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Temperature measurement plays a central role in determining pediatric patients' disease risk and management. However, current pediatric temperature thresholds may be outdated and not applicable to children.To characterize pediatric temperature norms and variation by patient characteristics, time of measurement, and thermometer route.In this cross-sectional study, we analyzed 134,641 well-child visits occurring between 2014-2019 at primary care clinics that routinely measured temperature. We performed bivariate and multivariable quantile regressions with clustered standard errors to determine temperature percentiles and variation by age, sex, time of measurement, and thermometer route. We performed sensitivity analyses: 1) using a cohort that excluded visits with infectious diagnoses that could explain temperature aberrations and 2) including clinic as a fixed effect.The median rectal temperature for visits of infants ≤12 months old was 37.2˚C, which was 0.4˚C higher than the median axillary temperature. The median axillary temperature for children 1-18 years old was 36.7˚C, which was 0.1˚C lower than the median values of all other routes. The 99th percentile for rectal temperatures in infants was 37.8˚C and the 99.9th percentile for axillary temperatures in children was 38.5˚C. Adjusted analyses did not demonstrate clinically significant variation in temperature by sex, age, or time of measurement.These updated temperature norms can serve as reference values in clinical practice and should be considered in the context of thermometer route used and the clinical condition being evaluated. Variations in temperature values by sex, age, and time of measurement were not clinically significant.

Objective To examine factors associated with water filter use (WFU) for drinking tap water at home and its association with consuming plain water and sugar-sweetened beverages (SSBs). Design Quantitative, cross-sectional study. Setting The 2018 SummerStyles survey data. Subjects U.S. adults (≥18 years; N=4042). Measures Outcomes were intake of plain water (tap/bottled water) and SSBs. Exposure was WFU (yes, no, not drinking tap water at home). Covariates included sociodemographics, weight status, Census regions, and home ownership status. Analysis We used multivariable logistic regressions to estimate adjusted odds ratios (AOR) and 95% confidence interval (CI) for consuming tap water, bottled water, or total plain water >3 cups/day (vs. ≤3 cups) and SSBs ≥1 time/day (vs. Results Overall, 36% of adults reported using a filter for drinking tap water at home; 14% did not drink tap water at home. Hispanics had significantly higher odds of using a water filter (AOR=1.50, 95% CI=1.14-1.98) vs non-Hispanic White. Factors significantly associated with lower odds of WFU were lower education (AOR=.69, 95% CI=.55-.86 for ≤high school; AOR=.78, 95% CI=.64-.95 for some college, vs college graduate), not being married (AOR=.81, 95% CI=.66-.98, vs married/domestic partnership), and lower household income (AOR=.68, 95% CI=.68-.90 for 3 cups/day of tap water (AOR=1.33, 95% CI=1.13-1.56) and lower odds of SSBs ≥1 time/day (AOR=.76, 95% CI=.62-.92). Not drinking tap water at home was associated with higher odds of drinking >3 cups/day bottled water (AOR=3.46, 95% CI=2.70-4.44). Conclusions WFU was associated with higher tap water intake and lower SSB intake among U.S. adults. WFU was higher among Hispanics, but lower among those with lower education and income and not married adults. Although WFU was associated with healthful beverage habits, additional considerations for WFU may include source water quality, oral health, cost, and proper use.

INTRODUCTION: Parents spend substantial time reading to their children, making storybooks a promising but understudied avenue for motivating parents to serve their children healthier beverages. This study examines parents’ reactions to messages promoting healthy beverage consumption embedded in a children’s storybook. METHODS: In 2020, a total of 2,164 demographically diverse parents of children aged 6 months to 5 years participated in an online survey. Participants were randomized to view control messages (school readiness) or 1 of 3 beverage message topics (sugary drink discouragement, water encouragement, or combined discouragement and encouragement) presented as pages from the storybook Potter the Otter. Survey items assessed parents’ reactions to the messages and their perceptions, beliefs, and intentions regarding sugary drinks and water. Data were analyzed in 2021. RESULTS: Compared with control messages, exposure to the beverage messages led to higher discouragement from serving children sugary drinks and higher encouragement to serve children more water (p-values

School-based nutrition programs are crucial to reducing food insecurity. The COVID-19 pandemic adversely impacted students’ school meal participation. This study seeks to understand parent views of school meals during COVID-19 to inform efforts to improve participation in school meal programs. Photovoice methodology was used to explore parental perception of school meals in San Joaquin Valley, California, a region of predominately Latino farmworker communities. Parents in seven school districts photographed school meals for a one-week period during the pandemic and then participated in focus group discussions and small group interviews. Focus group discussions and small group interviews were transcribed, and data were analyzed using a team-based, theme-analysis approach. Three primary domains emerged: benefits of school meal distribution, meal quality and appeal, and perceived healthfulness. Parents perceived school meals as beneficial to addressing food insecurity. However, they noted that meals were unappealing, high in added sugar, and unhealthy, which led to discarded meals and decreased participation in the school meal program. The transition to grab-and-go style meals was an effective strategy for providing food to families during pandemic school closures, and school meals remain an important resource for families experiencing food insecurity. However, negative parental perceptions of the appeal and nutritional content of school meals may have decreased school meal participation and increased food waste that could persist beyond the pandemic.

School meals play a major role in supporting children’s diets and food security, and policies for universal school meals (USM) have the potential to contribute to positive child health outcomes. During the COVID-19 pandemic, schools provided free school meals to all students in the United States, but this national USM policy ended in school year (SY) 2022–2023; however, a few states have adopted policies to continue USM statewide for SY 2022–2023. Research examining the challenges and strategies for successful continuation of USM is essential, along with studying pandemic-related challenges that are likely to persist in schools. Therefore, we conducted a study in Maine (with a USM policy) to evaluate the impact of COVID-19 and the concurrent implementation of USM, as well as examine differences in implementation by school characteristics, throughout the state. A total of n = 43 school food authorities (SFAs) throughout Maine completed surveys. SFAs reported multiple benefits of USM including increased school meal participation; reductions in the perceived stigma for students from lower-income households and their families; and no longer experiencing unpaid meal charges and debt. SFAs also experienced challenges due to the COVID-19 pandemic, particularly regarding costs. When considering future challenges, most respondents were concerned with obtaining income information from families, product and ingredient availability, and the costs/financial sustainability of the school meal programs. Overall, USM may have multiple important benefits for students and schools, and other states should consider implementation of a USM policy.

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.

Background Federal law requires water access in schools where meals are served. Schools report high rates of water accessibility in cafeterias, but observations indicate lower adherence. Although observation is costly, it permits a more detailed assessment of a water source to determine whether it provides effective access that encourages water consumption and thus, healthy hydration for students. Methods To offer a less costly alternative to observations, researchers developed and validated a photo-evidence tool to examine characteristics of effective school drinking water access. Two observers recorded characteristics of 200 water sources in 30 schools, including type, wear, cleanliness, and water flow, and examined obstructions and beverage promotion near sources, as well as, drinking vessel availability. Observers photographed sources which were coded by a separate research team. Agreement between observation audits and photograph coding was assessed through percent agreement, and kappa statistics and correlation coefficients. Results Kappas indicated substantial (K > 0.60) or near perfect agreement (K > 0.80) for all characteristics of effective drinking water access with exception of wear. There was moderate agreement (r = 0.66) for water source cleanliness. Conclusions Development and validation of a photo-evidence tool to examine characteristics of effective drinking water access in schools.

OBJECTIVES To determine the (1) frequency and visit characteristics of routine temperature measurement and (2) rates of interventions by temperature measurement practice and the probability of incidental fever detection. METHODS In this retrospective cohort study, we analyzed well-child visits between 2014–2019. We performed multivariable regression to characterize visits associated with routine temperature measurement and conducted generalized estimating equations regression to determine adjusted rates of interventions (antibiotic prescription, and diagnostic testing) and vaccine deferral by temperature measurement and fever status, clustered by clinic and patient. Through dual independent chart review, fever (≥100.4°F) was categorized as probable, possible, or unlikely to be incidentally detected. RESULTS Temperature measurement occurred at 155 527 of 274 351 (58.9%) well-child visits. Of 24 clinics, 16 measured temperature at >90% of visits (“routine measurement clinics”) and 8 at CONCLUSIONS Temperature measurement occurs at more than one-half of well-child visits and is a clinic-driven practice. Given the impact on subsequent interventions and vaccine deferral, the harm–benefit profile of this practice warrants consideration.

Objectives:To explore best practices and challenges in providing school meals during COVID-19 in a low-income, predominantly Latino, urban–rural region.Design:Semi-structured interviews with school district stakeholders and focus groups with parents were conducted to explore school meal provision during COVID-19 from June to August 2020. Data were coded and themes were identified to guide analysis. Community organisations were involved in all aspects of study design, recruitment, data collection and analysis.Setting:Six school districts in California’s San Joaquin Valley.Participants:School district stakeholders (n 11) included food service directors, school superintendents and community partners (e.g. funders, food cooperative). Focus groups (n 6) were comprised of parents (n 29) of children participating in school meal programmes.Results:COVID-19-related challenges for districts included developing safe meal distribution systems, boosting low participation, covering COVID-19-related costs and staying informed of policy changes. Barriers for families included transportation difficulties, safety concerns and a lack of fresh foods. Innovative strategies to address obstacles included pandemic-electronic benefits transfer (EBT), bus-stop delivery, community pick-up locations, batched meals and leveraging partner resources.Conclusions:A focus on fresher, more appealing meals and greater communication between school officials and parents could boost participation. Districts that leveraged external partnerships were better equipped to provide meals during pandemic conditions. In addition, policies increasing access to fresh foods and capitalising on United States Department of Agriculture waivers could boost school meal participation. Finally, partnering with community organisations and acting upon parent feedback could improve school meal systems, and in combination with pandemic-EBT, address childhood food insecurity.

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.

Introduction Recent legislation requires public and charter schools in California to test drinking water for lead. Our objective was to describe 1) results from this testing program in the context of other available water safety data and 2) factors related to schools and water utilities associated with access to safe drinking water in schools. Methods Our study focused on a random sample of 240 California public and charter schools. We used multivariable logistic regression, accounting for clustering of tested water sources in schools, to examine school-level factors associated with failure to meet lead-testing deadlines and any history of water utility noncompliance. Results Of the 240 schools, the majority (n = 174) tested drinking water for lead. Of the schools tested, 3% (n = 6) had at least 1 sample that exceeded 15 parts per billion (ppb) (California action level) and 16% (n = 28) exceeded 5 ppb (bottled water standard). Suburban schools had lower odds of being served by noncompliant water systems (OR = 0.17; CI, 0.05-0.64; P = .009) than city schools. Compared with city schools, rural schools had the highest odds of not participating in the water testing program for lead (OR = 3.43; CI, 1.46-8.05; P = .005). Hallways and common spaces and food services areas were the most frequent school locations tested; one-third of all locations sampled could not be identified. Conclusion In our study, geography influenced access to safe drinking water in schools, including both water utility safety standards and school lead-testing practices. Considerations for improving the implementation of state lead-testing programs include establishing priority locations for sampling, precisely labeling samples, and developing well-defined testing and reporting protocols.

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: Environmental interventions are more effective at changing nutrition behaviour than educational campaigns alone. As part of their health promotion efforts, the University of British Columbia (UBC) developed the Healthy Beverage Initiative (HBI) to ultimately reduce the consumption of sugar-sweetened beverages (SSB) on campus. We describe the development, implementation, preliminary evaluation and future of the HBI. DESIGN: Naturalistic observation of environmental changes to induce behaviour change. SETTING: Large urban research university campus. PARTICIPANTS: University community members and campus visitors. RESULTS: Three main activities have been implemented since the initiation of the UBC HBI: renegotiation of the cold beverage agreement, a media campaign to promote tap water consumption and the removal of SSB from select retail locations on campus (residence dining hall). No significant loss of revenue was observed following the removal of SSB from a residence dining hall compared with similar locations. Compensatory purchasing behaviour of SSB was not observed at the closest retail locations where they were still available. After the removal of SSB, ~75% of survey respondents were not aware that the beverages had been removed. CONCLUSIONS: The implementation of the HBI has met little resistance from the UBC community. The removal of SSB from residence dining locations did not result in any significant revenue loss or compensatory purchasing behaviour. This suggests that environmental intervention initiatives appear to be a viable option that may reduce SSB consumption on post-secondary campuses.

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

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.

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.

Objective. To examine food and beverage depictions in books for preschoolers. Methods. Books for preschoolers from Reach Out and Read (ROR; n = 42), public library (n = 27), and Publisher’s Weekly booklists (n = 31) were examined for nutritive and empty-calorie food and beverage depictions. Results. It was found that 66% of books depicted at least 1 food or beverage. More books depicted nutritive items than empty-calorie items (87.5% vs 54.7%, P < .001). There was a trend toward fewer empty-calorie depictions in ROR books than in other booklists. Yet nearly half of ROR books depicted at least 1 empty-calorie item. ROR books also accounted for 5 of 10 books with the most empty-calorie item depictions and 3 of 4 books with branding. With regard to messaging, approximately a third of books with the most empty-calorie depictions promoted unhealthy foods. Conclusions. When selecting books for ROR, it may be important to consider food and beverage depictions and messages.

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.

To determine trends in the consumption of sugar-sweetened beverages (SSBs) and 100% fruit juice by California children ages 2 to 11 years from 2003 to 2009.This analysis used serial cross-sectional data from the California Health Interview Survey, a telephone survey of households in California. Parents were asked how many servings of SSBs and 100% fruit juice the child consumed the day before. A test of trend was used to evaluate changes in consumption over time. Multivariate logistic regression was used to determine the independent effects of race/ethnicity, parental education, and household income on beverage consumption.The percentage of children consuming an SSB on the prior day declined from 40% in 2003 to 16% in 2009 (P.001) among children ages 2 to 5 and from 54% in 2003 to 33% in 2009 (P.001) among children ages 6 to 11. The percentage of children consuming any SSB decreased for all racial/ethnic groups, although there were disparities with higher consumption among Latinos. Among children ages 2 to 5, consumption of 2 or more servings of 100% fruit juice per day decreased among white children and increased among Latinos. For children ages 6 to 11, consumption of 2 or more servings of 100% fruit juice per day remained stable for white children and increased among Latinos and African Americans.The decrease in SSB consumption by California children from 2003 to 2009 is a promising trend. The increase in 100% fruit juice consumption among minority children during this period may be an unintended consequence of efforts to reduce SSB consumption.

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.

BACKGROUND AND OBJECTIVE:Hypertension occurs in 2% to 5% of children in the United States, and its prevalence has increased during the obesity epidemic. There is no consensus among professional organizations about how frequently blood pressure should be measured in children >3 years old. The purpose of this study was to estimate the frequency of hypertension screening during ambulatory pediatric visits in the United States and to determine patient- and provider-level factors associated with screening during visits specifically for preventive care.METHODS:We analyzed data from a nationally representative sample of ambulatory visits by using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 2000 through 2009. In the subset of visits involving patients aged 3 to 18 years, we estimated the frequency of screening during all visits, preventive visits, and preventive visits in which overweight/obesity was diagnosed. We used multivariable logistic regression to identify patient- and provider-level factors associated with screening.RESULTS:Hypertension screening occurred during 35% of ambulatory pediatric visits, 67% of preventive visits, and 84% of preventive visits in which overweight/obesity was diagnosed. Between 2000 and 2009, the frequency of screening increased in all visits and in preventive visits. Factors independently associated with screening included older age and overweight/obesity diagnosis.CONCLUSIONS:Providers do not measure blood pressure in two-thirds of pediatric visits and one-third of pediatric preventive visits. Providers may understand the importance of screening among overweight/obese children; however, efforts to encourage routine screening, particularly in young children, may be needed.

Purpose of review Inappropriate intake of sugar-sweetened beverages, fruit juice, and whole milk is associated with obesity and obesity-related comorbidities. As numerous children spend many hours in schools and child care, these settings provide a potential means for general pediatricians to reach children and their parents with interventions to encourage intake of guideline-recommended beverages. This review describes the beverages currently offered within child care facilities and schools and summarizes school and child care-based interventions and policies to encourage healthy beverage intake. Recent findings The major sources of beverages available in schools and child care include beverages provided through federal programs, competitive beverages (e.g., beverages for purchase through vending machines), water from drinking fountains, and beverages brought into facilities. Policies governing the types of beverages available in schools and child care settings have increased, but still vary in scope and jurisdiction. Although there are no child care-based interventions that exclusively target beverage intake, there are examples of school-based interventions to encourage healthy beverage consumption. Summary Although interventions and policies to encourage healthy beverage intake in schools and child care are increasing, there is a need for additional research, programs, and policies to guide beverage availability and intake in these settings.

Introduction Consumption of sugar-sweetened beverages (SSBs) such as sodas, fruit-flavored drinks, and sports drinks is a major contributor to childhood obesity. One strategy to reduce children’s SSB consumption has been to restrict the sale of SSBs in schools. However, such policies may not sufficiently curb students’ SSB intake, because students can obtain SSBs elsewhere, including from stores located on their school commute. Little is known about students’ purchases of beverages during the school commute or about whether this purchasing behavior is related to in-school SSB consumption. The objective of this study was to describe where students from low-income, ethnically diverse communities obtain the SSBs they drink during school lunchtime and to examine whether students who purchase beverages while traveling to and from school are more likely to drink SSBs during school lunchtime. Methods We analyzed survey data from a random sample of low-income, ethnically diverse middle school students (N = 597) who participated in a randomized controlled trial of a water promotion intervention. We used logistic regression analysis to examine the association between students’ purchase of beverages during the school commute and their SSB consumption during school lunchtime. Results One-fifth (20.4%) of students drank an SSB during lunch. Approximately 23% of SSBs were obtained during the school commute. Students who reported buying beverages during their school commute (50.1% of all students) were more likely to report drinking SSBs during lunch than students who reported that they do not buy beverages during the school commute (adjusted odds ratio 3.32, 95% confidence interval, 2.19–5.05, P < .001). Conclusion Students’ purchase of beverages during the school commute was strongly associated with SSB consumption during school lunchtime. Interventions could benefit from focusing on retail environments (eg, encouraging retailers to promote healthy beverages, posting beverage calorie information).

As pediatricians and professors dedicated to the prevention of childhood obesity, we were disappointed by the March 2015 American Academy of Pediatrics’ Policy Statement on “Snacks, Sweetened Beverages, Added Sugars, and Schools.”1 The American Academy of Pediatrics’ Committee on Nutrition and Council on School Health endorsed this statement, which seems to accept the trend that 70% of milk consumed in schools is “flavored” and minimizes the detrimental health effects of flavored milk because children consume “nutrient-rich nonfat milk” with added sugar and chocolate. The committees’ endorsement of adding sugar to the milk of millions … E-mail: 4dianedooley{at}gmail.com

INTRODUCTION Drinking water is promoted to improve beverage nutrition and reduce the prevalence of obesity. The aims of this study were to identify how water was provided to young children in child care and to determine the extent to which water access changed after a federal and state child care beverage policy was instituted in 2011 and 2012 in California. METHODS Two independent cross-sectional samples of licensed child care providers completed a self-administered survey in 2008 (n = 429) and 2012 (n = 435). Logistic regression was used to analyze data for differences between 2008 and 2012 survey responses, after adjustment for correlations among the measurements in each of 6 child care categories sampled. RESULTS A significantly larger percentage of sites in 2012 than in 2008 always served water at the table with meals or snacks (47.0% vs 28.0%, P = .001). A significantly larger percentage of child care sites in 2012 than in 2008 made water easily and visibly available for children to self-serve both indoors (77.9% vs 69.0%, P = .02) and outside (78.0% vs 69.0%, P = .03). Sites that participated in the federal Child and Adult Care Food Program had greater access to water indoors and outside than sites not in the program. In 2012 most (76.1%) child care providers reported no barriers to serving water to children. Factors most frequently cited to facilitate serving water were information for families (39.0% of sites), beverage policy (37.0%), and lessons for children (37.9%). CONCLUSION Water provision in California child care improved significantly between samples of sites studied in 2008 and 2012, but room for improvement remains after policy implementation. Additional training for child care providers and parents should be considered.

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.