Encouraging consumption of water in school and child care settings: access, challenges, and strategies for improvement

A Technology-Driven, Healthcare-Based Intervention to Improve Family Beverage Choices: Results from a Pilot Randomized Trial in the United States

Background: Healthcare-based interventions to address sugary beverage intake could achieve broad reach, but intensive in-person interventions are unsustainable in clinical settings. Technology-based interventions may provide an alternative, scalable approach. Methods: Within an academic health system in the United States that already performs electronic health record-based sugary drink screening, we conducted a pilot randomized trial of a technology-driven family beverage choice intervention. The goal of the intervention was to reduce sugar-sweetened beverage (SSB) and fruit juice (FJ) consumption in 60 parent-child dyads, in which children were 1-8 years old. The pediatrician-initiated intervention consisted of a water promotion toolkit, a video, a mobile phone application, and 14 interactive voice-response phone calls to parents over 6 months. The study was conducted between June 2021 and May 2022. The aim of the pilot study was to assess the potential feasibility and efficacy of the newly developed intervention. Results: Intervention fidelity was excellent, and acceptability was high for all intervention components. Children in both the intervention and the control groups substantially decreased their consumption of SSB and FJ over follow-up (mean combined baseline 2.5 servings/day vs. 1.4/day at 6 months) and increased water consumption, but constrained linear mixed-effects models showed no differences between groups on these measures. Compared to parents in the control group, intervention parents had larger decreases in SSB intake at 3 months (-0.80 (95% CI: -1.54, -0.06, p = 0.03) servings daily), but these differences were not sustained at 6 months. Conclusion: These findings suggest that, though practical to implement in a clinical care setting and acceptable to a diverse participant group, our multicomponent intervention may not be universally necessary to achieve meaningful behavior changes around family beverage choice. A lower-intensity intervention, such as EHR-based clinical screening alone, might be a less resource-intense way for health systems to achieve similar behavioral outcomes. Future studies might therefore explore whether, instead of applying a full intervention to all families whose children overconsume SSB or FJ, a stepped approach, starting with clinical screening and brief counseling, could be a better use of health system resources.

School environment and obesity in adolescents from a Brazilian metropolis: cross-sectional study

Background

Childhood-juvenile obesity is a globally acknowledged public health issue. The school environment has been widely assessed because it is where adolescents stay longer during the day, and it may have impact on obesity. School became a crucial environment for obesity prevention in children and adolescents. The aim of the present study was to associate schools’ internal environment factors and its surrounding areas with obesity in adolescents from a Brazilian metropolis.

Methods

Cross-sectional study based on data from the Study on Cardiovascular Risk in Adolescents. The sample comprised 2,530 adolescents in the age group 12–17 years, who were enrolled in public and private schools in Belo Horizonte City, Brazil. Obesity was the dependent variable based on the cut-off point score-z + 2 for body mass index based on age. School environment’s independent variables were ‘managerial dependence type’, ‘number of drinking fountains’, ‘school sports environment’ and ‘ready-to-eat food shops’ around the school (within an 800 m buffer).

Results

Obesity prevailed in 7.21% in sample. The largest number of drinking fountains decrease by 9% the chances of obesity in adolescents enrolled in public and private schools; however, the second and third terciles recorded for the number of ready-to-eat food shops within the 800 m buffer around schools increased by 24% and 44% the chances of obesity, respectively.

Conclusion

School food environment aspects such as the number of operational drinking fountains and the availability of ready-to-eat food shops around the school were associated with obesity in adolescents from a Brazilian metropolis.

Assessing Access to WASH in Urban Schools during COVID-19 in Kazakhstan: Case Study of Central Kazakhstan

The WHO/UNICEF Joint Monitoring Program (JMP) for Water Supply, Sanitation and Hygiene (WASH) produces global estimates of the real situation of access to water, sanitation and hygiene services, and sanitation and hygiene in households, educational institutes and health care facilities; however it is lacking data on schools in Kazakhstan. Thus, the aim of this research was to assess access to WASH in schools of urban area in Kazakhstan. The study was conducted in seven schools of Central Kazakhstan during the COVID-19 pandemic and restrictive measures. Three data collection methods were used: a questionnaire for administrative staff, a questionnaire for parents and observation. Parents of offline study pupils (only second and third grades due to the pandemic) were included in the survey. Students had access to in-building toilets in all schools connected to the centralized sewer. The number of school toilets varied from 7 (KAZ200085) to 61 (KAZ200089). The average amount of toilets was 28.08 ± 16.97. Only two out of seven schools complied with the requirements of Kazakhstan national sanitary standards for the ratio of school toilets to the number of students. From the questionnaire with the school administrations, it was defined that the primary source of drinking water was the public water supply. All schools regularly disinfect and check the water supply system. At the same time, the results also revealed discrepancies in the answers between administration and parents (2.6% of parents showed that their children have rare access to drinking water), and insufficient monitoring of implementation of WASH services. This study also confirmed that the full provision of access to water and water services in the structure of educational institutions solves several SDG targets.

Availability of a Flavored Beverage and Impact on Children's Hydration Status, Sleep, and Mood

Euhydration remains a challenge in children due to lack of access and unpalatability of water and to other reasons. The purpose of this study was to determine if the availability/access to a beverage (Creative Roots^®) influences hydration in children and, therefore, sleep quality and mood. Using a crossover investigation, 46 participants were randomly assigned to a control group (CON) or an intervention group and received Creative Roots^® (INT) for two-week periods. We recorded daily first morning and afternoon urine color (Ucol), thirst perception, and bodyweight of the two groups. Participants reported to the lab once per week and provided first morning urine samples to assess Ucol, urine specific gravity (USG), and urine osmolality (Uosmo). Participants also completed the questionnaires Profile of Mood States-Adolescents (POMS-a) and Pittsburgh Sleep Quality Index (PSQI). Dependent t-tests were used to assess the effects of the intervention on hydration, mood, and sleep quality. Uosmo was greater and Ucol was darker in the control group (mean ± SD) [Uosmo: INT = 828 ± 177 mOsm·kg⁻¹, CON = 879 ± 184 mOsm·kg⁻¹, (p = 0.037], [Ucol:INT = 5 ± 1, CON = 5 ± 1, p = 0.024]. USG, POMS-a, and PSQI were not significant between the groups. At-home daily afternoon Ucol was darker in the control group [INT = 3 ± 1, CON = 3 ± 1, p = 0.022]. Access to Creative Roots^® provides a small, potentially meaningful hydration benefit in children. However, children still demonstrated consistent mild dehydration based on Uosmo, despite consuming the beverage.

COVID-19 Pandemic and Remote Education Contributes to Improved Nutritional Behaviors and Increased Screen Time in a Polish Population-Based Sample of Primary School Adolescents: Diet and Activity of Youth during COVID-19 (DAY-19) Study

The Coronavirus-19 disease (COVID-19) pandemic has influenced the nutrition of individuals, including the diet followed, food availability, and food security. However, thus far, only a few studies have been published regarding the diet and activity of children and adolescents. The aim of the present study was to analyze the influence of the COVID-19 pandemic and remote education in this period on the diet and physical activity in a Polish population-based sample of primary school adolescents. In June 2020, the Diet and Activity of Youth during COVID-19 (DAY-19) Study was conducted on a population recruited based on stratified random sampling from all regions (schools sampled from counties, and counties from voivodeships). The sample consisted of a total of 1334 adolescents aged 10–16 years. The study assessed the diet and physical activity of the participants using a validated questionnaire which included questions about the period of remote education and the period before the COVID-19 pandemic. The participants were asked about the following: consumption of fruit, vegetables, soft drinks, water, French fries, and fast food; eating meals in front of the television; and the number of days they are physically active and the number of hours they spend watching television. The obtained data were analyzed by stratifying the respondents by the gender, age, size of the city and total COVID-19 morbidity in the voivodeship. It was observed that, during the pandemic and the resultant remote education, the proportion of respondents who declared the recommended intake of fruits and vegetables had increased compared to that before the pandemic—a higher proportion consumed at least three portions of fruit per day (19.0% before pandemic vs. 27.4% during pandemic; p < 0.0001), as well as three and four or more portions of vegetables per day (11.9% vs. 14.5% and 7.5% vs. 11.1%; p = 0.0004). At the same time, the proportion of respondents consuming at least three cups of water per day had increased (41.1% vs. 47.9%; p = 0.0020), whereas the proportion of respondents who never or rarely eat their meals in front of the television had decreased (35.6% vs. 28.9%; p < 0.0001), and the proportion watching television for more than 2 h a day had increased (78.3% vs. 88.4%; p < 0.0001). Based on the results, it may be concluded that, during the period of remote education due to the COVID-19 pandemic, the dietary behaviors of the studied population of Polish adolescents were more beneficial, which included a higher intake of fruit, vegetables, and water, compared to before the pandemic. In spite of the increasing screen time, including eating in front of the television, there was no reduction in the number of days the respondents were physically active.

Factors associated with water quality, sanitation, and hygiene in rural schools in 14 low- and middle-income countries

Improving access to water, sanitation, and hygiene (WaSH) and menstrual hygiene management (MHM) in schools is important to achieve Sustainable Development Goals (SDGs) 3 and 6. Inadequate WaSH and MHM in schools adversely affect student health and educational performance, as well as teacher satisfaction. However, there is little evidence describing factors associated with WaSH services and MHM in schools. We conducted 2690 surveys and collected 1946 water samples at randomly selected schools in rural areas of 14 low- and middle-income countries (LMICs). We developed multilevel mixed-effects logistic regression models to identify factors associated with basic water services, water quality, basic sanitation facilities, basic handwashing facilities, and availability of MHM materials. We found that 51% of schools had at least a basic, on-premises water service. Twenty-eight percent of schools had at least basic sanitation services, 12% had at least a basic handwashing facility, and 26% had MHM materials available. Four percent of schools had all basic WaSH services. Half (52%) of schools had drinking water compliant with the WHO guideline value for E. coli. In regression models, we found that schools that did not share their water point with a community, had a parent-teacher association that supported WaSH, or had support from an external WaSH program were more likely to have access to basic, continuous, on-premises water service versus worse access. Schools with an on-premises water point, water available on the day of survey, a health club, or handwashing stations near toilets were more likely to have a basic sanitation service versus a lower service. Schools with limited or basic sanitation, health clubs, an MHM curriculum, a designated MHM focal person, or school funds for WaSH were more likely to have MHM materials. We conclude that improved institutional management and external support, accountability mechanisms, and enhanced training and hygiene curriculum will support sustained WaSH service delivery in schools in LMICs.

SODA MAPS: A Framework for Understanding Caffeinated Sugary Drink Consumption Among Children

Excess sugary drink (SD) consumption is associated with childhood obesity and development of cardiometabolic disease. In addition to having high added sugar content, many SDs also contain caffeine, which may further encourage excess SD consumption among children. The objective of this study was to develop a conceptual framework of children's caffeinated SD consumption using group concept mapping, an applied social research multimethodology that collectively harnesses qualitative and quantitative data from participants to generate a visual representation of their ideas and input. Children, 8–14 years old, who reported consuming ≥12 ounces of caffeinated SDs (e.g., sodas, sweet teas) per day were recruited throughout Washington, D.C. and invited to participate. Concept mapping included three participant-driven activities: (1) brainstorming (n = 51), during which children reported reasons for their SD consumption, from which 58 unique reasons were identified; (2) sorting (n = 70), during which children sorted each of the reported reasons into categories and named each category; and (3) rating (n = 74), during which children rated the influence of each reason on their own caffeinated SD consumption. Similarity matrices, multidimensional scaling, and hierarchical cluster analysis were used to generate concept maps (hereafter “SODA MAPS”), which display the 58 reasons organized within eight overarching clusters. Among these eight clusters, Taste and Feel, Something to Do, and Energy were rated as particularly influential. Children's caffeinated SD consumption is encouraged not only by the palatable taste and reported preferences for these beverages (e.g., Taste and Feel), but also by psychological (e.g., Mood and Focus), biological (e.g., Energy), social (e.g., Something to Do) and environmental reasons (e.g., Nothing Better Available). Thus, the SODA MAPS can inform the development of tailored, multi-level SD reduction interventions that incorporate strategies to address important and currently overlooked reasons for caffeinated SD consumption among children.

Participatory Approaches to Understand Dietary Behaviours of Adolescents in the Secondary School Setting

Acknowledgement of wider socio-ecological factors that influence dietary behaviours needs greater consideration in nutrition research with young people. Additionally, children and adolescents have a right to have their voices heard in research that concerns them. The aim of this methods paper is to describe and evaluate participatory methodologies undertaken as part of a dietary behaviour study with adolescents in the school setting in Ireland. Photovoice and peer-led focus groups were the key participatory methodologies, undertaken alongside food diaries and anthropometry. These methodologies were evaluated through discussion with peer researchers, qualitative surveys and in the context of the wider study process and outcomes. Peer researchers reported learning new skills including research, facilitation, listening and social skills and many felt they gained confidence, as well as an awareness about healthy and unhealthy practices at school. The findings were found to be authentic according to students, except for two limitations. Students believed body image was not adequately represented in the findings, and alternative focus group compositions could have influenced discussion content. Youth participants were afforded genuine opportunities to have their voices heard as part of a diet and nutrition research and the methodologies were acceptable and enjoyable. They demonstrated agency in valuable contributions at project design, data collection, analysis and interpretation stages of the research process. Furthermore, the participatory methodologies complemented quantitative data by providing environmental, behavioural, and socio-cultural insights into food choice in the school setting.

Beyond taste and easy access: Physical, cognitive, interpersonal, and emotional reasons for sugary drink consumption among children and adolescents

Consumption of sugary drinks is associated with the development of obesity and cardiometabolic diseases among children and adolescents. In addition to high added sugar content, many sugary drinks also contain caffeine. However, whether the combination of sugar and caffeine uniquely influences children's sugary drink intake is presently unknown. This study aimed to evaluate contextual factors surrounding children's sugary drink consumption and investigate reasons for sugary drink intake among children and adolescents, with a specific focus on caffeinated sodas and sweet tea. We also evaluated how sugary drink consumption makes children feel and how they anticipated that they would respond if sugary drinks were restricted. Focus group discussions (n = 9, 2-8 participants per group) were conducted with 37 predominantly AfricanAmerican children and adolescents, ages 8-14 years, who consumed ≥1 caffeine-containing sugary drink(s) daily, based on parental report. Focus groups were audio-recorded and transcribed verbatim. Transcripts were independently coded by two coders, after which emergent themes were identified. Reported reasons for sugary drink consumption encompassed five themes: 1) perceived need (e.g., satisfy cravings, quench thirst); 2) physical and cognitive benefits (e.g., provide energy, improve attention); 3) emotional and interpersonal benefits (e.g., relieve anger, facilitate socializing); 4) sensory properties (e.g., taste, carbonation); and, 5) external cues (e.g., family/peer modeling, availability). Negative consequences resulting from excess intake were also reported, including gastrointestinal symptoms, headaches, fatigue, hyperactivity, and chronic disease. Perceived physical, cognitive, emotional, and interpersonal benefits encourage sugary drink consumption and exacerbate well-described challenges of sugary drink reduction, including their palatability, accessibility, and affordability. Findings also suggest that incorporation of strategies to enhance physical, cognitive, and emotional health may hold promise in reducing sugary drink consumption among children and adolescents.

Drinking water access in California schools: Room for improvement following implementation of school water policies

This study aims to investigate how access to free drinking water in California public schools changed after implementation of 2010 federal and state school water policies. Repeated cross-sectional surveys were conducted with administrators in a random sample of California public schools, stratified by school type and urban-centric geography, from 2010 to 2011 (n = 240) and from 2016 to 2018 (n = 240). Surveys assessed excellence in drinking water access, defined as 1) providing water in 4 of 5 key school locations, 2) having a high density of free water available, 3) providing water via a non-fountain source, 4) providing water that is perceived as safe, and 5) offering water sources that are reported as clean and functioning. Multivariate logistic regression was used to examine changes in excellence in drinking water access after implementation of school drinking water policies. Analysis was completed in 2019. In 2010-2011, 5% of schools met all water excellence criteria; in 2016-2018, 18% of schools met all excellence criteria. In adjusted models, post-legislation schools had 4 times the odds of meeting all drinking water excellence criteria compared to pre-legislation schools (OR: 4.34; 95% confidence interval = 2.07, 9.10). There were significant increases in public schools meeting the criteria for excellence in free drinking water access after school water policies were implemented; however, a majority of schools still lacked excellent water access. Findings suggest that policies mandating free water access in schools may help to improve excellence in access, and more work is needed to help all schools excel in this area.

Post-Healthy, Hunger-Free Kids Act Adherence to Select School Nutrition Standards by Region and Poverty Level: The Healthy Communities Study

OBJECTIVE

This study determined the extent to which schools adhered to select nutrition and wellness provisions of the 2010 Healthy, Hunger-Free Kids Act and examined differences by US region and school poverty level.

DESIGN

Comparison of cross-sectional observational data from the Healthy Communities Study (2013-2015) by region and school poverty level.

PARTICIPANTS

A total of 401 US elementary and middle schools.

MAIN OUTCOME MEASURES

Adherence with federal nutrition standards for meals and competitive foods; extent of implementation of select aspects of school wellness policies.

ANALYSIS

Descriptive statistics and multivariate regression were used. Differences were examined by school poverty level and region, adjusting for other school- and community-level covariates.

RESULTS

Most schools reported meeting reimbursable school meal nutrition standards (74%); more schools in the West met nutrition standards (82%) than in the Midwest (64%). Most grains offered at lunch were whole grain-rich (82%), and most competitive foods complied with standards (78%) before they were required. Most schools had a wellness coordinator (80%). Lowest levels of adherence were reported for guidelines for classroom or school event foods. No differences were observed by school poverty level.

CONCLUSIONS AND IMPLICATIONS

Findings suggest that Healthy Hunger-Free Kids Act provisions were feasible across a wide variety of schools, and schools successfully implemented reimbursable school meal nutrition standards regardless of school poverty level.

Cost-Effectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake

OBJECTIVE

This study aimed to estimate the cost-effectiveness and impact on childhood obesity of installation of chilled water dispensers ("water jets") on school lunch lines and to compare water jets' cost, reach, and impact on water consumption with three additional strategies.

METHODS

The Childhood Obesity Intervention Cost Effectiveness Study(CHOICES) microsimulation model estimated the cost-effectiveness of water jets on US childhood obesity cases prevented in 2025. Also estimated were the cost, number of children reached, and impact on water consumption of the installation of water jets and three other strategies.

RESULTS

Installing water jets on school lunch lines was projected to reach 29.6 million children (95% uncertainty interval [UI]: 29.4 million-29.8 million), cost $4.25 (95% UI: $2.74-$5.69) per child, prevent 179,550 cases of childhood obesity in 2025 (95% UI: 101,970-257,870), and save $0.31 in health care costs per dollar invested (95% UI: $0.15-$0.55). In the secondary analysis, installing cup dispensers next to existing water fountains was the least costly but also had the lowest population reach.

CONCLUSIONS

Installating water jet dispensers on school lunch lines could also save almost half of the dollars needed for implementation via a reduction in obesity-related health care costs. School-based interventions to promote drinking water may be relatively inexpensive strategies for improving child health.

Teachers as Healthy Beverage Role Models: Relationship of Student and Teacher Beverage Choices in Elementary Schools

Schools are a key setting for curbing student intake of sugar-sweetened beverages (SSBs). While studies suggest that restrictions on SSBs, increased access to healthier beverages, and education about the importance of drinking water instead of SSBs can promote healthier beverage patterns among students, there is little known about the impact that teachers' own beverage choices can have on those of their students. Data were drawn from cross-sectional surveys administered as part of a larger evaluation of a drinking water access and promotion intervention in public elementary schools in the San Francisco Bay Area region of California. Descriptive statistics were used to examine teacher (n = 56) and student (n = 1176) self-reported beverage consumption at school. Mixed-effects logistic regression was used to examine associations between teacher and student beverage intake adjusting for clustering of students by teacher. Teachers were also surveyed via open-ended questions about strategies to increase student water consumption at school. Nearly all teachers reported drinking water during the school day (95%), often in front of students. Teacher SSB intake was rare (9%). Students whose teachers drank water in front of their classes were significantly more likely to report drinking water during the school day. Teachers tend to select healthy beverages at work and may serve as role models to encourage student consumption of water instead of SSBs.

Public Health Consequences of Lead in Drinking Water

PURPOSE OF REVIEW

Lead can enter drinking water from lead service lines and lead-containing plumbing, particularly in the presence of corrosive water. We review the current evidence on the role of drinking water as a source of lead exposure and its potential impacts on health, with an emphasis on children. Drinking water guidelines and mitigation strategies are also presented.

RECENT FINDINGS

The impact of lead on neurodevelopmental effects in children even at low levels of exposure is well established. Population and toxicokinetic modeling studies have found a clear relationship between water lead levels and blood lead levels in children at low levels of lead in drinking water. Various mitigation strategies can lower lead levels in water. The importance of drinking water as a contributor to total lead exposure depends on water lead levels and the amount consumed, as well as the relative contribution of other sources. Efforts should be made to reduce lead exposure for all sources, including drinking water, considering that no threshold level of exposure exists for the neurodevelopmental effects of lead in children.

Health inequalities among children and adolescents in Germany. Developments over time and trends from the KiGGS study

This study examines the extent to which health inequalities among children and adolescents in Germany have developed over the past decade. The analyses are based on data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), which are representative of the 0- to 17-year-old population in Germany. The KiGGS data were collected in three waves: the KiGGS baseline study (2003-2006), KiGGS Wave 1 (2009-2012) and KiGGS Wave 2 (2014-2017). Prevalences of five health outcomes are considered: general health, mental health problems, physical activity, the consumption of sugary soft drinks, and smoking. Moreover, it defines health inequalities in relation to differences in the socioeconomic status of the family (SES), an index derived from the parents’ level of education, occupation and income, and considers both absolute and relative health inequalities. In order to do so, the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII) were calculated using linear probability or log-binomial models. Significant inequalities were identified to the detriment of young people from families with a low SES. These inequalities were particularly pronounced in the KiGGS Wave 2 data with regard to general health and the consumption of sugary soft drinks. Additionally, evidence from trend analyses for these two outcomes suggests that relative inequalities have increased. However, absolute inequalities decreased during the same period, and this also applies to smoking. The persistently high and, in some cases, widened levels of health inequalities indicate that adolescents from families with a low SES do not benefit to the same extent from disease prevention and health promotion measures for children and adolescents as young people from families with a higher SES.

Water intake and hydration state in children

PURPOSE

Although low water intake has been associated with adverse health outcomes, available literature indicated that the majority of children do not meet the water intake guidelines and they are underhydrated based on elevated hydration biomarkers. This review examined the water intake habits and hydration status in children from 32 observational studies (n = 36813).

METHODS

PubMed, Web of Science, and CINAHL were used to identify relevant articles. Total water/fluid intake from 25 countries was compared with water intake recommendations and underhydration (urine osmolality greater than 800 mmol kg^-1) was assessed. Risk of bias was assessed using customized categories following the review guideline for observational studies.

RESULTS

From 32 studies, only 11 studies reported both water intake and hydration status. 12 out of 24 studies reported mean/median water/fluid intake below the guidelines, while 4 out of 13 studies that assessed hydration status indicated underhydration based on urine osmolality (greater than 800 mmol kg^-1). Among the 19 countries that reported comparison of water/fluid intake with guidelines, 60 ± 24% of children (range 10-98%) failed to meet them.

CONCLUSION

These findings suggest that children are not consuming enough water to be adequately hydrated.

A comparison of drinking behavior using a harmonized methodology (Liq.In 7 ) in six countries

PURPOSE

To assess drinking occasions (volume and type) according to consumption with food in or outside meals, and location, for six countries.

METHODS

A total of 10,521 participants aged 4-65 years from Argentina, Brazil, China, Indonesia, Mexico and Uruguay completed a validated 7-day fluid intake record. For each drinking event, the volume consumed, the fluid type, the location of intake, and whether the drink was accompanied by food (meal or snack) or not, was recorded.

RESULTS

Similar drinking behaviors were found in Mexico and Argentina; fluid intake during meals was 48 and 45% of total fluid intake (TFI), respectively. In Brazil (55%), Indonesia (58%) and China (66%) most fluid was consumed without food. In Uruguay, 34% of TFI was with a main meal, 31% with food between meals and 35% without food. Indonesia had the highest median (25-75th percentile) TFI; 2520 (1750-3347) mL/day, and China the lowest 1138 (818-3347) mL/day. Water was consumed with meals for 37% of Chinese and 87% of Indonesian participants, while the four Latin-American American countries showed a preference for sweet drinks; 54% in Mexico, 67% in Brazil, 55% in Argentina and 59% in Uruguay. Diversity in fluid type was noted when drinking with food between meals. Apart from China, most drinking occasions (> 75%) occurred at home.

CONCLUSIONS

Three distinct drinking behaviors were identified, namely, drinking with meals, drinking as a stand-alone activity, and a type of 'grazing' (i.e., frequent drinks throughout the day) behavior. Most drinking occasions occurred at home.

Consumption of sugary soft drinks among children and adolescents in Germany. Results of the cross-sectional KiGGS Wave 2 study and trends

Consuming large amounts of sugary beverages has been related to developing obesity, diabetes mellitus type II and other chronic diseases. KiGGS Wave 2 (2014-2017) provides data on the consumption of sugary soft drinks in the 3-17 year age group in Germany. Overall, 13.7% of girls and 17.6% of boys consume one to three times a day sugary soft drinks and 3.3% of girls and 4.7% of boys four or more times. Consumption frequency increases with age and is higher among children and adolescents with low socioeconomic status (SES) than for those of the same age with high SES. The share of adolescents who drink sugary soft drinks daily has decreased since the KiGGS baseline study (2003-2006).

Do Preschools Offer Healthy Beverages to Children? A Nationwide Study in Poland

Background: Children’s beverage consumption patterns have received increased attention in light of the obesity epidemic in this group. In day care centers (DCCs), children spend up to 10 h a day, and typically consume half to three quarters of their daily food intake. The purpose of the study was to investigate what beverages are typically served to children in preschools in Poland, and to evaluate the practices associated with adding sugar and other sweetening agents to beverages. Methods: Direct interviews with preschools staff were conducted with a questionnaire regarding offered beverages and adding sugar and other sweetening agents. The menu of 10 consecutive days and inventory reports were analyzed to verify information. Results: A total of 720 preschools were included in the study. Cocoa and milk coffee substitute were served in 95% of preschools, followed by compote (92%), tea (84%), fruit/herbal tea (73%) and water (69%). Water was the only beverage available between meals (93% DCCs). 86% of preschools added sugar to tea/cocoa/coffee substitute drinks, and 74% to compote. Conclusions: In the majority of preschools, beverages which are not recommended were offered. Such an assortment of beverages and common practice of sweetening can increase the amount of added sugar in a children diet. Nutrition education and legal regulations concerning the assortment of beverages served in preschools are urgently needed.

School beverage environment and children's energy expenditure associated with physical education class: an agent-based model simulation

BACKGROUND

Physical activity contributes to children's energy expenditure and prevents excess weight gain, but fluid replacement with sugar-sweetened beverages (SSBs) may diminish this benefit.

OBJECTIVE

The aim of this study was to explore the net energy expenditure (EE) after physical education (PE) class given the competition between water and SSB consumption for rehydration and explore environmental factors that may influence the net EE, e.g. PE duration, affordability of SSB and students' SSB preference.

METHODS

We built an agent-based model that simulates the behaviour of 13-year-old children in a PE class with nearby water fountains and SSB vending machines available.

RESULTS

A longer PE class contributed to greater prevalence of dehydration and required more time for rehydration. The energy cost of a PE class with activity intensity equivalent to 45 min of jogging is about 300 kcal on average, i.e. 10-15% of average 13-year-old children's total daily EE. Adding an SSB vending machine could offset PE energy expenditure by as much as 90 kcal per child, which was associated with PE duration, students' pocket money and SSB preference.

CONCLUSIONS

Sugar-sweetened beverage vending machines in school may offset some of the EE in PE classes. This could be avoided if water is the only readily available source for children's fluid replacement after class.

Public Perception of Quality and Support for Required Access to Drinking Water in Schools and Parks

PURPOSE

We assessed public support for required water access in schools and parks and perceived safety and taste of water in these settings to inform efforts to increase access to and consumption of tap water.

DESIGN

Cross-sectional survey of the US public collected from August to November 2011.

SETTING

Random digit-dialed telephone survey.

PARTICIPANTS

Participants (n = 1218) aged 17 and older from 1055 US counties in 46 states.

MEASURES

Perceived safety and taste of water in schools and parks as well as support for required access to water in these settings.

ANALYSIS

Survey-adjusted perceived safety and taste as well as support for required access were estimated.

RESULTS

There was broad support for required access to water throughout the day in schools (96%) and parks (89%). Few participants believed water was unsafe in schools (10%) or parks (18%).

CONCLUSION

This study provides evidence of public support for efforts to increase access to drinking water in schools and parks and documents overall high levels of perceived taste and safety of water provided in these settings.

Limited School Drinking Water Access for Youth

PURPOSE

Providing children and youth with safe, adequate drinking water access during school is essential for health. This study used objectively measured data to investigate the extent to which schools provide drinking water access that meets state and federal policies.

METHODS

We visited 59 middle and high schools in Massachusetts during spring 2012. Trained research assistants documented the type, location, and working condition of all water access points throughout each school building using a standard protocol. School food service directors (FSDs) completed surveys reporting water access in cafeterias. We evaluated school compliance with state plumbing codes and federal regulations and compared FSD self-reports of water access with direct observation; data were analyzed in 2014.

RESULTS

On average, each school had 1.5 (standard deviation: .6) water sources per 75 students; 82% (standard deviation: 20) were functioning and fewer (70%) were both clean and functioning. Less than half of the schools met the federal Healthy Hunger-Free Kids Act requirement for free water access during lunch; 18 schools (31%) provided bottled water for purchase but no free water. Slightly over half (59%) met the Massachusetts state plumbing code. FSDs overestimated free drinking water access compared to direct observation (96% FSD reported vs. 48% observed, kappa = .07, p = .17).

CONCLUSIONS

School drinking water access may be limited. In this study, many schools did not meet state or federal policies for minimum student drinking water access. School administrative staff may not accurately report water access. Public health action is needed to increase school drinking water access.

Fluid Intake and Cognitive Performance: Should Schoolchildren Drink During Lessons?

BACKGROUND

Evidence suggests that an insufficient fluid intake impairs cognitive performance. Drinking policies at schools-especially drinking during lessons-is a point of controversy. To provide a scientific base for this debate, more empirical evidence is needed on which aspects of fluid intake are crucial for cognitive performance. This study makes a contribution by investigating associations between quantitative and temporal aspects of fluid intake and cognitive performance in everyday school life.

METHODS

The study comprised 125 children (age: mean = 10.98 years, SD = 0.38). Amount of fluid intake and time span between fluid intake and completion of cognitive tests were determined on basis of self-reports. Cognitive performance was assessed by standardized tests.

RESULTS

Quantitative and temporal aspects were associated with cognitive performance: The more fluid the children consumed and the shorter the time span between their last fluid intake and test completion, the better they performed.

CONCLUSIONS

The amount of fluid intake should be adequate and moreover the time span between intake and cognitive efforts should be as short as possible. Schoolchildren are thus recommended to drink at regular intervals and also during lessons.

The School Food Environment and Obesity Prevention: Progress Over the Last Decade

The school food environment-including when and where children obtain food and the types of options available during the school day-plays an important role in children's consumption patterns. Thus, childhood obesity prevention efforts often focus on altering the school food environment as a mechanism for improving student dietary intake. This review examines the role school food programs and policies play in improving children's diet, weight, and health. Overall, research suggests that significant improvements have been made in school nutrition policies and programs. Due to the recent program changes made as a result of the 2010 Healthy, Hunger-Free Kids Act, an emphasis was placed on research conducted over the past decade and especially on the evaluation of foods and beverages served and sold since implementation of this national law. This review also examines remaining gaps in the literature and opportunities for further improvements in school food programs and policies.

Grab a Cup, Fill It Up! An Intervention to Promote the Convenience of Drinking Water and Increase Student Water Consumption During School Lunch

OBJECTIVES

We evaluated a low-cost strategy for schools to improve the convenience and appeal of drinking water.

METHODS

We conducted a group-randomized, controlled trial in 10 Boston, Massachusetts, schools in April through June 2013 to test a cafeteria-based intervention. Signage promoting water and disposable cups were installed near water sources. Mixed linear regression models adjusting for clustering evaluated the intervention impact on average student water consumption over 359 lunch periods.

RESULTS

The percentage of students in intervention schools observed drinking water during lunch nearly doubled from baseline to follow-up compared with controls (+ 9.4%; P < .001). The intervention was associated with a 0.58-ounce increase in water intake across all students (P < .001). Without cups, children were observed drinking 2.4 (SE = 0.08) ounces of water from fountains; with cups, 5.2 (SE = 0.2) ounces. The percentage of intervention students observed with sugar-sweetened beverages declined (-3.3%; P < .005).

CONCLUSIONS

The current default of providing water through drinking fountains in cafeterias results in low water consumption. This study shows that an inexpensive intervention to improve drinking water's convenience by providing cups can increase student water consumption.

Increasing Water Intake of Children and Parents in the Family Setting: A Randomized, Controlled Intervention Using Installation Theory

On average, children and adults in developed countries consume too little water, which can lead to negative health consequences. In a one-year longitudinal field experiment in Poland, we compared the impact of three home-based interventions on helping children and their parents/caregivers to develop sustainable increased plain water consumption habits. Fluid consumption of 334 children and their caregivers were recorded over one year using an online specific fluid dietary record. They were initially randomly allocated to one of the three following conditions: Control, Information (child and carer received information on the health benefits of water), or Placement (in addition to information, free small bottles of still water for a limited time period were delivered at home). After three months, half of the non-controls were randomly assigned to Community (child and caregiver engaged in an online community forum providing support on water consumption). All conditions significantly increased the water consumption of children (by 21.9-56.7%) and of adults (by 22-89%). Placement + Community generated the largest effects. Community enhanced the impact of Placement for children and parents, as well as the impact of Information for parents but not children. The results suggest that the family setting offers considerable scope for successful installation of interventions encouraging children and caregivers to develop healthier consumption habits, in mutually reinforcing ways. Combining information, affordances, and social influence gives the best, and most sustainable, results.

Obese children and adolescents need increased gastric volumes in order to perceive satiety

OBJECTIVE

In order to develop effective weight management strategies, it is important to identify factors that influence energy intake. Portion size has been discussed as one such factor. To date, most studies focusing on the relationship between portion size, energy intake, and weight have analyzed questionnaire data and 24-h records. In this study, we assessed the onset of satiety using the water-load test in normal-weight and obese children and adolescents.

METHODS

60 obese and 27 normal-weight children and adolescents aged between 9 and 17 years participated in the water load test which involved drinking water for 3 min or until feeling full. The amount of water consumed was recorded.

RESULTS

Obese children and adolescents drank 20% more water until the onset of satiety when compared with normal-weight participants (478 ± 222 ml vs. 385 ± 115 ml, P < 0.05).

CONCLUSIONS

Obese children and adolescents need to ingest greater volumes to feel full which may predispose toward the consumption of larger portion sizes. This may easily lead to overeating if predominantly energy-dense foods are consumed. A reduction in energy-dense foods in the diet of obese children and adolescents appears to be a necessary strategy for managing body weight.

Tapping into water: key considerations for achieving excellence in school drinking water access

OBJECTIVES

We examined free drinking water access in schools.

METHODS

We conducted cross-sectional interviews with administrators from 240 California public schools from May to November 2011 to examine the proportion of schools that met excellent water access criteria (i.e., location, density, type, maintenance, and appeal of water sources), school-level characteristics associated with excellent water access, and barriers to improvements.

RESULTS

No schools met all criteria for excellent water access. High schools and middle schools had lower fountain:student ratios than elementary schools (odds ratio [OR] = 0.06; 95% confidence interval [CI] = 0.02, 0.20; OR = 0.30, 95% CI = 0.12, 0.70). Rural schools were more likely to offer a nonfountain water source than city schools (OR = 5.0; 95% CI = 1.74, 14.70). Newer schools were more likely to maintain water sources than older schools (OR = 0.98; 95% CI = 0.97, 1.00). Schools that offered free water in food service areas increased from pre- to postimplementation of California's school water policy (72%-83%; P < .048). Barriers to improving school water included cost of programs and other pressing concerns.

CONCLUSIONS

Awareness of the benefits related to school drinking water provision and funding may help communities achieve excellence in drinking water access.

Middle school student attitudes about school drinking fountains and water intake

OBJECTIVE

To describe middle school student attitudes about school drinking fountains, investigate whether such attitudes are associated with intentions to drink water at school, and determine how intentions relate to overall water intake.

METHODS

Students (n = 3211) in 9 California middle schools completed surveys between 2009 and 2011. We used multivariate linear regression, adjusting for school sociodemographic characteristics, to examine how attitudes about fountains (5-point scale; higher scores indicating more positive attitudes) were associated with intentions to drink water at school and how intentions to drink water at school were related to overall water intake.

RESULTS

Mean age of students was 12.3 (SD = 0.7) years; 75% were Latino, 89% low income, and 39% foreign born. Fifty-two percent reported lower than recommended overall water intake (<3 glasses/day), and 30% reported that they were unlikely or extremely unlikely to drink water at school. Fifty-nine percent reported that school fountains were unclean, 48% that fountain water does not taste good, 33% that fountains could make them sick, 31% that it was not okay to drink from fountains, and 24% that fountain water is contaminated. In adjusted analyses, attitudes about school drinking fountains were related to intentions to drink water at school (β = 0.41; P < .001); intentions to drink water at school were also associated with overall water intake (β = 0.20; P < .001).

CONCLUSIONS

Students have negative attitudes about school fountains. To increase overall water intake, it may be important to promote and improve drinking water sources not only at school but also at home and in other community environments.

Reducing Alaska Native paediatric oral health disparities: a systematic review of oral health interventions and a case study on multilevel strategies to reduce sugar-sweetened beverage intake

BACKGROUND

Tooth decay is the most common paediatric disease and there is a serious paediatric tooth decay epidemic in Alaska Native communities. When untreated, tooth decay can lead to pain, infection, systemic health problems, hospitalisations and in rare cases death, as well as school absenteeism, poor grades and low quality-of-life. The extent to which population-based oral health interventions have been conducted in Alaska Native paediatric populations is unknown.

OBJECTIVE

To conduct a systematic review of oral health interventions aimed at Alaska Native children below age 18 and to present a case study and conceptual model on multilevel intervention strategies aimed at reducing sugar-sweetened beverage (SSB) intake among Alaska Native children.

DESIGN

Based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement, the terms "Alaska Native", "children" and "oral health" were used to search Medline, Embase, Web of Science, GoogleScholar and health foundation websites (1970-2012) for relevant clinical trials and evaluation studies.

RESULTS

Eighty-five studies were found in Medline, Embase and Web of Science databases and there were 663 hits in GoogleScholar. A total of 9 publications were included in the qualitative review. These publications describe 3 interventions that focused on: reducing paediatric tooth decay by educating families and communities; providing dental chemotherapeutics to pregnant women; and training mid-level dental care providers. While these approaches have the potential to improve the oral health of Alaska Native children, there are unique challenges regarding intervention acceptability, reach and sustainability. A case study and conceptual model are presented on multilevel strategies to reduce SSB intake among Alaska Native children.

CONCLUSIONS

Few oral health interventions have been tested within Alaska Native communities. Community-centred multilevel interventions are promising approaches to improve the oral and systemic health of Alaska Native children. Future investigators should evaluate the feasibility of implementing multilevel interventions and policies within Alaska Native communities as a way to reduce children's health disparities.

Consistency of compliance with nutrition-related regulations among Delaware child care centers

BACKGROUND

As more calls are made in the literature for nutrition interventions to be delivered in child care settings, research on the implementation of these interventions becomes more important. This study examined compliance with Delaware's regulations related to nutrition in child care settings, which are designed to improve the nutrition-related environment in these settings.

METHODS

A stratified random sample of licensed child care centers (n=233) was created from the total population of eligible centers in Delaware (N=450). Study staff visited each center and distributed self-administered surveys to the director and two randomly selected teachers. Surveys contained items about classroom-level compliance with the regulations along with center-level characteristics. Bivariate analyses were conducted to explore relationships between consistent compliance with each regulation component and center-level characteristics.

RESULTS

A total of 179 of the 233 centers in the selected sample participated in the study. Compliance with the regulations varied within centers and across components; the highest levels of consistent compliance were reported for juice type (88.3%) and the lowest levels for whole grains (18.6%). Center characteristics, such as participation in the Child and Adult Care Food Program, were associated with consistent compliance for certain regulations components.

CONCLUSIONS

Our results suggest that these types of regulations can be implemented across a diversity of centers, but that certain components (e.g., those relating to whole grains and water) may need further clarification. Our results also suggest that there are certain types of centers on which to focus training efforts to maximize compliance.

Getting back on tap: the policy context and cost of ensuring access to low-cost drinking water in Massachusetts schools

BACKGROUND

Adequate water intake may have important health benefits for schoolchildren. Layers of federal, state, and local policy are relevant to provision of water within schools. Recently passed state and federal laws require free drinking-water access for students during mealtimes.

PURPOSE

To review Massachusetts local district wellness policies related to water access, provide estimates of costs for three water-provision strategies, and discuss implications for policy relevant to adequate drinking-water access.

METHODS

Legal research was conducted using the LexisNexis legal database and government websites. Local wellness policies were double-coded using existing research tools. Costs of three water-delivery options were estimated using a 10-year school-district perspective.

RESULTS

Prior to 2010, most Massachusetts public school district wellness policies (92%-94%) did not address access to free drinking water. Ten-year costs per school for providing water during mealtimes to students, including dispenser unit, installation, water testing, water, cups, and labor, range between $12,544 and $27,922 (depending on water-delivery option) assuming the average Massachusetts school enrollment. Water-provision strategies relying on tap water are more economical than bottled water in the long term.

CONCLUSIONS

Policy recommendations and cost considerations deserve attention at the local, state, and federal levels. Recommendations are discussed to ensure access to safe, free drinking water for all students.

Increasing water availability during afterschool snack: evidence, strategies, and partnerships from a group randomized trial

BACKGROUND

Providing drinking water to U.S. children during school meals is a recommended health promotion strategy and part of national nutrition policy. Urban school systems have struggled with providing drinking water to children, and little is known about how to ensure that water is served, particularly in afterschool settings.

PURPOSE

To assess the effectiveness of an intervention designed to promote water as the beverage of choice in afterschool programs.

DESIGN

The Out of School Nutrition and Physical Activity Initiative (OSNAP) used a community-based collaboration and low-cost strategies to provide water after school. A group RCT was used to evaluate the intervention. Data were collected in 2010-2011 and analyzed in 2011.

SETTING/PARTICIPANTS

Twenty afterschool programs in Boston were randomized to intervention or control (delayed intervention).

INTERVENTION

Intervention sites participated in learning collaboratives focused on policy and environmental changes to increase healthy eating, drinking, and physical activity opportunities during afterschool time (materials available at www.osnap.org). Collaboration between Boston Public Schools Food and Nutrition Services, afterschool staff, and researchers established water-delivery systems to ensure children were served water during snack time.

MAIN OUTCOME MEASURES

Average ounces of water served to children per day was recorded by direct observation at each program at baseline and 6-month follow-up over 5 consecutive school days. Secondary measures directly observed included ounces of other beverages served, other snack components, and water-delivery system.

RESULTS

Participation in the intervention was associated with an increased average volume of water served (+3.6 ounces/day; p=0.01) during snack. On average, the intervention led to a daily decrease of 60.9 kcals from beverages served during snack (p=0.03).

CONCLUSIONS

This study indicates the OSNAP intervention, including strategies to overcome structural barriers and collaboration with key actors, can increase offerings of water during afterschool snack. OSNAP appears to be an effective strategy to provide water in afterschool settings that can be helpful in implementing new U.S. Department of Agriculture guidelines regarding water availability during lunch and afterschool snack.

Contingent choice. Exploring the relationship between sweetened beverages and vegetable consumption

Adults and children are repeatedly exposed to the pairing of food and drink as found in meal deals and "combos". There may arise from this indoctrination, a contingent relationship between drink context and food preference. Our multi-method research examines food and drink combining. A survey-based study examines the food and drink pairing preferences of adults (N=60), while a laboratory study with young children (N=75, aged three to five) examines the role of drink context on vegetable consumption. The adult survey finds strong food and drink combining preferences. The pairing of soft drinks with calorie dense foods is regarded favorably, while the pairing of soft drinks with vegetables is not. In child food trials, vegetable consumption is not influenced by the child's fussiness but is influenced by the drink accompaniment. In limited contexts, these findings demonstrate the contingent relationship between drink context and food consumption. Both palate preference and associative learning may be mechanisms driving the effects of drink context on food consumption. The findings suggest simple consumer strategies that might be employed to change dietary patterns (e.g., drink water with meals), and hold straightforward policy implications (e.g., increase water as the default option in meal deals).