.However, recently in Bangladesh overweight and obesity is gaining attention under public health issues.These changes may be the consequences of better socio-economic condition, modified life style behaviour and dietary pattern as well.The findings of present study may be a snap shot of the hidden underlying burden and thus enhance further researches especially on daily behaviour on watching television by the mother's of young children becoming overweight and obese.

Table 1 .
Different nutritional status among under-5 children on the basis of mother's watching television (TV) regularly.

Table 2 .
Socio-demographic characteristics among under-5 children whose mother watched TV regularly.

Table 3 .
Socio-demographic characteristics of under-5 children by different nutritional status whose mother watched TV regularly.

Table 4 .
(a, b) Factors associated with children overweight and obese whose mother watched TV regularly.