2013 Brain Awareness Night: Branding and a Child's Brain

Dr. Amanda S. Bruce, Ph.D
Assistant Professor, Department of Psychology
University of Missouri - Kansas City

“Branding and a Child’s Brain”
Thursday, March 21, 2013

The relationship between food marketing and childhood obesity is the focus of research using neuroimaging techniques to better understand the brain’s role in obesity and neural responses to logos.


Every year Paul and I, when we start to organize this, we sit down and after we think about the topic that we want this year in collaboration with Katie, then we think about people and it's a lot of fun we have. We spend some hours looking at getting people's CVs from different universities when we find some subject matter that we want, so it's great.
We like to always bring in somebody from the outside every year, and this year is no exception. I got a chance to hear Amanda talk earlier today in this symposium. I think you'll be really interested in what she's going to talk about today. Dr. Amanda Bruce is currently at the University of Missouri, Kansas City where she's a clinical psychologist there.

Dr. Bruce: This has been my first trip to Memphis and I have greatly enjoyed myself despite the weather. It's actually colder in Kansas City right now than it is here. And congratulations, Memphis won today I saw for all you basketball fans out there. That's great news. KU, I am a basketball fan and the Jayhawks play tomorrow.
I actually had Memphis going pretty far in my bracket this year. I thought hey I'm coming to Memphis to give a talk, so I should be supportive.
So, I have a thank you slide usually at the beginning of my talks in case I go long, I would never want to rush over this or miss thanking the people that have been involved in this research, so not only the funding sources that I've been fortunate to have, but all the collaborators back in Kansas City at both the University of Kansas Medical Center where I did my postdoctoral work, and at the University of Missouri, Kansas City. Even though they're in separate states, it's like a five minute drive across the state line, so we work very closely with folks in Kansas as well.
This evening I'm going to spend some time talking about the prevalence of food advertising, particularly to children. And then I'm going to spend some time talking about childhood obesity which the information that I'm going to share with you is probably not going to be new, but I am going to focus on the brain's role in obesity, particularly childhood obesity and some techniques that we can use using brain imaging to better understand food motivation, the brain, the neural networks responsible for motivated behaviors like eating, and then ultimately obesity.
I want to end tonight with practical suggestions, so things that you can think about from tonight, things that you might want to consider doing and I'm happy to take questions at any point during this presentation, so please feel free to ask at any point.
This figure, $200 billion. This represents the market. In the United States alone that youth represents, so children and adolescents. I think we can all agree that this is a lot of money, right? $10 billion is also a lot of money, and this is the amount spent per year by companies here in the United States to market their products to children.
The reason that they do this, the reason they're willing to spend so much money is because it works. I was recently having a conversation with one of my brothers. He's in business, and he was discussing with me that kids don't necessarily buy things, and I said, "Oh Andrew, no, no. They might not physically go to the store and buy things, but they have tremendous influence over what their parents buy them.''
Companies know this. Companies have three goals. First they need kids to recognize the brands, and there have been studies that have been done looking at very young children, as young as two where kids may or may not even know all the letters of the alphabet yet, but they will recognize the golden arches.
We have twin daughters, and when they were two we were driving back from visiting my parents. We were along the interstate and it's evening. In the distance, they see the golden arches glowing. This beacon. They get all excited and say "an M! It's an M!'' So I'm thinking okay, this is good, they're learning their letters. This is good.
And I said yes you're right, what do you think it stands for? They think for a while and Ella says "M for mommy!'' They just turned four. They still don't know what the M actually stands for but my husband says that this is not necessarily a good thing because what you've done now is you've created a really positive association McDonald's. Every time they see the golden arches, they say "Mommy! M for Mommy!'' so, I don't know. It's probably not necessarily a good thing.

So companies initially want brand recognition. Once they've achieved that, obviously they want brand preference. How many of you are Pepsi people in here? Not too many, wow. I'm a Pepsi person. What about Coke? Okay. More Coke people.
So, what companies want to do is they want to get people preferring their brand. Ultimately they want people to be loyal to their brand, and they know if they can snag kids early on, that's going to be a customer, a consumer that's going to be devoted to their product for life, and the earlier they can do this, the better.
We also see advertising in many different places. So of course, we have commercials on TV. But we've started to see advertising embedded in the programs themselves. Do any of you watch American Idol? Any American Idol fans out there?

What do they have sitting in front of them on their desk? Coke. Exactly. I notice they've recently switched to Diet Coke, and I don't know if that was any sort of conscious effort to be healthier or not, but then they have the contestants do commercials as part of the show for Ford, so then they have a car commercial as part of the show itself. So we see that products are embedded in TV programs, in movies.
There was a big deal when James Bond started drinking a beer. I don't know if any of you are James Bond fans out there, but he chose Heineken and it was this big deal that the James Bond franchise was now promoting Heineken.
Now, there is a lot of TV advertising, and we can say so what. Maybe that's not so bad. Let me share with you a few pieces of information to help you understand just how prevalent it is. By three months of age, babies in the United States, almost half of them, so 40% are watching screen media regularly. This is our little girl [Julianna] when she was three months old. Almost half of infants are watching screen media regularly.
By the age of two--these are my twins--it's up to 90% of kids here in the United States are watching screen media regularly. You say so what again. Maybe that's not such a bad thing.
I would argue that it becomes slightly problematic when we think about what is actually being advertised to kids. Researchers have looked at this and they've done very careful studies and quantified what kids are being exposed to, and here in our country, about 98% of the food advertisements that kids see are for products that are high in fat, high in sugar, or high in salt.
Just like Dr. Boughter spoke about. These are these super-tasting foods that are infused with so much sodium, so much sugar, so much fat that our sense of taste is often overwhelmed by these foods. In addition to being exposed through TV advertising, I found this page in one of our girls' books, and it's a beautiful book and it has different themed pages. There's a page that has farm animals, there's a page that has jungle animals. This is the page of food. Is there anything that remotely resembling food that you'd find in nature here? Not really. It's candy. It's all junk food.

Audience question: I see a tomato.

Dr. Bruce: You see a tomato? Oh, yes. Right here. Maybe a sprig of lettuce. Okay. But is this a message that we want our kids to learn? I don't know. I'm not sure. The reason why companies spend so much money is because it works. It's effective, and researchers have published studies about this.
About six years ago or so, a study was published looking at preschoolers. They bought preschoolers into the lab and they said we're going to give you some food and we want you to tell us which tastes better, this food or that food, and they gave them the option of saying the foods taste the same. One of the foods was wrapped in McDonald's paper, the other food was wrapped in plain paper. What do you think won?

Audience: McDonald's.

Dr. Bruce: Hands down. Even when the foods were the same and the kids had the option of saying that they tasted the same, hands down they said the food in the McDonald's wrapper tasted the best, even when the food was not food sold at McDonald's. For example carrot sticks. You wrap carrot sticks in McDonald's wrapping paper, kids thought it tasted better.
More recently, researchers did a study and they asked healthy weight children and overweight children to come into the lab and they let them eat ad lib. They let them eat basically as much as they wanted. They were really interested in seeing how much food these kids consumed and they were particularly interested in branded foods versus generic foods, and what was really interesting was that the healthy weight children did not eat significantly different amounts of generic versus branded food.
However, the obese children ate significantly more calories of the branded food compared to the generic food. You might wonder how much is significantly different. On average, they ate 40 calories more, which might not sound like a lot, but if you think about eating 40 calories more over the course of a year, that translates to a weight gain of 12 pounds which is quite a bit.
Advertising works. Let me transition now to talk a bit about childhood obesity and as I said, I'm guessing to most of you in the room this is not new information. One way to look at obesity status is by using body mass index, BMI, and it's a weight-for-height ratio. In children it is also important to look at age and sex or gender so whether it's a boy or girl.
Right now in the United States, about one in three children are overweight or obese. When I give talks, I'll show you in a moment a graph that shows obesity and the increase in prevalence.
We know we've heard about the epidemic of childhood obesity. It's not only really important in the scientific community, but in the popular press as well. We see evidence of greater awareness of this and greater awareness of how serious this is.
The following graphs show the increase in prevalence of adult obesity within the United States, and what I'd like you to pay attention to is the years that are going to change up here. Also pay attention to this scale along the bottom. Less than 10% obesity. 10% to 14%. Watch those.
I'm going to scroll through these and watch what happens. That was a five year jump to 1990. In '92 they added a new category at the bottom. Another new category. I'll do that faster and you can see that it almost looks animated. Here's back to 1985, and I'll go quicker. It's pretty dramatic, isn't it? There's Tennessee right there.
Now these trends of increasing prevalence of obesity among adults, these are mirrored among children, and so we see that the national prevalence of child overweight and obesity has also risen dramatically, and not just for teenagers, middle childhood, it's also rising among the youngest children as well.
Why do we care about this? There are some pretty bad things that are associated with obesity. For children, often they run into social difficulties. They're bullied at school. They're picked on. They feel left out a lot. There have been some research studies looking at weight bias or discrimination based on weight, and these studies have shown that kids say they would rather befriend or play with a child who is in a wheelchair than play with a child who is obese. They face quite a bit of social discrimination.
They often report emotional difficulties as well. Lower quality of life. They're at an increased risk for anxiety and depression and often have lower self-esteem. These are just some of the psychological and emotional consequences.

There are also physical consequences as well that are very serious. We used to have type one diabetes which was known as child- onset or juvenile-onset diabetes, and type two diabetes which was known as adult-onset. We can't use those onset terms anymore because we're starting to see this type two diabetes develop in children.
They also have cardiovascular risk factors, they're at increased risk for high blood pressure and sleep apnea. They're at an increased risk for adult heart disease because we know that if children are overweight or obese, they're more likely to be overweight or obese as adults as well. This current generation of children is the first generation in many in the United States to actually have a decreased life expectancy compared to their parents because of obesity.

Audience question: How do you know if your child has diabetes?

Dr. Bruce: Oh, that's a good question. How do you know if your child has diabetes? I'm not a medical doctor, but I think what that would involve is going to a pediatrician and getting blood work done and looking at glucose levels and a glucose tolerance test. Does anybody know? Any doctors here? I would say go to a pediatrician and get blood work done.

Audience question: [inaudible 59:58]

Dr. Bruce: Okay. So if your child is thirsty a lot, excessively thirsty, that could be a sign. I think I've also read that urine can smell sweet. Can smell kind of sweet for people who have type two diabetes.

Audience question: [inaudible 59:22]

Dr. Bruce: If there's any question please go to the doctor.

Audience question: [inaudible 59:30]

Dr. Bruce: The question originally was how do you know if your child has diabetes. So, there are lots of really serious consequences associated with childhood obesity. Now the cause of obesity really boils down a pretty simple equation, and I say simple in quotes here because the reason for this imbalance becomes much more complex.
At its root, it's a very basic equation of energy intake compared to energy expenditure. If a person consumes more calories than they're burning and does that for a period of time, they will put on excess weight.
Now there are really important and this is where it becomes much more complicated. The reason for this energy imbalance is based a lot on social factors. It's based on economic factors. Genetic factors and epigenetic factors. I like to show this because it's such a dramatic illustration of how portion size has changed over the past 50 years or so.
We see that a hamburger at Burger King used to be about 2.8 ounces of meat. In 2004 here we've got a 3.4 ounce burger, and that's not even for the third a pound or bigger. French fries you can see the dramatic difference here, and chocolate bars. I think you can buy chocolate bars that are even larger than this now. Sometimes they're for Valentine's Day or I know for Easter you can find enormous chocolate bunnies. So, portion sizes have increased a great deal.
As a dog owner, I appreciate the spirit of this. Getting your dog exercise, that's important. But come on, you know. It's probably good to get some exercise yourself.
We also live in what's been called an obesogenic society. Our society is really easy in the sense that we don't have to do a lot of physical work. We don't have to get out the scrub board, the wash board and physically do our laundry. We push a button. Take it out, put it in the dryer, press a button. We don't have to go out and hang it on the clothes line to dry.
Technology has made it so that we don't have to expend much physical effort at all on a daily basis. The consequence of that is often increased sedentary activity. A lot of our lives are spent sitting.
This is also ridiculous. At least this Segway requires some sort of core muscle strength. You could argue that she's balancing on this.
Now this is an actual fitness center. You wouldn't want to do too much work, you wouldn't want to burn any more calories than you'd burn in your workout. This is San Diego actually. This fitness center.
So things like elevators, escalators, moving sidewalks in airports, getting from one end of the airport to the other. You can just stand there with your luggage instead of walking. Most people, when they get on an escalator, they don't continue walking up the stairs and get there faster, they just get on and stand, and then you can't get around them without acting like a jerk, right? So you're kind of stuck.
Our society is very easy from a physical activity standpoint. We have to often go out of our way to get physical exercise. As I mentioned, why there's a disruption in energy balance, why there is this chronic greater energy intake than expended is much more complicated, and the research that I'm going to talk to you a little bit about tonight really focuses on these three areas. The intersection of economic reasons, societal reasons, and brain reasons for this energy imbalance.
As I mentioned, I'm going to talk about functional neuroimaging. Brain imaging. It's a tool that allows us to better understand the brain's role in eating behaviors. From studies that my colleagues and I have published along with a lot of other researches in the field, we know that brains of obese individuals act different than brains of healthy weight individuals.
Those studies have been done mainly in adults. Let me talk a little about this brain imaging technique. Magnetic resonance imaging, MRI, some of you have probably had MRIs. The advantage of an MRI is that it does not involve radiation. When we approach families about their kids participating in studies, one of the things the parents often first say is I don't want my kid exposed to any radiation. We say no, this is essentially just a large magnet.
It's non-invasive. It doesn't involve radiation. The trick is that people have to hold very, very still. They can't move more than a few millimeters in any direction, and for kids, particularly, that can be a big challenge. What the MRI gives us is beautiful pictures of the structure of the brain.
This is a slide showing three different orientations, views, of the human brain. This coronal slice, the slice that's just like this. The sagittal slice, you can probably tell which way this is slicing because you can see this person's nose, so it's slicing exactly like this. And then, this axial view, think of an axe chopping. This is looking down at a person's brain. These are really beautiful, nice, crisp, clear images of the structures of the brain.
I used functional MRI which adds a dimension of which areas of the brain are active. So we are not only looking at just the structures of the brain, but when a person is doing a particular task while their brain is being scanned, we're able to see which areas of the brain are active.
The way an FMRI works is that it uses blood oxygenation. If an area of the brain is active, if any area of the body in fact, it needs energy, and energy comes in the form of oxygen. An FMRI uses blood oxygenation as a proxy for brain activity. We're able to see, and I'll show you some pictures in just a second, which areas of the brain are active, how much they're activated, and we're able to extract numbers from that.
Here are some FMRI images that show regions of the brain, and you see bright yellow, right red blobs. The bigger the blob, that means something. The brighter the blob also means something, and the color of the blob means something.
Here you can see blue. The blue indicates a deactivation, so relatively less activation, whereas a yellow or red area of activation indicates an increase of activation.
A study that we did a couple of years ago looked at obese children and compared them to healthy weight children when they were doing a visual food motivation paradigm in the scanner. We were showing them images of appetizing food and then we were showing them images of animals, and then we were showing them blurry baseline images.
One thing that we had to be careful of with the animal images is that none of them were reminiscent of animals we might eat. No chickens, no cows, although most people don't look at a cow and think yum I'm craving steak.
Most people don't. There might be some people that do that, but most of us are so far removed from our actual food source, the actual animal that when you see a cute little chicken you don't think about grilled chicken kebabs.
Basically what we found in this study is that there were differences between how obese children's brains responded to these food pictures and how the healthy weight children's brains responded. We scanned them both before they had eaten, so when their food motivation was high, when they were hungry, and then we scanned them again after that eaten, and overall the obese children showed hyperactivation, more activation, in brain regions involved in reward and motivation than the healthy weight kids. Both times. Both pre-meal and post-meal.
What they didn't show was reduction. So after they ate, their brains didn't normalize. Their brain activation didn't decrease in the same way that the healthy weight children's brain activation did. Does that make sense? They stayed hyperactivated even after they had eaten.
So here's an example of the paradigm. We've got some lovely looking blueberry muffins here. We have this cute dog. No one would want to eat him. And then here's the blurry baseline picture.
After we did this study, I started thinking it might be interesting to see what would happen if we showed obese children and healthy weight children images that represent food but aren't actually food. That led us to our next study looking at food logos.
Most of you probably recognize all of these on here. One thing we wanted to take particular care with when we chose our logos to put in this scanner is that they were familiar to the kids. We didn't want to show kids logos that they weren't familiar with.
We wanted to choose the most familiar food logos and non food logos when we put these kids in the scanner because neuroimaging research is very expensive. It costs $600 an hour, and it takes one hour to scan one person. So it's basically $600 per participant to run these studies.
We made sure that the logos that we used were familiar to the kids. We also wanted to make sure that they were matched on how happy they made the kids feel and how exciting they thought they were, because what we found is we asked a completely separate group of kids to rate these logos on how familiar they were, how happy they made them feel, and how much it made them think of food or drink.
In general, the food logos made the kids feel happier. They said on average I feel happier looking at those. So we had to throw out some of the happiest food logos to get the samples to match. We also had to throw out some of the non- food logos that reminded kids of food. I have these here at the bottom.
Shell, what's that? Gas, right? The kids said that makes me think of food. Their parents might be running inside to get them a Slurpee or a candy bar. That made them think of food. Target also. They said that makes me think of food. So we didn't use these in the non-food logo group because that would make results messy.

Audience question: [inaudible 01:13:30]

Dr. Bruce: I didn't. No. That's a good question. These kids were between the ages of 10 and 14. I've scanned as young as age eight, but it gets really difficult under the age of eight to get them to hold still.
There were 10 kids in each group, and the most interesting finding from this study that we published just this fall in the Journal of Pediatrics was that healthy weight kids showed greater activation bilaterally, which means both sides, in this middle prefrontal cortex to inferior prefrontal cortex.
What does that mean? This area of the brain has been shown in other studies to be related to self control, inhibition and self regulation. When the healthy weight kids are seeing these food logos, they have this brain activation that's kicking in self control regions that the obese kids don't seem to have.
All the kids showed activation in reward regions of the brains, so all of the kids lit up when they saw these logos. I piloted the study myself when we were getting ready to run participants and my brain lit up. These stimuli are rewarding, we know that, but what was different was that healthy weight kids showed this bilateral activation in a region associated with self control. Yeah?

Audience question: Had they eaten before the study?

Dr. Bruce: Good question. It had to have been about four hours since they had last eaten. They wouldn't have been incredibly hungry. We looked at hunger differences between the two groups, the healthy weight and obese, and they weren't significantly different. But that's a great question. Any other questions?

Audience question: Would you say these areas involve anything else besides self control?

Dr. Bruce: Yes. So the question is, are these areas involved in anything else? Yes. That's one of the most difficult things about interpretation of brain data. This particular region just doesn't do one thing. This region is also involved in decision making, in planning ahead.
It's hard to say that there is a one-to-one relationship. You're absolutely right. We collected some questionnaire data at the same time as this brain data, and one thing we did see with the questionnaire data is that the obese children were reporting higher levels of impulsivity than the healthy weight children were.
We had a little bit of behavioral data to back this up. Interestingly, we asked the parents to report on their kid's levels of self control and impulsivity, the parents of the obese kids and the parents of the healthy weight kids, there was no difference in how they talked about their kid's levels of self control, but for the kids themselves, the obese kids as a group were reporting higher levels of impulsivity than the healthy weight kids were.
How did we interpret this? Our preliminary interpretation of these findings is that these healthy weight kids are showing more brain activation in areas associated with self control, and as I mentioned just a moment ago, healthy weight children reported having more self control than the obese children on the questionnaire.
This is a very bizarre picture, but in terms of practical implications, to avoid having our kids, our babies, our young kids, any kids branded with these popular food logos. One thing I'd like to leave you with is just a sense of awareness of how prevalent marketing is in our society. Just to think and be a little more aware of how you are influenced by marketing.
The next time you go and buy toothpaste, for example. I don't know if any of you have bought toothpaste recently. The toothpaste aisle is overwhelming. It stretches. It starts here and probably stretches all the way across to the edge of that whiteboard. Floor to ceiling. Different whitening.
The next time you're buying toothpaste just stop and think why am I buying the toothpaste I'm buying. Is it because of marketing? Think about how you're influenced by advertising just on a daily basis.
Another really important thing is to limit screen time for children. The American Academy of Pediatrics says under the age of two, kids should not have screen time. They should not be watching TV. They should not be playing on your smartphone. They should not be engaging in any sort of screen time under the age of two.
This is not easy. As a mom of three little kids, this is not easy to do. It's very tempting, very easy. Kids are sucked in by TV. It's not easy to do but it's really important to do.
Then for older kids, it should be a maximum of two hours a day. The more time they're spending in front of a screen, the less time they're spending reading, being physically active, doing other things that are really, really important for development.
I think another important piece is that kids, and really all of us as adults need to be more critical about advertising. When you see an ad or a commercial on TV, think about what message are the selling. What are they actually selling versus what is the truth?
I think one supreme example of this is Abercrombie & Fitch. For a while their models were nude. They're not wearing clothes and they're trying to sell clothes. Doesn't that seem ironic? That seems totally ironic to me.
So think about the message, and we've worked with our girls on the messages advertisers are trying to tell them, and they'll say something like you'll have so much fun when you wear these shoes and you'll be happy when you wear these shoes, and we say is that true and they say no. So we're trying to work with them to be critical of advertising.
Another piece of this that's very important is to practice self control. Both ourselves and to teach our children self regulation and self control. There have been so many studies done on looking at the ability to delay gratification and the ability to wait for a delayed reward.

One of my favorite studies is the marshmallow test. Maybe you've heard of it. Back in the late 1960s and early 1970s they brought preschoolers into the lab and they set them in front of this big puffy marshmallow and said you can eat this marshmallow, you can have it, but if you wait until I come back in the room, you can have two. They timed these kids to see how long they could wait.
I encourage you to go on YouTube and type in "The Marshmallow Test''. They have adorable little videos of these poor kids that look tortured by this puffy marshmallow, and what they found was that the longer the kids waited, and if they were able to wait until the researcher returned to the room, they predicted all kinds of really good things later on.
They're still following these kids now turned into adults, and the ability to wait for that marshmallow predicted SAT scores, it predicted GPA, success in school, success in relationships, and income in their jobs. They just came out with a study that looked at BMI, body mass index, and that ability to wait as a preschooler predicted body mass index. So, self control is incredibly important.
From a broader perspective, we need to think about self regulation training into both obesity prevention and intervention programs. I think we also need to think very carefully about marketing to children and whether it's ethical that we market these incredibly addictive, for lack of a better word, foods, high in sugar, high in fat, high in salt, to children who may be more vulnerable.
From this preliminary brain data that we have, there is something different about the brains of healthy weight kids and obese kids that might be making obese children more vulnerable to advertising.
Thinking about Joe Camel and how there was a very long, uphill struggle to get him banned, and tobacco companies could no longer market using Joe Camel to kids. Maybe we need to think about that with the food industry and food marketing. That would not be an easy task by any stretch, but it might be something we need to think about.
Thank you all for your attention and for your questions. I'm happy to take any more questions at this point.

Audience question: I'd like to ask a question.

Bill: Yeah, please.

Audience question: I don't see any hope for children unless their parents are educated about the right things to eat. I didn't know until a few months ago that kale was one of the top nutrient foods. I had never heard about it before, so it's a learning process.

Dr. Bruce: It is. Education for parents is key to this.

Bill: Other questions for Amanda?

Audience question: This isn't a question so much as it is a comment. I cannot cite the source, but I believe a couple of months ago I ran across a follow up on that marshmallow test, and in the follow up the researcher either made a promise and kept it to a child, or made a promise and broke it, and if the child had been the recipient of the broken promise, then their willingness to wait was much, much lower, so you're talking about issues of trust and relationship in the development in the ability to wait and to have good executive function.

Dr. Bruce: I was fascinated when I read that study. It's a wonderful study and it speaks a lot to how important the environment is for kids, and if kids are able to trust their environment, if someone promises them something in the future can they trust that? And for kids from disadvantaged backgrounds, if someone says you're going to get something in the future and they learn they cannot count on it, it's actually a better decision for them, a more rational decision to take what's right in front of them at the time. Yeah. Thanks for bringing that up. That's such an interesting point.

Audience question: Can trying new foods as you get older have something to do with obesity, or trying new foods that your parents wouldn't let you eat, but as you got older you tried it? Could that be a thing?

Dr. Bruce: Sure. Trying new foods. We see that with kids, especially with vegetables. The first several times they've tried a vegetable they do not like it. Research shows that it's about 17 tries of a new food before you learn to like it. I used to hate avocado and mushrooms and now I love them. It took me a long time and we've told our daughters this and now Ella was saying she didn't like something the other day and Aida said Ella, you're going to have to try that 16 more times before you learn to like it.

Audience question: I was wondering was it the brain activation patterns that lead to the obesity or whether is it the obesity that leads to the brain activation patterns. Has anybody ever looked at individuals who were once obese but are no longer obese to see if in response to food imagery would they show the brain activation patterns of a healthy weight or an obese person?

Dr. Bruce: That's a fantastic question, and yes. People have looked at that. Brain patterns change after weight loss. We have a study under review right now that's comparing people who have lost weight from a surgical intervention, laparoscopic banding surgery.
We scanned them before and after they lost weight, and then people who've lost weight from a diet intervention, so they changed what they ate, went on a diet, and lost the weight. We matched these groups for the amount of weight that they lost. Both groups brain activations changed, and interestingly they changed in different ways. The method of weight loss also predicted how the brain changed.
I don't have the slide in this presentation, but the most interesting finding that we interpreted was the diet participants showed an increase in the medial prefrontal cortex, kind of smack dab in the middle of your forehead, and the bariatric surgical participants after they lost weight showed a decrease in that area, and that area has been known to be associated with how you value something and how attentive and salient it is.
So, our interpretation is that the folks who lost weight from a diet, when they see appetizing food, they're still very attentive to that. But for some reason, the surgery makes people not value those food stimuli as much.

Audience question: I had a question. You keep saying screen time. Are you specifically talking about TV with ads, or are you talking about and sedentary time like sitting in front of a video or something like that. Since you're directing toward advertisement and exposure to ads.

Dr. Bruce: Right. So there are degrees. If you're going to have your kid have screen time, an educational video is going to be better than TV with commercials in it for sure. The American Academy of Pediatrics recommendation for kids under the age of two not having screen time, that means any. All screen time.
I had trouble with that because we have relatives that are far away in Maine, and we like to Skype with them, and so for Skyping, the grandparents need to see the grandkids, the babies that were under two were going to Skype with them. But you're right. For older kids with screen time, a video with no commercials is definitely preferable to programming TV.

Audience question: Are there any studies of the imaging of how food is presented to children? What happens to their brain when a person says they'd give them a strawberry and they talk about how good this is? This is what we do with chocolate chip cookies. They're wonderful and we present it like that. Is there a study done of any type of presentation like that?

Dr. Bruce: That's a great question. Not neuroimaging studies. I'm sure there are behavioral studies, but no neuroimaging studies that I know of have looked at how foods are presented to kids. But you're right. I think that watching their parents eat them too, do parents eat their vegetables, are they eating their broccoli or kale, or are they just trying to get the kids to eat it, yeah. That's a really important piece.

Audience question: Do the self control regions of the brain go through development with age from childhood to adulthood, and do you think that maybe would allow the individuals to have more ability to control and make better decisions as far as diet?

Dr. Bruce: That's a fantastic question and you've hit the nail on the head. You're absolutely right. This area of the prefrontal cortex that we saw lit up doesn't really develop fully until a person is in their mid 20s. It's also the last region of the brain to develop and that's one reason why adolescents often make very risky choices, very impulsive choices leading to risky health behaviors and often trouble.
You're absolutely right. This brain area develops last and the trick is going to be to see if you can work on self control despite the fact that it's developing last. Awesome question.

Bill: Any other questions?

Audience question: Yes. I had a question about the American Academy of Pediatrics. Why did they choose two years as the limit?

Dr. Bruce: I don't know the answer to that question. I don't know why it's two years. There have been studies looking at screen time and correlations made between the development of ADHD and more screen time. The way our brains are wired, particularly as infants, the way TV comes at us, it's so fast and stimulating. Especially a lot of kids programs are very fast, and that's not the way our brains are meant to work. It's not good for their brains early on. I don't know why it's age two though.

Audience question: If I can piggyback on that question a little bit, too. I guess that brings up the two hour time limit or even less than. It brings up the question of interactive games that are educational games. Does that have the same impact as if they're sitting in front of a television that's not interactive? Does it still have the same impact because of that?
A few years back, it's my recollection that the limit was one year before they could watch any television but then after that because of studies that linked it to the development of ADHD and other things of that nature. Are even the interactive games are included in that time limit as well?

Dr. Bruce: Yeah. Interactive games are included in that time limit. As I said, there are certain types of screen time that are better than others, so an interactive educational game is going to be better than putting them in front of a PG-13 movie or putting them in front of adult programming with advertisements.

Bill: Well, thank you all for coming; look for us again next year. I want to thank Dr. Bruce for coming from Kansas, and Dr. Boughter for helping us out from UT. Drive safe and see you next year.