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Recent water quality crises in the United States, and recognition of the health importance of drinking water in lieu of sugar-sweetened beverages, have raised interest in water safety, access, and consumption. This review uses a socioecological lens to examine these topics across the life course. We review water intakes in the United States relative to requirements, including variation by age and race/ethnicity. We describe US regulations that seek to ensure that drinking water is safe to consume for most Americans and discuss strategies to reduce drinking water exposure to lead, a high-profile regulated drinking water contaminant. We discuss programs, policies, and environmental interventions that foster effective drinking water access, a concept that encompasses key elements needed to improve water intake. We conclude with recommendations for research, policies, regulations, and practices needed to ensure optimal water intake by all in the United States and elsewhere.

Purpose: To examine factors associated with frequency of plain water (ie, tap, bottled, and unflavored sparkling water) intake among US high school students. Design: Quantitative, cross-sectional study. Setting: The 2017 national Youth Risk Behavior Survey data. Subjects: US high school students with plain water intake data (N = 10 698). Measures: The outcome was plain water intake. Exposure variables were demographics, academic grades, and behavioral characteristics. Analysis: We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for factors associated with infrequent plain water intake (Results: Overall, 48.7% of high school students reported drinking plain water Conclusions: Infrequent plain water intake was associated with younger age, poor academic grades, poor dietary behaviors, and physical inactivity. These findings can inform intervention efforts to increase water intake to promote healthy lifestyles among adolescents.

Objective:Drinking water instead of beverages with added sugar can help prevent obesity and cavities and promote overall health. Children spend much of their day in school, where they have variable access to drinking water. In 2010, federal and state law required California public schools to provide free potable water to students in areas where meals are served and/or eaten. The current study aims to identify factors associated with an excellent drinking water culture in schools.Design:A qualitative assessment of barriers and facilitators to providing excellent water quality and access in a purposive sample of California schools. In-depth interviews with key informants were conducted using a snowball sampling approach, after which data were analysed using both inductive and deductive methods.Setting:California public elementary, middle/junior and high schools.Participants:Knowledgeable individuals involved in initiatives related to school drinking water accessibility, quality or education at each selected school.Results:Thirty-four interviewees participated across fifteen schools. Six themes emerged as prominent facilitators to a school’s success in providing excellent water access to students: active and engaged champions, school culture and policy, coordination between groups, community influences, available resources and environmentalism.Conclusions:While policy is an important step for achieving minimum standards, resources and interest in promoting excellence in drinking water access and quality can vary among schools. Ensuring that schools have dedicated staff committed to advancing student health and promoting the benefits of water programs that are more salient to schools could help reduce disparities in drinking water excellence across schools.

Objective:To evaluate whether a multipronged pilot intervention promoting healthier beverage consumption improved at-home beverage consumption and weight status among young children.Design:In this exploratory pilot study, we randomly assigned four childcare centres to a control (delayed-intervention) condition or a 12-week intervention that promoted consumption of healthier beverages (water, unsweetened low- or non-fat milk) and discouraged consumption of less-healthy beverages (juice, sugar-sweetened beverages, high-fat or sweetened milk). The multipronged intervention was delivered via childcare centres; simultaneously targeted children, parents and childcare staff; and included environmental changes, policies and education. Outcomes were measured at baseline and immediately post-intervention and included children’s (n 154) at-home beverage consumption (assessed via parental report) and overweight/obese status (assessed via objectively measured height and weight). We estimated intervention impact using difference-in-differences models controlling for children’s demographics and classroom.Setting:Two northern California cities, USA, 2013–2014.Participants:Children aged 2–5 years and their parents.Results:Relative to control group children, intervention group children reduced their consumption of less-healthy beverages from baseline to follow-up by 5·9 ounces/d (95 % CI −11·2, −0·6) (–174·5 ml/d; 95 % CI –331·2, –17·7) and increased their consumption of healthier beverages by 3·5 ounces/d (95 % CI −2·6, 9·5) (103·5 ml/d; 95 % CI –76·9, 280·9). Children’s likelihood of being overweight decreased by 3 percentage points (pp) in the intervention group and increased by 3 pp in the control group (difference-in-differences: −6 pp; 95 % CI −15, 3).Conclusions:Our exploratory pilot study suggests that interventions focused comprehensively on encouraging healthier beverage consumption could improve children’s beverage intake and weight. Findings should be confirmed in longer, larger studies.

BACKGROUND: Maintaining high water intake reduces kidney stone recurrence, but is difficult to do. Strategies to reduce stone recurrence among adolescents are lacking. METHODS: We conducted an ecological momentary assessment study to identify factors associated with water intake among 25 adolescents with nephrolithiasis. Over 7-days, participants used smart bottles to self-monitor water intake and received questionnaires randomly four times daily that were completed in real-time on mobile devices. The questionnaires ascertained awareness of water intake volume, awareness of water intake goals, perceived need to drink, access to water, alternative beverage consumption, and attitudes towards bathrooms. Linear mixed-effects models were fit to estimate the association between momentary responses and daily water intake. RESULTS: Over 175 person-days, 595 (85%) assessments were completed. Median daily water intake was 1304mL (IQR 848–1832); 20% of participants met their intake goal for ≥4 days. Unawareness of water intake volume was associated with drinking 690mL less water a day (p=0.04). A strong self-perceived need to drink more was associated with drinking 1954 mL less water each day compared to no need to drink more (p

Sugar-sweetened beverages (SSBs) increase risk of cardiometabolic disease. Young people consume the largest amounts of SSBs and have experienced the greatest relative gains in obesity in the past several decades. There is evidence of addictive properties of both caffeine and sugar, the primary ingredients in SSBs, but little research into such properties of SSBs in naturally occurring consumption patterns. Thus, in this exploratory study, we sought to examine potentially addictive properties of SSBs during a 3-day SSB cessation intervention in overweight and obese adolescents who typically consume ≥3 SSBs daily. Participants (n = 25) were aged 13-18 years, mostly female (72%), and African American (56%) or Hispanic (16%) with a BMI≥95th percenttile (76%). Withdrawal symptoms and SSB craving were assessed approximately 1-week apart, during both regular SSB consumption and a 3-day period of SSB cessation in which participants were instructed to drink only plain milk and water. During SSB cessation, adolescents reported increased SSB cravings and headache and decreased motivation, contentment, ability to concentrate, and overall well-being (uncorrected Ps

Objective: As tap water distrust has grown in the USA with greater levels among Black and Hispanic households, we aimed to examine recent trends in not drinking tap water including the period covering the US Flint Water Crisis and racial/ethnic disparities in these trends. Design: Cross-sectional analysis. We used log-binomial regressions and marginal predicted probabilities to examine US nationally representative trends in tap and bottled water consumption overall and by race/ethnicity. Setting: The National Health and Nutrition Examination Survey data, 2011–2018. Participants: Nationally representative sample of 9439 children aged 2–19 years and 17 268 adults. Results: Among US children and adults, respectively, in 2017–2018 there was a 63 % (adjusted prevalence ratio (PR): 1·63, 95 % CI (1·25, 2·12), P < 0·001)) and 40 % (PR: 1·40, 95 % CI (1·16, 1·69), P = 0·001)) higher prevalence of not drinking tap water compared to 2013–2014 (pre-Flint Water Crisis). For Black children and adults, the probability of not drinking tap water increased significantly from 18·1 % (95 % CI (13·4, 22·8)) and 24·6 % (95 % CI (20·7, 28·4)) in 2013–2014 to 29·3 % (95 % CI (23·5, 35·1)) and 34·5 % (95 % CI (29·4, 39·6)) in 2017–2018. Among Hispanic children and adults, not drinking tap water increased significantly from 24·5 % (95 % CI (19·4, 29·6)) and 27·1 % (95 % CI (23·0, 31·2)) in 2013–2014 to 39·7 % (95 % CI (32·7, 46·8)) and 38·1 % (95 % CI (33·0, 43·1)) in 2017–2018. No significant increases were observed among Asian or White persons between 2013–2014 and 2017–2018. Similar trends were found in bottled water consumption. Conclusions: This study found persistent disparities in the tap water consumption gap from 2011 to 2018. Black and Hispanics’ probability of not drinking tap water increased following the Flint Water Crisis.

Objective:To assess trends in consumption of soda, sweetened fruit drinks/sports drinks and any sugar-sweetened beverage (SSB) from 2013 to 2016 among all children in California aged 2–5 and 6–11 years and by racial-ethnic group.Design:Serial cross-sectional study using the California Health Interview Survey (CHIS).Setting:CHIS is a telephone survey of households in California designed to assess population-level estimates of key health behaviours. Previous research using CHIS documented a decrease in SSB consumption among children in California from 2003 to 2009 coinciding with state-level policy efforts targeting child SSB consumption.Participants:Parents of children in California aged 2–11 years (n 4901 in 2013–2014; n 3606 in 2015–2016) were surveyed about the child’s consumption of soda and sweetened fruit drinks/sports drinks on the day prior.Results:Among 2–5-year-olds, consumption of soda, sweetened fruit drinks/sports drinks and any SSB remained stable. Sweetened fruit drink/sports drink consumption was higher than soda consumption in this age group. Latino 2–5- year-olds were more likely to consume any SSB in both 2013–2014 and 2015–2016 compared with Whites. Among 6–11-year-olds, consumption of soda, sweetened fruit drinks/sports drinks and any SSB also remained stable over time. Latino and African-American 6–11-year-olds were more likely to consume an SSB in 2013–2014 compared with White children.Conclusions:SSB consumption among children in California was unchanged from 2013 to 2016 and racial-ethnic disparities were evident. Increased policy efforts are needed to further reduce SSB consumption, particularly among children of Latino and African-American backgrounds.

Objective(s) Assess the quality of water language in California school district wellness policies and examine how language quality relates to school drinking water access. Design Cross-sectional study. Participants Random sample of 240 schools selected from all California public schools, stratified by geography and grades served. Variables Measured Policies (2016–2018) were coded for quality (strength and comprehensiveness) using an adapted school wellness policy tool. School administrators completed phone interviews about drinking water access on their campus. Analysis Descriptive statistics (eg, means, standard deviations) summarized school-level characteristics and main outcomes. Mixed-effects linear regression models were used to examine the relationship between the strength and comprehensiveness of water policy language and water access. Results On a scale of 0–100, mean strength was 11.3 (SD, 5.7), and mean comprehensiveness was 28.8 (SD, 8.7). There was an inverse association between the quality of water language in policies and excellence in drinking water access in schools. Conclusions and Implications The strength and comprehensiveness of water language in California school district wellness policies were low. Districts would benefit from improving the quality of water language in their wellness policies and examining challenges to implementing policies.

Objective To determine the frequency and predictors of temperature measurement at well-child visits in the US and report rates of interventions associated with visits at which temperature is measured and fever is detected. Study design In this cross-sectional study, we analyzed 22 518 sampled well-child visits from the National Ambulatory Medical Care Survey between 2003 and 2015. We estimated the frequency of temperature measurement and performed multivariable regression to identify patient, provider/clinic, and seasonal factors associated with the practice. We described rates of interventions (complete blood count, radiograph, urinalysis, antibiotic prescription, and emergency department/hospital referral) by measurement and fever (temperature ≥100.4 °F, ≥38.0 °C) status. Results Temperature was measured in 48.5% (95% CI 45.6-51.4) of well-child visits. Measurement was more common during visits by nonpediatric providers (aOR 2.0, 95% CI 1.6-2.5; reference: pediatricians), in Hispanic (aOR 1.9, 95% CI 1.6-2.3) and Black (aOR 1.5, 95% CI 1.2-1.9; reference: non-Hispanic White) patients, and in patients with government (aOR 2.0, 95% CI 1.7-2.4; reference: private) insurance. Interventions were more commonly pursued when temperature was measured (aOR 1.3, 95% CI 1.1-1.6) and fever was detected (aOR 3.8, 95% CI 1.5-9.4). Conclusions Temperature was measured in nearly one-half of all well-child visits. Interventions were more common when temperature was measured and fever was detected. The value of routine temperature measurement during well-child visits warrants further evaluation.

Introduction Previous interventions to increase water access and consumption have focused on school settings, have shown mixed results on sugar-sweetened beverage (SSB) consumption, and have rarely addressed tap water safety. Our randomized controlled trial examined how improving access and appeal of water in recreation centers in low-income neighborhoods affected counts of SSBs carried by youth attending summer camp. Methods Recreation centers (N = 28) matched on their characteristics were randomly assigned to control or intervention groups. Intervention centers received a new water fountain with a bottle filler (hydration station), water testing services, reusable water bottles, and water promotion and education training and materials. Primary outcomes were 1-year changes in center-level average daily gallons of water from fountains and hydration stations (flowmeter readings). Secondary outcomes were counts of SSBs observed, use of bottled water and reusable water bottles, staff SSB consumption, and hydration station maintenance. Results Results showed increased water use (b = 8.6, 95% CI, 4.2-13.0) and reusable bottle counts (b = 10.2, 95% CI, 4.2-16.1) in intervention centers compared with control centers. No change occurred in youth carrying SSBs at camp, but center staff's past 30-day SSB consumption frequency decreased (b = -34.8, 95% CI, -67.7 to -1.9). Intervention sites had marginally lower odds of maintenance problems (OR = 0.09; 95% CI, 0.004-0.76, P = .06) than control sites. Conclusion Although providing hydration stations along with water testing, reusable water bottles, education, and promotion increased water consumption among youth at recreation centers, it had no effect on the number of SSBs observed during camp. Future strategies to increase water consumption should also address reducing SSB intake.

Beverage consumption habits are associated with weight outcomes for children and adolescents. Many studies have examined youth's beverage consumption, but little is known about what methods are commonly used to assess youth beverage consumption and whether these strategies are valid and reliable. This study aimed to systematically review articles assessing beverage consumption among children and adolescents. We searched PubMed and Scopus for English-language articles published between February 2007 and February 2017 that measured and reported on American youth's (ages 2-18 years) beverage consumption. Searches yielded 17,165 articles, of which 589 articles describing 615 measures were extracted. We examined the types of assessment methods used, characteristics of these methods (e.g. validity, reliability, and literacy level), characteristics of study samples, and beverages assessed. The most common assessment methods were questionnaires/screeners (used by 65.4% of articles) and recalls (24.4%). About three-quarters of articles did not address validity (70.5%) or reliability (79.5%) of any measures used. Study populations were diverse: 54.7% of articles included low-income children, and 90.2% included non-White children. The most commonly assessed beverage category was sugar-sweetened beverages. Findings suggest that improved measurement techniques and reporting are both needed to track progress towards a goal of ensuring all youth have healthy beverage consumption.

Taxes on sugary drinks are being implemented to prevent chronic diseases. Sugar-sweetened milk has been exempt from such policies because of its nutritional value. This systematic review sought to examine whether flavored milk consumption was associated with milk and energy intake, and obesity among children. A search of PubMed, EMBASE, Cochrane, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials and the grey literature was conducted for peer-reviewed publications published before June 6, 2016 that met the following criteria: 1) English-language publications 2) studies of children ages 1 to 18 years, 3) controlled experimental, cohort, case-control, systematic reviews, or meta-analysis studies 4) dependent variable: flavored milk consumption 5) independent variable: weight, weight gain, weight change, body mass index, metabolic syndrome, waist circumference, cholesterol, triglycerides, blood pressure, serum glucose, calories, sugar, or milk consumed. Of 3978 studies identified, 13 met inclusion criteria. Ten studies were experimental and three were longitudinal cohort studies. Eleven studies found that flavored milk increased overall milk intake, five of seven studies that examined energy intake showed that flavored milk increased energy intake, and one of three studies that assessed obesity outcomes demonstrated an increase in weight gain with flavored milk consumption. Only one study was a randomized controlled trial, most studies had high bias, and over half were industry-funded or did not disclose funding. Although flavoring milk may increase milk intake, added sugars may promote increased energy intake. More data regarding flavored milk's impact on health is needed to inform its role in sugary drink policies.

Introduction Drinking water instead of sugar-sweetened beverages may reduce obesity and dental caries. Tap water is more affordable and sustainable than bottled water and more likely to contain fluoride, which prevents caries. To address inequities in access to safe tap water, cross-sector partners established the Agua4All safe drinking-water program in 2 rural San Joaquin Valley, California, communities. The program’s objective was to examine Agua4All’s feasibility, acceptability, and effect on water intake. Methods We provided bottle-filling stations dispensing safe water at 12 sites in 2 communities and provided limited promotional support. To compare the effect of different levels of promotion, sites in 1 community also received a promotions toolkit, a stipend, and assistance in developing and conducting their own promotional activities (site-led promotion). Beverage intake at sites was observed at baseline (pre-installation), at time 1 (post-installation), and at times 2 and 3 (post-promotion). Flowmeters tracked water dispensings. Staff interviews examined implementation barriers and facilitators. Results From baseline to time 3, a nonsignificant increase (21.16%) occurred in the proportion of people drinking water at sites with water stations and site-led promotion compared with sites with water stations and limited promotion (5.13%) (P = .14). Mean daily gallons of water taken from stations per site was 3.61 (standard deviation, 3.84). Most staff members (77%) at the sites preferred water stations to traditional drinking fountains. Conclusion Bottle-filling stations with safe water and site-led promotion are a promising strategy for increasing water intake in communities without safe tap water. Larger studies should examine the effects of such stations on intake of sugar-sweetened beverages and on overall health.

We described sociodemographic differences in perceptions of drinking water safety and examined associations between perceptions and plain water intake. We used the 2015 Estilos survey of 1,000 US Hispanic adults conducted in both Spanish and English. Outcome was water intake. Exposures were the level of agreement about water perceptions (My tap water is safe to drink; Community tap water is safe to drink; Bottled water is safer; I would buy less bottled water if my tap water was safe). Covariates were sociodemographics, region, Hispanic heritage, and acculturation. We used chi-square tests and multinomial logistic regression to examine associations of water perceptions and intake. Overall, 24% of Hispanic adults consumed water ≤1 time/day. Although 34% disagreed their home tap water was safe to drink, and 41% disagreed their community tap water was safe to drink, 65% agreed bottled water is safer than tap water, and 69% agreed they would buy less bottled water if they knew their tap water was safe. Perceptions differed by some covariates but were not significantly associated with plain water intake. In conclusion, negative perceptions of tap water were common among US Hispanic adults, which can inform efforts to increase awareness about safe public water systems.

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.

Author(s): Moreno, Gala D; Schmidt, Laura A; Ritchie, Lorrene D; McCulloch, Charles E; Cabana, Michael D; Brindis, Claire D; Green, Lawrence W; Altman, Emily A; Patel, Anisha I | Abstract: IntroductionPromoting water consumption among children in schools is a promising intervention to reduce sugar-sweetened beverage (SSB) intake and achieve healthful weight. To date, no studies in the United States have examined how a school-based water access and promotion intervention affects students' beverage and food intake both in and out of school and weight gain over time. The Water First trial is intended to evaluate these interventions.MethodsInformed by the PRECEDE-PROCEED model and Social Cognitive Theory, the Water First intervention includes: 1) installation of lead-free water stations in cafeterias, physical activity spaces, and high-traffic common areas in lower-income public elementary schools, 2) provision of cups/reusable water bottles for students, and 3) a 6-month healthy beverage education campaign. A five year-long cluster randomized controlled trial of 26 low-income public elementary schools in the San Francisco Bay Area is examining how Water First impacts students' consumption of water, caloric intake from foods and beverages, and BMI z-score and overweight/obesity prevalence, from baseline to 7nmonths and 15nmonths after the start of the study. Intervention impact on outcomes will be examined using a difference-in-differences approach with mixed-effects regression accounting for the clustering of students in schools and classrooms.DiscussionThis paper describes the rationale, study design, and protocol for the Water First study. If the intervention is effective, findings will inform best practices for implementing school water policies, as well as the development of more expansive policies and programs to promote and improve access to drinking water in schools.

IntroductionAsthma is a common health condition for children in childcare. National recommendations for asthma in childcare exist. However, no studies have investigated the extent to which childcare centers adhere to these recommendations. We aimed to assess childcare center adherence to National Asthma Education and Prevention Program (NAEPP) recommendations for asthma care and preparedness and to identify characteristics associated with increased adherence to national asthma recommendations.MethodsWe developed a standardized instrument. Each childcare center received a score of 0 through 7 based on number of recommendations met. We conducted t-tests, chi square tests and linear regression to identify childcare center factors associated with increased asthma preparedness.Results36 out of 40 eligible childcare centers (90%) participated. These sites served 1570 children primarily between the ages of 2 to 5years. On average, centers met 3.8 out of 7 (SD = 1.3) recommendations. Staff familiarity caring for children with asthma (p

Introduction Improving children's tap water intake and reducing sugar-sweetened beverage (SSB) consumption is beneficial for health and health equity, particularly in low-income communities and communities of color. Existing community level interventions to improve the intake of tap water have predominantly occurred in schools and have focused on promoting water consumption in cafeterias during lunch or snack periods. Methods The “Hydrate Philly” intervention was developed to target multiple environmental and social factors to improve tap water consumption in community recreation centers in low-income communities: replacing old and unappealing water fountains with appealing water-bottle-filling “hydration stations”, conducting water safety testing and publicizing results, disseminating reusable water bottles, promoting tap water, and discouraging SSB consumption. Efficacy of the intervention will be tested through a group-randomized controlled trial (n = 28 centers) of the intervention's impact on center-level water fountain/station use as measured by flow meters during a youth summer camp program primarily for children aged 6–12 years. Intervention impact on the primary outcome (use of drinking water sources) will be examined with a difference-in-differences approach using an ordinary least squares regression model for analysis at the center level. Secondary outcomes include SSBs brought to summer camp, reusable and single-use bottled water use, program trash, and recreation center staff SSB consumption. Discussion Multilevel approaches are needed to increase tap water intake and decrease SSB consumption among low-income and minority youth beyond school and meal settings. The current study describes the Hydrate Philly intervention, the study design, and baseline characteristics of recreation centers participating in the study. ClinicalTrials.gov Registration: #NCT03637465

The objective of this study is to identify promising strategies for improving drinking-water access and consumption among children aged 0 to 5 years. MEDLINE/PubMed, Embase, ERIC, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched in this review. Studies included peer-reviewed, full-text studies from high-income countries, published in English between January 1, 2000, and January 12, 2018, that evaluated interventions to increase water access or consumption in children aged 0 to 5 years. Twenty-five studies met inclusion criteria; 19 used an effective intervention strategy to increase water access or water consumption. Three studies addressed both water access and consumption. Frequently used strategies included policy and practice changes, increasing water access and convenience, and education, training, or social support for caregivers. Studies were of fair methodological quality (average score: 18.8 of 26) for randomized studies and of moderate quality (5.1 of 9) for non-randomized studies. To date, few high-quality studies with objectively measured outcomes have clearly demonstrated strategies that may influence water intake and consumption among young children aged 0 to 5 years.

ObjectiveEnsuring ready access to free drinking-water in schools is an important strategy for prevention of obesity and dental caries, and for improving student learning. Yet to date, there are no validated instruments to examine water access in schools. The present study aimed to develop and validate a survey of school administrators to examine school access to beverages, including water and sports drinks, and school and district-level water-related policies and practices.DesignSurvey validity was measured by comparing results of telephone surveys of school administrators with on-site observations of beverage access and reviews of school policy documents for any references to beverages. The semi-structured telephone survey included items about free drinking-water access (sixty-four items), commonly available competitive beverages (twenty-nine items) and water-related policies and practices (twenty-eight items). Agreement between administrator surveys and observation/document review was calculated using kappa statistics for categorical variables, and Pearson correlation coefficients and t tests for continuous variables.SettingPublic schools in the San Francisco Bay Area, California, USA.SubjectsSchool administrators (n 24).ResultsEighty-one per cent of questions related to school beverage access yielded κ values indicating substantial or almost perfect agreement (κ>0·60). However, only one of twenty-eight questions related to drinking-water practices and policies yielded a κ value representing substantial or almost perfect agreement.ConclusionsThis school administrator survey appears reasonably valid for questions related to beverage access, but less valid for questions on water-related practices and policies. This tool provides policy makers, researchers and advocates with a low-cost, efficient method to gather national data on school-level beverage access.

ObjectiveBeverage consumption is an important determinant of youth health outcomes. Beverage interventions often occur in schools, yet no brief validated questionnaires exist to assess whether these efforts improve in-school beverage consumption. This study validated a brief questionnaire to assess beverage consumption during school lunch.MethodsResearchers observed middle school students' (n=25) beverage consumption during school lunchtime using a standardized tool. After lunch, students completed questionnaires regarding their lunchtime beverage consumption. Kappa statistics compared self-reported with observed beverage consumption across 15 beverage categories.ResultsEight beverages showed at least fair agreement (kappa [κ]>0.20) for both type and amount consumed, with most showing substantial agreement (κ>0.60). One beverage had high raw agreement but κ&nbsp

Background Youth water consumption is inadequate. Increasing adolescent water consumption could support decreased dental caries and body mass index (BMI). Most schools are required to provide free, potable water. However, there is evidence that schools' self-reported compliance data overestimate access to water in schools. We tested the feasibility of using student citizen scientists to collect high quality observational data about water sources in schools. Methods We trained 12 teams of high school students to use a validated photo-evidence protocol to photograph and submit data on water sources in elementary and secondary schools. We surveyed students and advisors to assess student learning, advisor burden, and project feasibility. Results Students submitted data for 325 water sources across 40 racially and economically diverse schools. We were able to use 99% of the student-submitted photographs to measure water source wear, cleanliness, accessibility, and flow. The majority of students (72%, N = 70) spent under 2 hours photographing each school. The majority of students and advisors felt the project was valuable and feasible. Conclusions High school students can use a photographic method to collect data for analysis, and understand access to water in schools. This is a feasible, scalable, cost-effective method to gather valid water source data.

To evaluate whether differences in tap water and other beverage intake explain differences in inadequate hydration among US adults by race/ethnicity and income.We estimated the prevalence of inadequate hydration (urine osmolality ≥ 800 mOsm/kg) by race/ethnicity and income of 8258 participants aged 20 to 74 years in the 2009 to 2012 National Health and Nutrition Examination Survey. Using multivariable regression models, we estimated associations between demographic variables, tap water intake, and inadequate hydration.The prevalence of inadequate hydration among US adults was 29.5%. Non-Hispanic Blacks (adjusted odds ratio [AOR] = 1.44; 95% confidence interval [CI] = 1.17, 1.76) and Hispanics (AOR = 1.42; 95% CI = 1.21, 1.67) had a higher risk of inadequate hydration than did non-Hispanic Whites. Lower-income adults had a higher risk of inadequate hydration than did higher-income adults (AOR = 1.23; 95% CI = 1.04, 1.45). Differences in tap water intake partially attenuated racial/ethnic differences in hydration status. Differences in total beverage and other fluid intake further attenuated sociodemographic disparities.Racial/ethnic and socioeconomic disparities in inadequate hydration among US adults are related to differences in tap water and other beverage intake. Policy action is needed to ensure equitable access to healthy beverages.

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.

Introduction US legislation requires that schools offer free drinking water where meals are served. However, little information is available about what types of water delivery systems schools should install to meet such requirements. The study objective was to examine the efficacy and cost of 2 water delivery systems (water dispensers and bottleless water coolers) in increasing students’ lunchtime intake of water in low-income middle schools. Methods In 2013, twelve middle schools in the San Francisco Bay Area participated in a cluster randomized controlled trial in which they received 6 weeks of promotional activities, received provision of cups, and were assigned to 1 of 2 cafeteria water delivery systems: water dispensers or bottleless water coolers (or schools served as a control). Student surveys (n = 595) and observations examined the interventions’ effect on students’ beverage intake and staff surveys and public data assessed intervention cost. Results Analysis occurred from 2013 through 2015. Mixed-effects logistic regression, accounting for clustering and adjustment for student sociodemographic characteristics, demonstrated a significant increase in the odds of students drinking water in schools with promotion plus water dispensers and cups (adjusted odds ratio = 3.1; 95% confidence interval, 1.4–6.7; P = .004) compared with schools with traditional drinking fountains and no cups or promotion. The cost of dispenser and bottleless water cooler programs was similar ($0.04 per student per day). Conclusion Instead of relying on traditional drinking fountains, schools should consider installing water sources, such as plastic dispensers with cups, as a low-cost, effective means for increasing students’ water intake.

Purpose To examine the potential impact of California SB 1413, which required school districts to provide free, fresh drinking water during mealtimes in food service areas by July 1, 2011, on greater water consumption among California adolescents. Methods Data were drawn from the 2012 and 2013 state-representative California Health Interview Survey. A total of 2,665 adolescents aged 12–17 years were interviewed regarding their water consumption and availability of free water during lunchtime at their school. Results Three-fourths reported that their school provided free water at lunchtime, mainly via fountains. In a multivariate model that controlled for age, gender, income, race/ethnicity, body mass index, and school type, adolescents in schools that provided free water consumed significantly more water than adolescents who reported that water was not available, bivariate (standard error) = .67 (.28), p = .02. School water access did not significantly vary across the 2 years. Conclusions Lunchtime school water availability was related to water consumption, but a quarter of adolescents reported that their school did not provide free water at lunch. Future research should explore what supports and inducements might facilitate provision of drinking water during school mealtimes.

Introduction Recent legislation requires schools to provide free drinking water in food service areas (FSAs). Our objective was to describe access to water at baseline and student water intake in school FSAs and to examine barriers to and strategies for implementation of drinking water requirements. Methods We randomly sampled 24 California Bay Area public schools. We interviewed 1 administrator per school to assess knowledge of water legislation and barriers to and ideas for policy implementation. We observed water access and students’ intake of free water in school FSAs. Wellness policies were examined for language about water in FSAs. Results Fourteen of 24 schools offered free water in FSAs; 10 offered water via fountains, and 4 provided water through a nonfountain source. Four percent of students drank free water at lunch; intake at elementary schools (11%) was higher than at middle or junior high schools (6%) and high schools (1%). In secondary schools when water was provided by a nonfountain source, the percentage of students who drank free water doubled. Barriers to implementation of water requirements included lack of knowledge of legislation, cost, and other pressing academic concerns. No wellness policies included language about water in FSAs. Conclusion Approximately half of schools offered free water in FSAs before implementation of drinking water requirements, and most met requirements through a fountain. Only 1 in 25 students drank free water in FSAs. Although schools can meet regulations through installation of fountains, more appealing water delivery systems may be necessary to increase students’ water intake at mealtimes.