Dr. Anisha I. Patel is an Associate Professor in the Division of General Pediatrics at Stanford University. Dr. Patel earned a medical degree at the University of North Carolina at Chapel Hill, completed a residency and chief residency in pediatrics at Stanford University, a fellowship in the Robert Wood Johnson Clinical Scholars Program at UCLA and a post-doctoral fellowship in the Philip R. Lee Institute for Health Policy Studies at UCSF. Dr. Patel practices general pediatrics at the Gardner Packard Children's Health Center.
Associate Professor - Med Center Line, Pediatrics - General Pediatrics
Member, Stanford Diabetes Research Center (2018 - Present)
Residency:Stanford University Pediatric Residency (2005) CA
Board Certification: Pediatrics, American Board of Pediatrics (2005)
MSHS, University of California, Los Angeles, Health Services (2008)
MD, University of North Carolina, Chapel Hill, Medicine (2002)
Medical Education:University of North Carolina School of Medicine (2002) NC
MSPH, University of North Carolina, Chapel Hill Gillings School of Public Health, Maternal and Child Health (2001)
BS, University of North Carolina, Chapel Hill, Chemistry, Anthropology (1997)
Current Research and Scholarly Interests
Dr. Patel's research interests focus on reducing socioeconomic disparities in chronic diseases, including childhood obesity. Over the past 10 years, Dr. Patel has led numerous studies to encourage healthy beverage intake among children and adolescents. These studies include analyses of large national data sets, conduct of randomized controlled trials in schools, child care, and community settings to examine how interventions to increase children’s intake of water instead of sugar-sweetened beverages impact child health, and the evaluation of policy efforts to improve the healthfulness of beverages offered in schools and community settings.
Dr. Patel has a diverse funding portfolio ranging from the Robert Wood Johnson Foundation Healthy Eating Research Program, the W.K. Kellogg Foundation, and the National Institutes of Health. Dr. Patel has presented her research to local, national and international audiences. She has also been recognized for her research with awards from the American Academy of Pediatrics and the University of North Carolina, Chapel Hill School of Public Health.
School Water Access, Food and Beverage Intake, and Obesity
It is widely argued that the promotion of water consumption, as an alternative to sugar-sweetened beverages, can assist in childhood obesity prevention efforts. Yet no studies have tested this argument in real world schools where flavored milk or juices are available. This trial will fill gaps by examining how promoting fresh water intake-both in schools that do and do not provide access to caloric beverages -impacts children's consumption of food and beverages both during and outside of school, and obesity.
Water First:The Impact of School Water Access on Child Food and Beverage Intake and Obesity, Stanford University, University of California, San Francisco, Nutrition Policy Institute (8/1/2016 - 5/31/2021)
This study examines whether increased access to fresh water and rigorous promotion of its consumption in elementary schools will reduce students' intake of caloric beverages, thereby leading to lower rates of obesity.
San Francisco Bay Area
Examining Policies Providing Access to Free Water in Schools and the Health Impact of an Alternative to Sugar-Sweetened Beverages, Stanford University, Nutrition Policy Institute, California Food Policy Advocates, Enigami Ventures
This natural experiment will (1) examine the change in free drinking water access in food service areas in California public schools from before to after Senate Bill 1413/Healthy Hunger-Free Kids Act implementation; (2) assess changes in the proportion of schools with excellent water access following implementation of the water in schools laws; and (3) investigate the addition of water language to school district wellness policies over the past five years and if the strength/comprehensiveness of water language in the district wellness policy correlates with excellence in water access at the school.
Testing Drinking Water in California Public Schools for Lead and Other Contaminants in the Context of an Obesity-Prevention Strategy, Stanford University, Virginia Tech, Nutrition Policy Institute
The aims of this study are to: 1) assess the quality of drinking water (by testing for the key contaminants lead, copper, arsenic, nitrate, hexavalent chromium) in food service areas (FSAs) in a representative sample of 240 California public schools; 2) examine school characteristics associated with water quality violations in FSA water sources in California public schools; and 3) understand if school administrators’ report of water quality testing is associated with water quality violations in FSAs.
Independent Studies (3)
- Community Health and Prevention Research Master's Thesis Writing
CHPR 399 (Aut, Win, Spr, Sum)
- Curricular Practical Training and Internship
CHPR 299 (Aut, Win, Spr, Sum)
- Directed Reading
CHPR 298 (Aut, Win, Spr, Sum)
- Community Health and Prevention Research Master's Thesis Writing
A randomized trial of a multi-level intervention to increase water access and appeal in community recreation centers.
Contemporary clinical trials
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.
View details for DOI 10.1016/j.cct.2019.02.003
View details for PubMedID 30771559
The association of flavored milk consumption with milk and energy intake, and obesity: A systematic review
2018; 111: 151–62
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.
View details for DOI 10.1016/j.ypmed.2018.02.031
View details for Web of Science ID 000432867400020
View details for PubMedID 29501475
Measuring beverage consumption in US children and adolescents: a systematic review.
Obesity reviews : an official journal of the International Association for the Study of Obesity
2018; 19 (8): 1017–27
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.
View details for DOI 10.1111/obr.12692
View details for PubMedID 29938891
View details for PubMedCentralID PMC6103833
Potentially addictive properties of sugar-sweetened beverages among adolescents.
2018; 133: 130–37
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 < 0.05). After controlling the false discovery rate, changes in motivation, craving, and well-being remained significant (corrected Ps < 0.05). Using 24-hr recalls and drink journals, participants reported lower total daily consumption of sugar (-80 g) and added sugar (-16 g) (Ps < 0.001) during cessation. This study provides preliminary evidence of withdrawal symptoms and increased SSB cravings during cessation in a diverse population of overweight or obese adolescents.
View details for DOI 10.1016/j.appet.2018.10.032
View details for PubMedID 30385262
Ecological Momentary Assessment of Factors Associated with Water Intake Among Adolescents with Kidney Stone Disease.
The Journal of urology
Maintaining high water intake reduces kidney stone recurrence, but is difficult to do. Strategies to reduce stone recurrence among adolescents are lacking.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.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<0.01). Unawareness of intake goals was weakly associated with drinking 1129 mL less water each day(p=0.1). Access to water, alternative beverage consumption, and bathroom aversion were not associated with water intake.Unawareness of water volume consumed and low responsiveness to the perceived need to drink more were associated with low water intake. Interventions that help adolescents recognize when and identify how to increase water intake may be effective in reducing stone recurrence.
View details for DOI 10.1016/j.juro.2018.07.064
View details for PubMedID 30076905
Validation of a survey to examine drinking-water access, practices and policies in schools.
Public health nutrition
Ensuring 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.Survey 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.Public schools in the San Francisco Bay Area, California, USA.School administrators (n 24).Eighty-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.This 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.
View details for DOI 10.1017/S1368980017002312
View details for PubMedID 28893341
- Water Access in the United States: Health Disparities Abound and Solutions Are Urgently Needed. American journal of public health 2017; 107 (9): 1354–56
Validation of a Brief Questionnaire Against Direct Observation to Assess Adolescents' School Lunchtime Beverage Consumption.
Journal of nutrition education and behavior
Beverage 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.Researchers 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.Eight 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 < 0.20. Six beverages had too few ratings to compute κ's.This brief questionnaire was useful for assessing school lunchtime consumption of many beverages and provides a low-cost tool for evaluating school-based beverage interventions.
View details for DOI 10.1016/j.jneb.2017.06.006
View details for PubMedID 28743436
Public Perception of Quality and Support for Required Access to Drinking Water in Schools and Parks.
American journal of health promotion
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.Cross-sectional survey of the US public collected from August to November 2011.Random digit-dialed telephone survey.Participants (n = 1218) aged 17 and older from 1055 US counties in 46 states.Perceived safety and taste of water in schools and parks as well as support for required access to water in these settings.Survey-adjusted perceived safety and taste as well as support for required access were estimated.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%).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.
View details for PubMedID 27698227
View details for PubMedCentralID PMC5378665
San Francisco childcare centers' preparedness in the prevention and management of asthma among preschool-aged children
JOURNAL OF ASTHMA
2016; 53 (7): 691-698
Asthma 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.We 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.36 out of 40 eligible childcare centers (90%) participated. These sites served 1570 children primarily between the ages of 2 to 5 years. On average, centers met 3.8 out of 7 (SD = 1.3) recommendations. Staff familiarity caring for children with asthma (p < 0.001) and the center's asthma prevalence (p = 0.01) was positively associated with the center's asthma preparedness. The 3 areas most in need of improvement related to asthma medications, asthma action plans and asthma policies. None of the managers reported being familiar with the NAEPP recommendations.There is room for improvement in the asthma care and preparedness of childcare centers. The 3 areas in which centers performed poorly (appropriate asthma medication management, use of asthma action plans, and presence of appropriate asthma policies) suggest that closer collaboration between clinicians and childcare centers may be a key to improving asthma management for young children.
View details for DOI 10.3109/02770903.2015.1135944
View details for Web of Science ID 000381298500005
View details for PubMedID 27164036
- Maximizing School Policies to Reduce Youth Consumption of Sugar-Sweetened Beverages JOURNAL OF ADOLESCENT HEALTH 2016; 59 (1): 1-2
A Trial of the Efficacy and Cost of Water Delivery Systems in San Francisco Bay Area Middle Schools, 2013
PREVENTING CHRONIC DISEASE
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.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.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).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.
View details for DOI 10.5888/pcd13.160108
View details for Web of Science ID 000393106200002
View details for PubMedID 27390074
View details for PubMedCentralID PMC4951080
Lunchtime School Water Availability and Water Consumption Among California Adolescents
JOURNAL OF ADOLESCENT HEALTH
2016; 58 (1): 98-103
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.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.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.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.
View details for DOI 10.1016/j.jadohealth.2015.09.007
View details for Web of Science ID 000367062200015
View details for PubMedID 26552740
View details for PubMedCentralID PMC4695239
Association Between Student Purchases of Beverages During the School Commute and In-School Consumption of Sugar-Sweetened Beverages, San Francisco Bay Area, 2013
PREVENTING CHRONIC DISEASE
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.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.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).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 (e.g., encouraging retailers to promote healthy beverages, posting beverage calorie information).
View details for DOI 10.5888/pcd12.150306
View details for Web of Science ID 000368665800010
View details for PubMedID 26679489
View details for PubMedCentralID PMC5241631
- Chocolate Milk in Schools PEDIATRICS 2015; 136 (6): E1680-E1680
Reach Out and Eat: Food and Beverages Depicted in Books for Preschoolers
2015; 54 (13): 1257-1264
To examine food and beverage depictions in books for preschoolers.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.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.When selecting books for ROR, it may be important to consider food and beverage depictions and messages.
View details for DOI 10.1177/0009922815574078
View details for Web of Science ID 000363063800004
View details for PubMedID 25715825
View details for PubMedCentralID PMC4547902
Development of a Tool to Evaluate Asthma Preparedness and Management in Child-Care Centers
PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY
2015; 28 (2): 121-128
Introduction: Asthma is a common condition affecting many children in child-care centers. The National Asthma Education and Prevention Program offers recommendations about creating an asthma-friendly child-care setting. However, no studies have investigated the extent to which child-care centers adhere to these recommendations. This study describes the development of a novel instrument to determine the ability of child-care centers to meet national recommendations for asthma. Methods: The Preparing for Asthma in Child Care (PACC) Instrument was developed using information from existing recommendations and standards, the peer-reviewed literature, site visits, and expert interviews. The survey questions were pilot-tested at 36 child-care centers throughout San Francisco. Results: The instrument is composed of 43 items across seven domains: smoking exposure, presence of a medical consultant and policies, management of ventilation and triggers, access to medication, presence of asthma action plans, staff training, and encouragement of physical activity. Discussion: The PACC Instrument is an evidence-based and comprehensive tool designed to identify areas to target to improve asthma care for children in child-care centers.
View details for DOI 10.1089/ped.2014.0471
View details for Web of Science ID 000363877000010
View details for PubMedID 26155370
View details for PubMedCentralID PMC4491155
Drinking Water in California Child Care Sites Before and After 2011-2012 Beverage Policy
PREVENTING CHRONIC DISEASE
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.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.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%).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.
View details for DOI 10.5888/pcd12.140548
View details for Web of Science ID 000356764300004
View details for PubMedID 26043304
View details for PubMedCentralID PMC4456856
Middle School Student Attitudes About School Drinking Fountains and Water Intake
2014; 14 (5): 471-477
To describe middle school student attitudes about school drinking fountains, investigate whether such attitudes are associated with intentions to drink water at school, and determine how intentions relate to overall water intake.Students (n = 3211) in 9 California middle schools completed surveys between 2009 and 2011. We used multivariate linear regression, adjusting for school sociodemographic characteristics, to examine how attitudes about fountains (5-point scale; higher scores indicating more positive attitudes) were associated with intentions to drink water at school and how intentions to drink water at school were related to overall water intake.Mean age of students was 12.3 (SD = 0.7) years; 75% were Latino, 89% low income, and 39% foreign born. Fifty-two percent reported lower than recommended overall water intake (<3 glasses/day), and 30% reported that they were unlikely or extremely unlikely to drink water at school. Fifty-nine percent reported that school fountains were unclean, 48% that fountain water does not taste good, 33% that fountains could make them sick, 31% that it was not okay to drink from fountains, and 24% that fountain water is contaminated. In adjusted analyses, attitudes about school drinking fountains were related to intentions to drink water at school (β = 0.41; P < .001); intentions to drink water at school were also associated with overall water intake (β = 0.20; P < .001).Students have negative attitudes about school fountains. To increase overall water intake, it may be important to promote and improve drinking water sources not only at school but also at home and in other community environments.
View details for Web of Science ID 000341900200009
View details for PubMedID 25169158
View details for PubMedCentralID PMC4193898
Tapping Into Water: Key Considerations for Achieving Excellence in School Drinking Water Access
AMERICAN JOURNAL OF PUBLIC HEALTH
2014; 104 (7): 1314-1319
We examined free drinking water access in schools.We conducted cross-sectional interviews with administrators from 240 California public schools from May to November 2011 to examine the proportion of schools that met excellent water access criteria (i.e., location, density, type, maintenance, and appeal of water sources), school-level characteristics associated with excellent water access, and barriers to improvements.No schools met all criteria for excellent water access. High schools and middle schools had lower fountain:student ratios than elementary schools (odds ratio [OR] = 0.06; 95% confidence interval [CI] = 0.02, 0.20; OR = 0.30, 95% CI = 0.12, 0.70). Rural schools were more likely to offer a nonfountain water source than city schools (OR = 5.0; 95% CI = 1.74, 14.70). Newer schools were more likely to maintain water sources than older schools (OR = 0.98; 95% CI = 0.97, 1.00). Schools that offered free water in food service areas increased from pre- to postimplementation of California's school water policy (72%-83%; P < .048). Barriers to improving school water included cost of programs and other pressing concerns.Awareness of the benefits related to school drinking water provision and funding may help communities achieve excellence in drinking water access.
View details for DOI 10.2105/AJPH.2013.301797
View details for Web of Science ID 000341809500049
View details for PubMedID 24832141
View details for PubMedCentralID PMC4056210
- Striving for Meaningful Policies to Reduce Sugar-Sweetened Beverage Intake Among Young Children PEDIATRICS 2013; 132 (3): 566-568
Sociodemographic Characteristics and Beverage Intake of Children Who Drink Tap Water
AMERICAN JOURNAL OF PREVENTIVE MEDICINE
2013; 45 (1): 75-82
Tap water provides a calorie-free, no-cost, environmentally friendly beverage option, yet only some youth drink it.To examine sociodemographic characteristics, weight status, and beverage intake of those aged 1-19 years who drink tap water.National Health and Nutrition Examination Survey data (2005-2010) were used to examine factors associated with tap water consumption. A comparison was made of beverage intake among tap water consumers and nonconsumers, by age, race/ethnicity, and income.Tap water consumption was more prevalent among school-aged children (OR=1.85, 95% CI=1.47, 2.33, for those aged 6-11 years; OR=1.85, 95% CI=1.32, 2.59, for those aged 12-19 years) as compared to those aged 1-2 years. Tap water intake was less prevalent among girls/women (OR=0.76, 95% CI=0.64, 0.89); Mexican Americans (OR=0.32, 95% CI=0.23, 0.45); non-Hispanic blacks (OR=0.48, 95% CI=0.34, 0.67); and others (OR=0.50, 95% CI=0.36, 0.68) as compared to whites; Spanish speakers (OR=0.72, 95% CI=0.55, 0.95); and among referents with a lower than Grade-9 education (OR=0.52, 95% CI=0.31, 0.88); Grade 9-11 education (OR=0.50, 95% CI=0.32, 0.77); and high school/General Educational Development test completion (OR=0.50, 95% CI=0.33, 0.76), as compared to college graduates. Tap water consumers drank more fluid (52.5 vs 48.0 ounces, p<0.01); more plain water (20.1 vs 15.2 ounces, p<0.01); and less juice (3.6 vs 5.2 ounces, p<0.01) than nonconsumers.One in six children/adolescents does not drink tap water, and this finding is more pronounced among minorities. Sociodemographic disparities in tap water consumption may contribute to disparities in health outcomes. Improvements in drinking water infrastructure and culturally relevant promotion may help to address these issues.
View details for DOI 10.1016/j.amepre.2013.04.001
View details for Web of Science ID 000320827500009
View details for PubMedID 23790991
View details for PubMedCentralID PMC4452285
Trends in Sugar-Sweetened Beverage and 100% Fruit Juice Consumption Among California Children
2013; 13 (4): 364-370
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.
View details for Web of Science ID 000322058600013
View details for PubMedID 23688439
View details for PubMedCentralID PMC3706491
Is severity of obesity associated with diagnosis or health education practices?
INTERNATIONAL JOURNAL OF OBESITY
2012; 36 (12): 1571-1577
To assess the association of the severity of obesity with diagnosis and health education, and to identify any differences within demographic or other subgroups.Clinician visits for 2-18 year olds from the 2005-2008 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were combined. Descriptive, bivariate and multivariate analyses were used to compare diagnosis of obesity and health education (nutrition, exercise and weight reduction) across elevated body mass index (BMI) groups (overweight, obese and extreme or very obese, defined as >120% of the 95th percentile for age and gender), patient socio-demographic characteristics, physician specialty and type of visit (well child visits (WCV) versus non-well child visits (non-WCV).A total of 17,808 visits had a calculated BMI, of which 5.8% were extremely obese, 13% were obese and 15.2% were overweight, with the highest percentages among older children, blacks and Hispanics. Diagnosis and weight reduction education were higher among children with an extreme BMI. Nutrition and exercise education were not correlated with severity of obesity. Race, ethnicity or gender biases were not identified. Severity of obesity was significantly associated with presentation to a non-WCV rather than a WCV.Extremely obese children have higher, but still insufficient, rates of diagnosis and health education. Nutrition and exercise education are not prevalent throughout all age groups. Providers may be relying inconsistently and insufficiently on visual cues to drive their obesity prevention practices. Furthermore, lower rates of diagnosis and education at non-WCV may result in a missed opportunity to prevent comorbidities. This is of particular concern as overweight children are less likely to be seen at WCV than non-WCV.
View details for DOI 10.1038/ijo.2012.1
View details for Web of Science ID 000312383700012
View details for PubMedID 22270382
Hypertension Screening During Ambulatory Pediatric Visits in the United States, 2000-2009
2012; 130 (4): 604-610
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.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.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.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.
View details for DOI 10.1542/peds.2011-3888
View details for Web of Science ID 000309412100043
View details for PubMedID 22987883
Missing Documentation of Weight and Height at Preventive Visits for Children
2012; 51 (10): 933-938
Despite the importance of measuring weight and height at well-child visits, there are limited data on frequency of anthropometric documentation. The authors aimed to identify characteristics associated with missing weight and height documentation at preventive visits for children. Among preventive visits for children from birth to 18 years old, recorded in the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys for 2005-2009, the authors found that 20.8% had missing weight and/or height (n = 19,033) documentation. Compared with infants younger than 2 years, school-age children (odds ratio [OR] = 1.30; 95% confidence interval [CI] = 1.03-1.64), and adolescents (OR = 1.61; 95% CI = 1.26-2.04) were more likely to lack documentation. Missing documentation was also more likely for visits with nonphysicians (OR = 4.53; 95% CI = 3.17-6.48) and nonpediatricians (OR = 2.63; 95% CI = 2.02-3.41) compared with pediatricians. Efforts to improve weight and height surveillance should be directed to clinics in which midlevel providers and nonpediatric physicians are caring for school-age children and adolescents.
View details for DOI 10.1177/0009922812441668
View details for Web of Science ID 000310378000005
View details for PubMedID 22511198
Observations of Drinking Water Access in School Food Service Areas Before Implementation of Federal and State School Water Policy, California, 2011
PREVENTING CHRONIC DISEASE
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.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.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.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.
View details for DOI 10.5888/pcd9.110315
View details for Web of Science ID 000306650900001
View details for PubMedID 22765930
View details for PubMedCentralID PMC3468310
Encouraging Consumption of Water in School and Child Care Settings: Access, Challenges, and Strategies for Improvement
AMERICAN JOURNAL OF PUBLIC HEALTH
2011; 101 (8): 1370-1379
Children and adolescents are not consuming enough water, instead opting for sugar-sweetened beverages (sodas, sports and energy drinks, milks, coffees, and fruit-flavored drinks with added sugars), 100% fruit juice, and other beverages. Drinking sufficient amounts of water can lead to improved weight status, reduced dental caries, and improved cognition among children and adolescents. Because children spend most of their day at school and in child care, ensuring that safe, potable drinking water is available in these settings is a fundamental public health measure. We sought to identify challenges that limit access to drinking water; opportunities, including promising practices, to increase drinking water availability and consumption; and future research, policy efforts, and funding needed in this area.
View details for Web of Science ID 000293149500010
View details for PubMedID 21680941
View details for PubMedCentralID PMC3134515
Increasing the Availability and Consumption of Drinking Water in Middle Schools: A Pilot Study
PREVENTING CHRONIC DISEASE
2011; 8 (3)
Although several studies suggest that drinking water may help prevent obesity, no US studies have examined the effect of school drinking water provision and promotion on student beverage intake. We assessed the acceptability, feasibility, and outcomes of a school-based intervention to improve drinking water consumption among adolescents.The 5-week program, conducted in a Los Angeles middle school in 2008, consisted of providing cold, filtered drinking water in cafeterias; distributing reusable water bottles to students and staff; conducting school promotional activities; and providing education. Self-reported consumption of water, nondiet soda, sports drinks, and 100% fruit juice was assessed by conducting surveys among students (n = 876), preintervention and at 1 week and 2 months postintervention, from the intervention school and the comparison school. Daily water (in gallons) distributed in the cafeteria during the intervention was recorded.After adjusting for sociodemographic characteristics and baseline intake of water at school, the odds of drinking water at school were higher for students at the intervention school than students at the comparison school. Students from the intervention school had higher adjusted odds of drinking water from fountains and from reusable water bottles at school than students from the comparison school. Intervention effects for other beverages were not significant.Provision of filtered, chilled drinking water in school cafeterias coupled with promotion and education is associated with increased consumption of drinking water at school. A randomized controlled trial is necessary to assess the intervention's influence on students' consumption of water and sugar-sweetened beverages, as well as obesity-related outcomes.
View details for Web of Science ID 000298968400011
View details for PubMedID 21477500
View details for PubMedCentralID PMC3103565
Encouraging healthy beverage intake in child care and school settings
CURRENT OPINION IN PEDIATRICS
2010; 22 (6): 779-784
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.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.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.
View details for DOI 10.1097/MOP.0b013e32833f2fe2
View details for Web of Science ID 000284143600016
View details for PubMedID 20814303
Underdiagnosis of Pediatric Obesity during Outpatient Preventive Care Visits
2010; 10 (6): 405-409
To examine obesity diagnosis, obesity-related counseling, and laboratory testing rates among obese pediatric patients seen in US preventive outpatient visits and to determine patient, provider, and practice-level factors that are associated with obesity diagnosis.By using 2005-2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data, outpatient preventive visits made by obese (body mass index ≥95%) 2- to 18-year-old patients were examined for frequencies of obesity diagnosis, diet, exercise, or weight reduction counseling, and glucose or cholesterol testing. Multivariable logistic regression was used to examine whether patient-level (gender, age, race/ethnicity, insurance type) and provider/practice-level (geographic region, provider specialty, and practice setting) factors were associated with physician obesity diagnosis.Physicians documented an obesity diagnosis in 18% (95% confidence interval, 13-23) of visits made by 2- to 18-year-old patients with a body mass index ≥95%. Documentation of an obesity diagnosis was more likely for non-white patients (odds ratio 2.87; 95% confidence interval, 1.3-6.3). Physicians were more likely to provide obesity-related counseling (51% of visits) than to conduct laboratory testing (10% of visits) for obese pediatric patients.Rates of documented obesity diagnosis, obesity-related counseling, and laboratory testing for comorbid conditions among obese pediatric patients seen in US outpatient preventive visits are suboptimal. Efforts should target enhanced obesity diagnosis as a first step toward improving pediatric obesity management.
View details for Web of Science ID 000284253800009
View details for PubMedID 21075322
Perceptions about availability and adequacy of drinking water in a large California school district.
Preventing chronic disease
2010; 7 (2): A39-?
Concerns about the influence of sugar-sweetened beverage consumption on obesity have led experts to recommend that water be freely available in schools. We explored perceptions about the adequacy of drinking water provision in a large California school district to develop policies and programs to encourage student water consumption.From March to September 2007, we used semistructured interviews to ask 26 California key stakeholders - including school administrators and staff, health and nutrition agency representatives, and families - about school drinking water accessibility; attitudes about, facilitators of, and barriers to drinking water provision; and ideas for increasing water consumption. Interviews were analyzed to determine common themes.Although stakeholders said that water was available from school drinking fountains, they expressed concerns about the appeal, taste, appearance, and safety of fountain water and worried about the affordability and environmental effect of bottled water sold in schools. Stakeholders supported efforts to improve free drinking water availability in schools, but perceived barriers (eg, cost) and mistaken beliefs that regulations and beverage contracts prohibit serving free water may prevent schools from doing so. Some schools provide water through cold-filtered water dispensers and self-serve water coolers.This is the first study to explore stakeholder perceptions about the adequacy of drinking water in US schools. Although limited in scope, our study suggests that water available in at least some schools may be inadequate. Collaborative efforts among schools, communities, and policy makers are needed to improve school drinking water provision.
View details for PubMedID 20158967
View details for PubMedCentralID PMC2831793
School Site Visits for Community-Based Participatory Research on Healthy Eating
AMERICAN JOURNAL OF PREVENTIVE MEDICINE
2009; 37 (6): S300-S306
School nutrition policies are gaining support as a means of addressing childhood obesity. Community-based participatory research (CBPR) offers an approach for academic and community partners to collaborate to translate obesity-related school policies into practice. Site visits, in which trained observers visit settings to collect multilevel data (e.g., observation, qualitative interviews), may complement other methods that inform health promotion efforts. This paper demonstrates the utility of site visits in the development of an intervention to implement obesity-related policies in Los Angeles Unified School District (LAUSD) middle schools.In 2006, trained observers visited four LAUSD middle schools. Observers mapped cafeteria layout; observed food/beverage offerings, student consumption, waste patterns, and duration of cafeteria lines; spoke with school staff and students; and collected relevant documents. Data were examined for common themes and patterns.Food and beverages sold in study schools met LAUSD nutritional guidelines, and nearly all observed students had time to eat most or all of their meal. Some LAUSD policies were not implemented, including posting nutritional information for cafeteria food, marketing school meals to improve student participation in the National School Lunch Program, and serving a variety of fruits and vegetables. Cafeteria understaffing and costs were obstacles to policy implementation.Site visits were a valuable methodology for evaluating the implementation of school district obesity-related policies and contributed to the development of a CBPR intervention to translate school food policies into practice. Future CBPR studies may consider site visits in their toolbox of formative research methods.
View details for DOI 10.1016/j.amepre.2009.08.009
View details for Web of Science ID 000272770000017
View details for PubMedID 19896033
View details for PubMedCentralID PMC2921547