Dr. Anisha I. Patel is a 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 Dean of Research, Stanford School of Medicine (2022 - Present)
Equity Analytics - Co-Director, Stanford Office of Child Health Equity (2022 - Present)
Director of Community-Engaged Research, Stanford Maternal and Child Health Research Institute (2022 - Present)
Member, Stanford Diabetes Research Center (2018 - Present)
Residency: Stanford Health Care at Lucile Packard Children's Hospital (2005) CA
Board Certification: American Board of Pediatrics, 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.
Childcare Healthy Beverage Access, Food and Beverage Intake, and Obesity
Interventions that promote water consumption in place of sugar-sweetened beverages have shown promise for preventing childhood obesity in schoolchildren. Yet to date, no studies have examined whether applying this approach in childcare centers could help to prevent childhood obesity at an even earlier stage of development. This cluster-randomized controlled trial will fill gaps by examining how a multilevel childcare-based healthy beverage intervention affects young children's consumption of beverages and obesity.
Communication and Marketing of School Meals
Currently, millions of children in preschools, schools, and in afterschool continue to receive breakfast, lunch, snacks and supper through these programs. Thanks to federal nutrition standards and reimbursements, school meals are generally healthier than meals from home, particularly for students from low-income households. Participation in these programs, beginning in the earliest years, reduces food insecurity and improves child health and academic performance. Despite USDA administrative flexibilities issued during the COVID-19 pandemic, participation in school nutrition programs has decreased. This trial will examine whether an intervention that focuses on communicating the benefits of child nutrition programs and establishes a feasible and sustainable strategy for parents to provide ongoing feedback to improve the appeal, cultural relevance, and quality of school meals will increase school meal participation to reduce food insecurity and promote child 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.
Stanford is currently not accepting patients for this trial. For more information, please contact Anisha Patel, MD, MSPH, 650-497-1181.
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 (4)
- Community Health and Prevention Research Master's Thesis Writing
CHPR 399 (Aut, Win, Spr, Sum)
- Curricular Practical Training and Internship
CHPR 290 (Aut, Win, Spr, Sum)
- Directed Reading
CHPR 299 (Aut, Win, Spr, Sum)
- Medical Scholars Research
MED 370 (Sum)
- Community Health and Prevention Research Master's Thesis Writing
A Comprehensive Examination of the Contaminants in Drinking Water in Public Schools in California, 2017-2022.
Public health reports (Washington, D.C. : 1974)
Reports of unsafe school drinking water in the United States highlight the importance of ensuring school water is safe for consumption. Our objectives were to describe (1) results from our recent school drinking water sampling of 5 common contaminants, (2) school-level factors associated with exceedances of various water quality standards, and (3) recommendations.We collected and analyzed drinking water samples from at least 3 sources in 83 schools from a representative sample of California public schools from 2017 through 2022. We used multivariate logistic regression to examine school-level factors associated with lead in drinking water exceedances at the American Academy of Pediatrics (AAP) recommendation level (1 part per billion [ppb]) and state action-level exceedances of other contaminants (lead, copper, arsenic, nitrate, and hexavalent chromium).No schools had state action-level violations for arsenic or nitrate; however, 4% had ≥1 tap that exceeded either the proposed 10 ppb action level for hexavalent chromium or the 1300 ppb action level for copper. Of first-draw lead samples, 4% of schools had ≥1 tap that exceeded the California action level of 15 ppb, 18% exceeded the US Food and Drug Administration (FDA) bottled water standard of 5 ppb, and 75% exceeded the AAP 1 ppb recommendation. After turning on the tap and flushing water for 45 seconds, 2%, 10%, and 33% of schools exceeded the same standards, respectively. We found no significant differences in demographic characteristics between schools with and without FDA or AAP exceedances.Enforcing stricter lead action levels (<5 ppb) will markedly increase remediation costs. Continued sampling, testing, and remediation efforts are necessary to ensure drinking water meets safety standards in US schools.
View details for DOI 10.1177/00333549231192471
View details for PubMedID 37667618
Drink Tap: A Multisector Program to Promote Water Access and Intake in San Francisco Parks.
Preventing chronic disease
2023; 20: E74
Taxes on sugar-sweetened beverages (SSBs), or drinks with added sugars, show promise in decreasing purchases and consumption of SSBs. Some have called for coupling such taxes with improvements in access to safe drinking water as a strategy for reducing inequities in SSB intake, yet no studies have examined such an approach. Drink Tap is a San Francisco-based program in which public tap water stations were installed in parks and public spaces (winter 2017) and promotional efforts (fall and winter 2018) encouraged water intake. At the same time, San Francisco and surrounding communities were also implementing SSB taxes. We conducted a quasi-experimental study to examine whether water access and promotion combined with SSB taxes affected beverage intake habits more than SSB taxes alone. We conducted 1-hour observations (N = 960) at 10 intervention parks (Drink Tap plus SSB taxes) and 20 comparison parks (SSB taxes only) in San Francisco Bay Area cities before (July-September 2016) and after (June-August 2019) implementation of Drink Tap. We found significant adjusted percentage increases in drinking water among visitors to intervention parks, compared with comparison parks: water from park water sources (+80%, P < .001) and water from reusable bottles (+40%, P = .02). We found no significant reductions in visitors observed drinking bottled water, juices, or SSBs. The Drink Tap intervention led to increases in water intake from park sources and reusable bottles across parks that surpassed increases achieved through SSB taxes alone. Jurisdictions should consider coupling tap water access and promotion with policies for reducing intake of SSBs.
View details for DOI 10.5888/pcd20.230007
View details for PubMedID 37616470
Effectiveness of a School Drinking Water Promotion and Access Program for Overweight Prevention.
BACKGROUND AND OBJECTIVE: Drinking water promotion and access shows promise for preventing weight gain. This study evaluated the impact of Water First, a school-based water promotion and access intervention on changes in overweight.METHODS: Low-income, ethnically diverse elementary schools in California's Bay Area were cluster-randomized to intervention and control groups. Water First includes classroom lessons, water stations, and schoolwide water promotion over 1 school year. The primary outcome was overweight prevalence (BMI-for-age-and-sex ≥85th percentile). Students (n = 1249) in 56 fourth-grade classes in 18 schools (9 intervention, 9 control) from 2016 to 2019 participated in evaluation at baseline, 7, and 15 months. Data collection was interrupted in 8 additional recruited schools because of coronavirus disease 2019.RESULTS: Of 1262 students from 18 schools, 1249 (47.4% girls; mean [SD] age, 9.6 [0.4] years; 63.4% Hispanic) were recruited. From baseline to 7 months, there was no significant difference in changes in overweight prevalence in intervention schools (-0.2%) compared to control schools (-0.4%) (adjusted ratio of odds ratios [ORs]: 0.7 [confidence interval (CI): 0.2-2.9] P = 0.68). From baseline to 15-months, increases in overweight prevalence were significantly greater in control schools (3.7%) compared to intervention schools (0.5%). At 15 months, intervention students had a significantly lower change in overweight prevalence (adjusted ratio of ORs: 0.1 [CI: 0.03-0.7] P = .017) compared to control students. There were no intervention effects for obesity prevalence.CONCLUSIONS: Water First prevented increases in the prevalence of overweight, but not obesity, in elementary school students.
View details for DOI 10.1542/peds.2022-060021
View details for PubMedID 37545466
Incidence of Neonatal Hypothermia in the Newborn Nursery and Associated Factors.
JAMA network open
2023; 6 (8): e2331011
Thermoregulation is a key component of well-newborn care. There is limited epidemiologic data on hypothermia in late preterm and term infants admitted to the nursery. Expanding on these data is essential for advancing evidence-based care in a population that represents more than 3.5 million births per year in the US.To examine the incidence and factors associated with hypothermia in otherwise healthy infants admitted to the newborn nursery following delivery.A retrospective cohort study using electronic health record data from May 1, 2015, to August 31, 2021, was conducted at a newborn nursery at a university-affiliated children's hospital. Participants included 23 549 infants admitted to the newborn nursery, from which 321 060 axillary and rectal temperature values were analyzed.Infant and maternal clinical and demographic factors.Neonatal hypothermia was defined according to the World Health Organization threshold of temperature less than 36.5 °C. Hypothermia was further classified by severity (mild: single episode, temperature 36.0-36.4 °C; moderate/severe: persistent or recurrent hypothermia and/or temperature <36.0 °C) and timing (early: all hypothermic episodes occurred within the first 24 hours after birth; late: any episode extended beyond the first 24 hours).Of 23 549 included infants (male, 12 220 [51.9%]), 5.6% were late preterm (35-36 weeks' gestation) and 4.3% were low birth weight (≤2500 g). The incidence of mild hypothermia was 17.1% and the incidence of moderate/severe hypothermia was 4.6%. Late hypothermia occurred in 1.8% of infants. Lower birth weight and gestational age and Black and Asian maternal race and ethnicity had the highest adjusted odds across all classifications of hypothermia. The adjusted odds ratios of moderate/severe hypothermia were 5.97 (95% CI 4.45-8.00) in infants with a birth weight less than or equal to 2500 vs 3001 to 3500 g, 3.17 (95% CI 2.24-4.49) in 35 week' vs 39 weeks' gestation, and 2.65 (95% CI 1.78-3.96) in infants born to Black mothers and 1.94 (95% CI 1.61-2.34) in infants born to Asian mothers vs non-Hispanic White mothers.In this cohort study of infants in the inpatient nursery, hypothermia was common, and the incidence varied by hypothermia definition applied. Infants of lower gestational age and birth weight and those born to Black and Asian mothers carried the highest odds of hypothermia. These findings suggest that identifying biological, structural, and social determinants of hypothermia is essential for advancing evidence-based equitable thermoregulatory care.
View details for DOI 10.1001/jamanetworkopen.2023.31011
View details for PubMedID 37642965
Parent Perception of School Meals in the San Joaquin Valley during COVID-19: A Photovoice Project.
2023; 15 (5)
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.
View details for DOI 10.3390/nu15051087
View details for PubMedID 36904087
Perceptions of Water Safety and Tap Water Taste and Their Associations With Beverage Intake Among U.S. Adults.
American journal of health promotion : AJHP
OBJECTIVES: Examine differences in perceptions of tap water (TW) and bottled water (BW) safety and TW taste and their associations with plain water (PW) and sugar-sweetened beverage (SSB) intake.DESIGN: Quantitative, cross-sectional study.SETTING: United States.SUBJECTS: 4,041 U.S. adults (≥18years) in the 2018 SummerStyles survey data.MEASURES: Outcomes were intake of TW, BW, PW (tap and bottled water), and SSB. Exposures were perceptions of TW and BW safety and TW taste (disagree, neutral, or agree). Covariates included sociodemographics.ANALYSIS: We used chi-square analysis to examine sociodemographic differences in perceptions and multivariable logistic regressions to estimate adjusted odds ratios (AOR) for consuming TW ≤ 1cup/day, BW > 1cup/day, PW ≤ 3cups/day, and SSB ≥ 1 time/day by water perceptions.RESULTS: One in 7 (15.1%) of adults did not think their home TW was safe to drink, 39.0% thought BW was safer than TW, and 25.9% did not think their local TW tasted good. Adults who did not think local TW was safe to drink had higher odds of drinking TW ≤ 1cup/day (AOR = 3.12) and BW >1 cup/day (AOR = 2.69). Adults who thought BW was safer than TW had higher odds of drinking TW ≤1 cup/day (AOR = 2.38), BW > 1cup/day (AOR = 5.80), and SSB ≥ 1time/day (AOR = 1.39). Adults who did not think TW tasted good had higher odds of drinking TW ≤ 1cup/day (AOR = 4.39) and BW > 1cup/day (AOR = 2.91).CONCLUSIONS: Negative perceptions of TW safety and taste and a belief BW is safer than TW were common and associated with low TW intake. Perceiving BW is safer than TW increased the likelihood of daily SSB intake. These findings can guide programs and services to support water quality to improve perceptions of TW safety and taste, which might increase TW intake and decrease SSB intake.
View details for DOI 10.1177/08901171221150093
View details for PubMedID 36609168
Implementation of Universal School Meals during COVID-19 and beyond: Challenges and Benefits for School Meals Programs in Maine.
2022; 14 (19)
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.
View details for DOI 10.3390/nu14194031
View details for PubMedID 36235683
A Cross-sectional Study Characterizing Pediatric Temperature Percentiles in Children at Well-Child Visits.
BACKGROUND: 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.OBJECTIVE: To characterize pediatric temperature norms and variation by patient characteristics, time of measurement, and thermometer route.METHODS: 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.RESULTS: 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.CONCLUSIONS: 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.
View details for DOI 10.1016/j.acap.2022.07.015
View details for PubMedID 35914730
Water Security Experiences and Water Intake among Elementary Students at Low Income Schools: A Cross-Sectional Study.
OBJECTIVE: To examine students' experiences of water security at school and how experiences relate to intake of water from different sources of water at school.DESIGN/METHODS: In this cross-sectional study, 651 students in grades 3-5 in 12 low-income public elementary schools in the San Francisco area completed surveys about their daily intake of water from different sources of water at school, experiences of water security including safety, cleanliness, and taste of water at school, and their demographics. Multivariable linear regressions examined associations between students' water security experiences at school and reported intake from different sources of water at school.RESULTS: Approximately half of students were Latino (56.1%) and had overweight/obesity (50.4%). Most (74.5%) had some negative water security experience at school. Students drank from the school fountain or water bottle filling station a mean of 1.2 times/day (SD=1.4), sinks 0.2 times/day (SD=0.7), tap water dispensers 0.2 times/day (SD=0.6), and bottled water 0.5 times/day (SD=1.0). In multivariable linear regression, students with more negative experiences of school water security drank less frequently from fountains (-0.5 times/day, p-value <0.001), but more frequently from tap water dispensers (0.1 times/day, p-value 0.040) and sinks (0.1 times/day, p-value 0.043), compared to students with no negative perceptions.CONCLUSION: On average, students had negative school water security experiences, which decreased their consumption of water from tap water sources. However, relationships between negative water security experiences and reported water intake appeared to be mitigated by water source. Schools should consider installing more appealing water sources to promote water intake.
View details for DOI 10.1016/j.acap.2022.04.008
View details for PubMedID 35537674
- Association of park drinking water source characteristics and water intake in San Francisco Bay Area parks H2OPEN JOURNAL 2022
Factors Related to Water Filter Use for Drinking Tap Water at Home and Its Association with Consuming Plain Water and Sugar-Sweetened Beverages among U.S. Adults.
American journal of health promotion : AJHP
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).Quantitative, cross-sectional study.The 2018 SummerStyles survey data.U.S. adults (≥18 years; N=4,042).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.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. <1 time) by WFU.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=0.69, 95%CI=0.55-0.86 for ≤high school; AOR=0.78, 95%CI=0.64-0.95 for some college, vs. college graduate), not being married (AOR=0.81, 95%CI=0.66-0.98, vs. married/domestic partnership) and lower household income (AOR=0.68, 95%CI=0.68-0.90 for <$35,000, vs. ≥$100,000). Using a water filter was associated with higher odds of drinking >3 cups/day of tap water (AOR=1.33, 95%CI=1.13-1.56) and lower odds of SSBs ≥1 time/day (AOR=0.76, 95%CI=0.62-0.92). 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).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. While WFU was associated with healthful beverage habits, additional considerations for WFU may include source water quality, oral health, cost, and proper use.
View details for DOI 10.1177/08901171211073304
View details for PubMedID 35081754
Water Security Experiences and Water Intake Among Elementary Students at Low-Income Schools: A Cross-Sectional Study
2022; 23 (1): 68-75
View details for Web of Science ID 000918343900001
Storybooks About Healthy Beverage Consumption: Effects in an Online Randomized Experiment With Parents.
American journal of preventive medicine
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<0.001). The beverage messages also elicited more thinking about beverages' health impacts and led to stronger perceptions that sugary drinks are unhealthy (p<0.001). Moreover, the beverage messages led to higher intentions to limit serving children sugary drinks and higher intentions to serve children more water (p≤0.02). Parents' reactions to the beverage messages did not differ by most demographic characteristics. Few differences in outcomes were observed among the 3 beverage message topics.CONCLUSIONS: Embedding beverage messages in storybooks is a promising, scalable strategy for motivating parents from diverse backgrounds to serve children more water and fewer sugary drinks.
View details for DOI 10.1016/j.amepre.2021.07.016
View details for PubMedID 34688521
Mitigating Childhood Food Insecurity during COVID-19: A Qualitative Study of how School Districts in California's San Joaquin Valley Responded to Growing Needs.
Public health nutrition
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 was coded and themes were identified to guide analysis. Community organizations 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 co-operative). Focus groups (n=6) were comprised of parents (n=29) of children participating in school meal programs.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-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 capitalizing on USDA waivers could boost school meal participation. Finally, partnering with community organizations and acting upon parent feedback could improve school meal systems, and in combination with pandemic-EBT, address childhood food insecurity.
View details for DOI 10.1017/S1368980021003141
View details for PubMedID 34325769
Strength and Comprehensiveness of Drinking Water Language in California School District Wellness Policies.
Journal of nutrition education and behavior
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.
View details for DOI 10.1016/j.jneb.2021.04.466
View details for PubMedID 34167919
Examining Recent Trends in the Racial Disparity Gap in Tap Water Consumption: NHANES 2011-2018.
Public health nutrition
OBJECTIVE: As tap water distrust has grown in the US 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 examined 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 9,439 children aged 2-19 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 2013-14 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 2013-14 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 2013-14 and 2017-18. Similar trends were found in bottled water consumption.CONCLUSIONS: This study found persistent disparities in the tap water consumption gap from 2011-2018. Black and Hispanics' probability of not drinking tap water increased following the Flint Water Crisis.
View details for DOI 10.1017/S1368980021002603
View details for PubMedID 34114536
- The Importance of Body Mass Index Assessment and Surveillance in Schools. JAMA pediatrics 2021
Frequency and Consequences of Routine Temperature Measurement at Well-Child Visits.
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.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.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 <20% of visits ("occasional measurement clinics"). After adjusting for age, ethnicity, race, and insurance, antibiotic prescription was more common (adjusted odds ratio: 1.21; 95% CI 1.13-1.29), whereas diagnostic testing was less common (adjusted odds ratio: 0.76; 95% CI 0.71-0.82) at routine measurement clinics. Fever was detected at 270 of 155 527 (0.2%) routine measurement clinic visits, 47 (17.4%) of which were classified as probable incidental fever. Antibiotic prescription and diagnostic testing were more common at visits with probable incidental fever than without fever (7.4% vs 1.7%; 14.8% vs 1.2%; P < .001), and vaccines were deferred at 50% such visits.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.
View details for DOI 10.1542/peds.2021-053412
View details for PubMedID 34890449
Temperature Measurement at Well-Child Visits in the United States.
The Journal of pediatrics
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.In this cross-sectional study, we analyzed 22,518 sampled well-child visits from the National Ambulatory Medical Care Survey (NAMCS) 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, x-ray, urinalysis, antibiotic prescription, and emergency department/hospital referral) by measurement and fever (temperature ≥100.4˚F, ≥38.0˚C) status.Temperature was measured in 48.5% (95% CI 45.6-51.4) of well-child visits. Measurement was more common during visits by non-pediatric providers (adjusted odds ratio [aOR] 2.0, 95% CI 1.6-2.5; ref: pediatricians), in Hispanic (aOR 1.9, 95% CI 1.6-2.3) and Black (aOR 1.5, 95% CI 1.2-1.9; ref: non-Hispanic White) patients, and in patients with government (aOR 2.0, 95% CI 1.7-2.4; ref: 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).Temperature was measured in nearly 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.
View details for DOI 10.1016/j.jpeds.2021.01.045
View details for PubMedID 33508277
- Healthy beverage initiatives in higher education: an untapped strategy for health promotion. Public health nutrition 2020: 1–3
Trends in sugar-sweetened beverage consumption among California children.
Public health nutrition
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.
View details for DOI 10.1017/S1368980020001147
View details for PubMedID 32597746
Correlates of Infrequent Plain Water Intake Among US High School Students: National Youth Risk Behavior Survey, 2017.
American journal of health promotion : AJHP
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 (<3 vs ≥3 times/day).RESULTS: Overall, 48.7% of high school students reported drinking plain water <3 times/day. Factors associated with infrequent plain water intake were younger age (≤15 years; aOR = 1.20, CI = 1.05-1.37); earning mostly D/F grades (aOR = 1.37, CI = 1.07-1.77); consuming regular soda 1 to 6 times/week (aOR = 1.92, CI = 1.67-2.20) or ≥1 time/day (aOR = 3.23, CI = 2.65-3.94), sports drinks 1 to 6 times/week (aOR = 1.30, CI = 1.14-1.49), milk <2 glasses/day (aOR = 1.51, CI = 1.31-1.73), fruits <2 times/day (aOR = 1.92, CI = 1.66-2.22), and vegetables <3 times/day (aOR = 2.42, CI = 2.04-2.89); and being physically active ≥60 minutes/day on <5 days/week (aOR = 1.83, CI = 1.60-2.08). Students with obesity were less likely to have infrequent water intake (aOR = 0.63, CI = 0.53-0.74).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.
View details for DOI 10.1177/0890117120911885
View details for PubMedID 32186199
Development and Validation of a Photo-Evidence Tool to Examine Characteristics of Effective Drinking Water Access in Schools.
The Journal of school health
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.
View details for DOI 10.1111/josh.12873
View details for PubMedID 31994194
Drinking Water in the United States: Implications of Water Safety, Access, and Consumption.
Annual review of nutrition
2020; 40: 345–73
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.
View details for DOI 10.1146/annurev-nutr-122319-035707
View details for PubMedID 32966189
Stories of success: a qualitative examination of contributors to excellence in school drinking water access.
Public health nutrition
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.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.California public elementary, middle/junior and high schools.Knowledgeable individuals involved in initiatives related to school drinking water accessibility, quality or education at each selected school.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.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.
View details for DOI 10.1017/S1368980019003975
View details for PubMedID 32100660
Hydrate Philly: An Intervention to Increase Water Access and Appeal in Recreation Centers.
Preventing chronic disease
2020; 17: E15
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.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 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.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.
View details for DOI 10.5888/pcd17.190277
View details for PubMedID 32078503
Drinking water access in California schools: Room for improvement following implementation of school water policies.
Preventive medicine reports
2020; 19: 101143
This study aims to investigate how access to free drinking water in California public schools changed after implementation of 2010 federal and state school water policies. Repeated cross-sectional surveys were conducted with administrators in a random sample of California public schools, stratified by school type and urban-centric geography, from 2010 to 2011 (n = 240) and from 2016 to 2018 (n = 240). Surveys assessed excellence in drinking water access, defined as 1) providing water in 4 of 5 key school locations, 2) having a high density of free water available, 3) providing water via a non-fountain source, 4) providing water that is perceived as safe, and 5) offering water sources that are reported as clean and functioning. Multivariate logistic regression was used to examine changes in excellence in drinking water access after implementation of school drinking water policies. Analysis was completed in 2019. In 2010-2011, 5% of schools met all water excellence criteria; in 2016-2018, 18% of schools met all excellence criteria. In adjusted models, post-legislation schools had 4 times the odds of meeting all drinking water excellence criteria compared to pre-legislation schools (OR: 4.34; 95% confidence interval = 2.07, 9.10). There were significant increases in public schools meeting the criteria for excellence in free drinking water access after school water policies were implemented; however, a majority of schools still lacked excellent water access. Findings suggest that policies mandating free water access in schools may help to improve excellence in access, and more work is needed to help all schools excel in this area.
View details for DOI 10.1016/j.pmedr.2020.101143
View details for PubMedID 32577338
View details for PubMedCentralID PMC7305375
Water Safety in California Public Schools Following Implementation of School Drinking Water Policies.
Preventing chronic disease
2020; 17: E166
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.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.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.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.
View details for DOI 10.5888/pcd17.200366
View details for PubMedID 33416472
A cluster-randomized controlled trial of an elementary school drinking water access and promotion intervention: Rationale, study design, and protocol.
Contemporary clinical trials
Promoting 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.Informed 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 7 months and 15 months 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.This 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.
View details for DOI 10.1016/j.cct.2020.106255
View details for PubMedID 33370616
Teachers as Healthy Beverage Role Models: Relationship of Student and Teacher Beverage Choices in Elementary Schools.
Journal of community health
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.
View details for DOI 10.1007/s10900-019-00717-7
View details for PubMedID 31407126
Effects of a multipronged beverage intervention on young children's beverage intake and weight: a cluster-randomized pilot study.
Public health nutrition
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.
View details for DOI 10.1017/S1368980019001629
View details for PubMedID 31303190
Training High School Student "Citizen Scientists" to Document School Water Access: A Feasibility Study.
The Journal of school health
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 2hours 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.
View details for DOI 10.1111/josh.12790
View details for PubMedID 31155729
- A randomized trial of a multi-level intervention to increase water access and appeal in community recreation centers CONTEMPORARY CLINICAL TRIALS 2019; 79: 14–20
- Ecological Momentary Assessment of Factors Associated with Water Intake among Adolescents with Kidney Stone Disease JOURNAL OF UROLOGY 2019; 201 (3): 606–13
A systematic review of strategies to increase drinking-water access and consumption among 0- to 5-year-olds.
Obesity reviews : an official journal of the International Association for the Study of Obesity
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.
View details for DOI 10.1111/obr.12833
View details for PubMedID 31250960
Perceptions of drinking water safety and their associations with plain water intake among US Hispanic adults.
Journal of water and health
2019; 17 (4): 587–96
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.
View details for DOI 10.2166/wh.2019.015
View details for PubMedID 31313996
View details for PubMedCentralID wh_2019_015
Agua4All: Providing Safe Drinking Water in Rural California Communities.
Preventing chronic disease
2019; 16: E151
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.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.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.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.
View details for DOI 10.5888/pcd16.190165
View details for PubMedID 31726021
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 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 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 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 PubMedID 26043304
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