School Water Access, Food and Beverage Intake, and Obesity

Maintaining a healthy weight is important for young children because childhood obesity is
predictive of adult obesity and related chronic illness. Intake of sugar-sweetened beverages
(SSBs: sodas, flavored milks, fruit-flavored drinks, and other drinks with added sugar) is a
major contributor to obesity. This is particularly true for low income children who are more
likely to drink SSBs and to be obese. Children spend substantial time in schools where they
consume up to 50% of daily calories, including those from SSBs. Consequently, many obesity
prevention efforts have targeted reductions in SSB intake in schools. Recently, scientific
authorities have also recommended that schools improve the availability of potable and free
drinking water - a healthy alternative to SSBs - as a low-cost and feasible obesity
prevention strategy. Emerging policies also mandate water access in schools; but
implementation is poor. Although the 2010 Healthy, Hunger-Free Kids Act requires schools
participating in federal meal programs to provide free potable water where meals are served,
25% of US schools still fail to do so. And even in schools that offer free water, drinking
fountains may be avoided due to concerns about cleanliness or sub-standard water quality.
While promotion of drinking water intake in schools is a plausible obesity prevention
strategy, no large studies have systematically examined how this tactic can change children's
overall dietary patterns and obesity rates in schools that offer SSBs and juices. This
study's central hypothesis is that in elementary schools, increased access to fresh water and
rigorous promotion of its consumption will reduce student intake of caloric beverages,
thereby leading to lower rates of obesity. This hypothesis will be tested through a
cluster-randomized trial in 26 low-income elementary schools in the San Francisco Bay Area,
in which 13 schools will receive a water promotion intervention and 13 schools will serve as
controls. The intervention, based on Social Cognitive Theory and the PRECEDE-PROCEED Model
and cultivated in the investigators' prior developmental studies, promotes water consumption
by: 1) installing lead-free water stations in cafeterias, physical activity spaces and
high-traffic common areas, 2) providing cups and reusable water bottles for students, and 3)
conducting a 6-month health education campaign that includes a kick-off play, class lessons,
family homework activities, signage, and rewards. From baseline to 9 and 15 months after the
start of the intervention, researchers will measure differences in: 1) water intake
(observations and measurements of water taken from water sources) 2) total caloric intake
from foods and beverages (24-hour food and beverage diaries) and 3) overweight/obesity
prevalence between students in intervention and control schools. If the proposed school water
intervention is effective, school officials will have a feasible and low-cost obesity
prevention tool. US schools will soon be federally mandated to reevaluate their wellness
policies in order to implement new food and beverage regulations. This study presents a
timely opportunity to provide leaders with an evidence-based strategy for improving student
nutrition and health.

Inclusion Criteria:

- 4th grade students, students in 4th grade combination classes who speak English or
Spanish and who don't have health conditions that preclude intake of water

Exclusion Criteria:

- Students not in the 4th grade or 4th grade combination classes

- Students who do not speak English or Spanish