Television Advertising and Development of Dental Caries in Children Aged 6 to 12 Years

Introduction: Advertising today is increasingly seen to be targeting children as they can be easily persuaded. The influence on them is reinforced by children’s difficulty in perceiving messages critically, in distinguishing the real from the imaginary, in their great confidence in messages from the media and popular characters and personalities, and in their inability to recognize risk and their propensity for imitation. Aim: The aim of the study was to investigate the impact of television advertising on children’s nutritional preferences and the intensity of dental caries in children aged 6 to 12 years. Materials and methods: The study included 277 children (158 boys and 119 girls) aged 6 to 12 years from different schools in Sofia. A survey was used to assess the nutritional preferences of these children who are under the influence of watching television commercials. The DMF (T+t) index introduced by Klein, Palmer & Knutson (1938) was used to assess the intensity of dental caries. A correlation analysis was performed between the time spent watching TV and the development of dental caries. Results: Many children buy on their own or ask their parents to buy advertised sweet candies, fizzy drinks and fruit juices, which are a risk factor for the development of dental caries. The results show that the longer they spend in front of the TV, the stronger the pronounced caries activity in children, supported by a statistically significant difference (p<0.001), Rho (277)=0.438. Conclusions: The studied children aged 6 to 12 years have unhealthy dietary preferences for low molecular weight carbohydrate foods, increasing their oral risk profile. Prolonged standing in front of the TV screen correlated with an increase in the intensity of dental caries in half of the children.


INTRODUCTION
Television is the most modern channel for mass communication. The role of television as a source of human impact has increased in recent years. In Bulgaria, research shows that food and beverage ads are 124 (33.4%) of all ads, with 96.8% being for unhealthy foods. 1 It is stated that 57% of these ads are specifically aimed at children, with the most advertised products being salty and sweetened snacks, cereals, pastries, soft drinks and carbohydrate juices and salty foods. 1 Children watch TV most of their free time. They are exposed to advertisers' messages and are vulnerable to complex food advertisements, often harmful to oral and general health. 2 Globally, television is considered the most widely used form of media for advertising food and beverages, especially those high in sugar, fat and salt, and therefore playing an important role in food choices. 3 Thus, the time spent watching TV can be considered a risk factor for higher consumption of food and beverages of low nutritional quality, through the impact of advertising on food preferences 4 and the consumption of unhealthy foods, especially when they are children and adolescents 5 .
Over the last 15 years, the correlation between the television and unhealthy eating habits has been well documented especially when it comes to children and adolescents; this contributes to the increase of overweight and obesity in them. [6][7][8] A high-sugar diet is an important risk factor not only for the development of obesity, diabetes, but also for the dental caries which is one of the most common chronic non-infectious diseases with the second highest incidence in the world. 9,10 It constitutes an important public health problem worldwide. 2 A diet containing foods rich in sugar is always associated with the development of caries. 11

AIM
The aim of the study was to investigate the impact of television advertising on children's nutritional preferences and the intensity of dental caries in children aged 6 to 12 years.

MATERIALS AND METHODS
The study included 277 children aged 6 to 12 years from different schools in Sofia. There were 158 boys and 119 girls in the study cohort. Some of the survey questions by Neeta Ghimire and Arathi Rao 2 were used. The DMF (T+t) index of Klein, Palmer & Knutson (1938) was used to assess the intensity of dental caries.

Statistical analysis
The results were statistically analysed using IBM SPSS Statistics 20 (IBM, USA). We used the following descriptive evaluation methods: variational analysis of quantitative variables and frequency analysis of qualitative variables (nominal and rank), which includes absolute and relative frequencies. To test the null hypothesis that there is no connection/association between television advertising, children's nutritional preferences and the intensity of dental caries, a χ 2 test of association was performed. The Spearman rank correlation coefficient was used to study the association between caries and time spent in front of the TV.
To calculate the size of the effect in those nominal variables, the Cramer V test (or Phi coefficient) was performed. Values of V=0.06 to 0.17 would refer to a small effect; V=0.18 to 0.29 to a medium effect, and V>0.30 would refer to a large effect size (Cramer, 2016).

RESULTS
The results of the survey are presented in Tables 1 and 2. In order to determine whether there is a difference in the eating habits and watching TV commercials for girls and boys in different age groups, χ² analyses were performed and the Pearson ratio was calculated. Where there was statistical significance, the magnitude of the effect was calculated.
The results of the survey show that all surveyed children watch TV. Approximately half of them watch TV at any time, and the rest do it in the afternoon and evening.
Most of the children watch TV for more than an hour and a half a day, which is a worrying fact, as research shows that spending more than an hour a day in front of a TV or computer is a predisposing factor for obesity.
The majority of children prefer to watch movies and music programs, and the rest -cartoons, popular science films, and series. Almost equal numbers are the children of both genders who watch commercials and others who do not. As a reason not to watch commercials, the majority of children indicated a prohibition from parents. Another reason given by one-third of the surveyed children is that the ads are boring. The rest of the respondents noted that they watch other channels during the broadcast of advertisements.
It is noticeable in the children's answers that most of them ask their parents to buy advertised sweet treats, carbonated drinks and fruit juices, which are a risk factor for the development of dental caries.
On the last question, most of the children's answers show that the reason for buying the advertised products is the attractive advertising with color and music. The answers of the other children, who indicated other reasons for buying advertised products, are almost equally distributed. These are the habit of buying the advertised products and advertising presented by a favourite character or actor.
The results in Table 1 show that there is a statistically significant difference in the answers to questions 1, 2, 4, 5, 9 by children of both sexes.
The results ( Table 2) suggest that there is significant difference between the answers to all questions from the children in both age groups. We have found in our study that the most commonly purchased advertised foods are sweet treats -chocolate, candies, cookies, cakes and others, as well as soft drinks -carbonated drinks and fruit juices, which have a high cariogenic potential. There are fewer toys and oral hygiene products that are bought after watching advertisements. Fig. 1 presents the results of the children's answers, how much time they spend in front of the TV screen during the day. Half of the children watch TV for more than 90 minutes a day. Prolonged TV watching is harmful to health, increases the risk of obesity, diabetes, cardiovascular diseases, hypertension, and decreases visual acuity.
The results show that the longer children spend in front of the TV, the stronger the pronounced caries activity in them, supported by a statistically significant difference (p<0.001), Rho (277)=0.438 (Table 3) Cohen's guide (Cohen, 1988) we found that the magnitude of the effect was close to average. Our study demonstrates a strong relation between the times spent watching TV and the results of dental caries.

DISCUSSION
Television appeared on the advertising market in the United States in 1943, when television advertising was first broadcast. In the early 60's, television advertising entered the life of almost all developed countries. 12,13 It uses color, sound, different characters, actions, plots, rhymes, brevity and clarity of messages to attract children's attention. Expressive means influence their emotional choice. Television advertising has a great power to persuade and inform children and influences not only the choice of the child and his parents, but also forms patterns of behavior, creates stereotypes, preferences and attitudes.
Children are becoming a very attractive object for the advertising business because they consume many products that are designed specifically for them, but also because they also influence the choice of their parents.   There is still little evidence in the scientific literature on the link between watching television, particularly TV advertisings, and dental caries. Oliveira et al. point out that account must be taken of the fact that children and adolescents watch television an average of 2 hours a day, as well as the fact that dental caries is associated with frequent carbohydrate intake and the presence of free sugars, which are metabolized to acids by microorganisms in dental biofilm, leading to demineralization of enamel 12 , as this process continues throughout life 14 . The high content of sugar in the diet is a serious risk factor for the development of dental caries, which is one of the most common diseases and the second most common one in the world, but also for obesity, diabetes and other chronic non-infectious diseases. 8,9 This has an impact on the health budget in lowincome countries and covers approximately 60%-90% of school-age children in the world. 15 In 2015, the World Health Organization recommended a new direction in the prevention of these diseases by reducing the consumption of free sugars, as they are less than 10% of the total caloric intake of children and adults in a way that can lead to even larger reduction of up to 5% of total calorie intake. 16 Folia Medica I 2021 I Vol. 63 I No. 4 Children today spend many hours watching television, and working parents spend less time with their children, which is why the media enter children's lives very early. Most TV programs are often interrupted by commercials. Under the influence of advertising, children put pressure on parents to buy advertised products and very often they are a source of conflict between children who want to buy a product and the refusing parents.
The people responsible for the children -parents, teachers, paediatricians, and dentists -need to know where the dangers lie and react to them accordingly.
The role of advertisements in the overall health of children is an issue that has been carefully studied by paediatricians, with an emphasis on the impact of these advertisements on children's eating habits and the role they play in the development of obesity. 17,18 Legal analysis of the content of television channels and the role they play in the promotion of oral health and the marketing of products considered both harmful and beneficial to oral health. [19][20][21][22] According to Galcheva et al. 1 , one-thirds of the advertisements of products watched by Bulgarian children are food and drinks, supporting the results of previous surveys. [22][23][24] Almost all food advertisements recorded by researchers do not support the Bulgarian dietary recommendations for healthy and balanced nutrition of children, optimal health and avoidance of obesity (www.mh.government.bg/ norm_acts.php). 1 The obtained results confirm the results of international research projects. [25][26][27][28][29] Dentists should be aware of the effect of these advertisements and advise parents about the dangers of targeted advertising of high-sugar products on the Internet.
Greater exposure of children to unhealthy advertising in the morning on weekends, when children are not at school, resting at home and watching certain television programs (cartoons, shows) that do not require parental supervision, should be considered as a smart marketing method.
Children need to be protected from aggressively targeted unhealthy food promotions during children's television programs. 7,30 In the Hawkes report 31 and in the WHO Global Strategy 32 for diet, physical activity and health is stated, food advertisements should not take advantage of children's trust and mislead them by encouraging the overconsumption of unhealthy foods that may be harmful to their physical and mental health.
Today, some of the world's market leaders in food and beverage companies began announcing self-regulatory actions to combat childhood obesity such as processing products to reduce calories, fat and sugar and adding vitamins, offering smaller portion sizes; clear labeling and advertising and promotion of training programs in the field of nutrition and physical activity. 33 Our results are in support of the results reported by authors such as Ghimire N et al. 2 , Silva et al. 13 , and Zeng et al. 34 that television can influence children's eating habits by stimulating the consumption of cariogenic foods and contributing to the development of dental caries.

CONCLUSIONS
The studied children aged 6 to 12 years had unhealthy dietary preferences for low molecular weight carbohydrate foods, increasing their oral risk profile. Prolonged standing in front of the TV screen correlated with an increase in the intensity of dental caries in half of the children. Dentists, parents and teachers must work actively to change the harmful eating habits in children. The school is a very suitable environment for the promotion of oral health and the development of healthy eating habits and preferences.