Does the provision of cooled filtered water in secondary school cafeterias increase water drinking and decrease the purchase of soft drinks?

Effects of policies or interventions that influence the school food environment on children's health and nonhealth outcomes: a systematic review

CONTEXT

Globally, 1 in 3 children under 5 years is undernourished or overweight, and 1 in 2 suffers from hidden hunger due to nutrient deficiencies. As children spend a considerable time at school, school-based policies that aim to improve children's dietary intake may help address this double burden of malnutrition.

OBJECTIVE

This systematic review aimed to assess the effects of implementing policies or interventions that influence the school food environment on children's health and nonhealth outcomes.

DATA SOURCES, EXTRACTION, AND ANALYSIS

Eleven databases were searched up to April 2020 and the World Health Organization (WHO) released a call for data due in June 2020. Records were screened against the eligibility criteria, and data extraction and risk-of-bias assessment were conducted by 1 reviewer and checked by another. The synthesis was based on effect direction, and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

CONCLUSIONS

Seventy-four studies reporting 10 different comparisons were included. The body of evidence indicates that interventions addressing the school food environment may have modest beneficial effects on certain key outcomes. Nutrition standards for healthy foods and beverages at schools, interventions that change how food is presented and positioned, and fruit and vegetable provision may have a beneficial effect on the consumption of healthy foods and beverages. Regarding effects on the consumption of discretionary foods and beverages, nutrition standards may have beneficial effects. Nutrition standards for foods and beverages, changes to portion size served, and the implementation of multiple nudging strategies may have beneficial effects on energy intake. Regarding effects of purchasing or selecting healthier foods, changes to how food is presented and positioned may be beneficial. This review was commissioned and supported by the WHO (registration 2020/1001698-0). WHO reviewed and approved the protocol for the systematic review and reviewed the initial report of the completed systematic review.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no: CRD42020186265.

A choice architecture intervention targeting school meals and water frequency intake: A school-based randomized trial

Our aim was to evaluate the impact of choice architecture on school meals and water intake frequency. We conducted a school-based randomized trial in seven elementary municipal public schools (control = 3; intervention = 4) in Rio de Janeiro, Brazil. The interventions group received the following modifications: (1) banner of the daily school meal menu and two superheroes, (2) waterproof tablecloths, (3) posters on healthy eating habits, (4) displays with playful names, (5) new containers for fruits, and (6) colored footprints for one month. Changes in school meals and daily water frequency consumption were evaluated through intention-to-treat analyses, using generalized estimating equations models for repeated measures, considering the classes' cluster effect. Data from 974 students in the fifth and sixth elementary school grades were analyzed (control = 356; intervention = 618). At baseline, 47.1% of students were female, with a mean age of 12 years (SD = 1.4), 39.2% reported daily consumption of school meals, and 45.7% consumed water from the school drinking fountain three or more times a day. We observed an increase in the odds of daily water intake in the intervention group compared to the control (OR = 1.4 95% CI = 1.1-1.9), no changes in the school meals (OR = 1.2 95% CI = 0.9; 1.6). Low-complexity strategies based on choice architecture applied in the school environment can be promising in increasing water intake frequency among elementary students in public schools. TRIAL REGISTRATION: This study was registered on the Clinicaltrials.gov platform under the number NCT03136016. Access: https://clinicaltrials.gov/ct2/show/NCT03136016.

Use and Acceptance of Drinking Fountains: A Pilot Study in Two Secondary Schools in Dortmund, Germany

(1) Background: Water drinking is essential to reduce obesity in children, but effective means for implementation remain controversial. Our study assesses students' and teachers' use of and attitudes towards drinking fountains in two urban secondary schools. (2) Methods: In a cross-sectional study, answers from students and teachers to a 28- and 19-item questionnaire, respectively, containing closed- and open-ended questions and short interviews with the schools' two principals were described and analysed using the question-specific number of responses as the denominator. (3) Results: Questionnaires of one hundred sixty-two students and ten teachers were analysed; 36.1% of students responded. Students viewed the schools' two fountains as a good idea (73.3%, n = 118), recommended them to other schools (73.1%, n = 117), and felt able to distinguish healthy from unhealthy drinks (70.5%, n = 110). In contrast, 55.7% (n = 88) reported using the fountains regularly; over a week, 39.8% (n = 47) used them less than once; 26.3% (n = 31) used them one to two times. Only about a third (26.5%, n = 43) reported consuming more water since the fountains' installation. Teachers' responses were similar to students'; principals stressed planning and costs. (4) Conclusions: A discrepancy between a good attitude towards and actual use of drinking fountains may exist; school communities may need to look for measures to overcome it.

Childhood overweight and obesity abatement policies in Europe

Over the past two decades, a concerted effort to combat the rising tide of childhood overweight and obesity has taken shape. The World Health Organization (WHO) Commission on Ending Childhood Obesity (ECHO) provides recommendations for six priority areas of action, including the promotion of healthy food consumption, promotion of physical activity, preconception and pregnancy care, early childhood diet and physical activity, healthy nutrition and physical activity for school-aged children, and community-based weight management. This paper provides a snapshot of policies and measures aligned to these areas of action within the WHO European Region in order to encourage other countries to make similar efforts. Examples are drawn from Portugal (sugar-sweetened beverage tax, integrated nutrition strategy), the United Kingdom (soft drink levy, active commuting programs, urban design principles), Lithuania (prohibition of energy drinks), Norway (industry and government partnerships to promote healthier foods, nutrition education curriculum for schools), Hungary (tax subsidies to promote healthy diets), the European Union (cross-border marketing regulations, preconception and pregnancy care), Slovenia (food marketing restrictions), Spain (marketing restrictions within educational settings), Poland (investing in sports infrastructure), Russia (increasing sports participation), Estonia (redevelopment of the physical education curriculum), Netherlands (preconception and pregnancy care), Croatia (conditions to support breastfeeding), Austria (perinatal and early childhood nutrition), Czechia (life-course strategy), San Marino (nutrition and physical activity for school-aged children), Ukraine (potable water for schools), Ireland and Italy (community-based weight management approaches). Our findings suggest that a large disparity exists among the type and breadth of policies adopted by Member States, with a mix of single-issue policy responses and more cohesive strategies. The role of data, implementation research, and ongoing surveillance of country-level progress related to childhood overweight and obesity policies are discussed as an essential part of the iterative process of policy development. Additional work to systematically gather context-specific information on policy development, implementation, and reach according to ECHO's six areas of action by WHO European Region countries will inform future policy paradigms within the region.

Evaluation of the 'H2NOE Water Schools' programme to promote water consumption in elementary school children - a non-randomised controlled cluster trial

Objective:

This study evaluated a simple environmental intervention called ‘Water Schools’ in Lower Austria providing free refillable water bottles and educational material.

Design:

Non-randomised controlled cluster trial with three measurements: at baseline (T0), after the intervention at 9 months (T1) and after 1-year follow-up (T2).

Setting:

Half-day elementary schools in Lower Austria (Austria).

Participants:

Third-grade pupils from twenty-two schools in the intervention group (IG) and thirty-two schools in the control group (CG) participated in the study. Data were analysed for 569 to 598 pupils in the IG and for 545 to 613 in the CG, depending on the time of measurement.

Results:

The consumption of tap water increased in the IG from baseline to T1 and then decreased again at T2, but this was similar in the CG (no statistically significant difference in the time trend between the IG and CG). Similar results were seen for tap water consumption in the mornings. The proportion of children who only drank tap water on school mornings increased significantly from baseline to T1 in the IG compared to the CG (P = 0·020). No difference in the changes over time occurred between the groups for the proportion of pupils drinking approximately one bottle of tap water during school mornings.

Conclusions:

Not only the children in the IG but also those in the CG drank more tap water after 1 school year than at the beginning. The measurement of drinking habits in the CG may have been intervention enough to bring about changes or to initiate projects.

Thirsty? Choose Water! Encouraging Secondary School Students to choose water over sugary drinks. A descriptive analysis of intervention components

BACKGROUND

Childhood obesity is a significant public health issue. Sugar-sweetened beverage (SSB) consumption contributes to this and adolescents are high consumers. This paper provides a descriptive overview of a school-based intervention to address this.

METHODS

61 secondary schools in New South Wales were randomised to receive a behavioural intervention (BI), a chilled water station (CWS), both interventions or neither (control). The BI was delivered through classroom lessons, school-based promotion and vaccination clinic. The CWS intervention included the installation of one CWS per school. Intervention effectiveness over time was assessed via student surveys at baseline, post-intervention and follow-up (individual-level outcomes), feedback from teachers and vaccination nurses, a school information survey, and remotely monitored CWS water usage (school-level outcomes).

RESULTS

Teachers reported the BI was useful in teaching students about drinking water and negative consequences of SSBs. Nurses considered the post-vaccination waiting period a good opportunity to deliver health promotion messages. Students in this group showed statistically significant changes in knowledge about SSBs, dehydration effects and changes in daily SSB consumption (T1 23.18%; T3 18.20%). Positive feedback regarding CWSs was received with an increase in water consumption reported for students in this group (T1 86.15% to T3 89.66%) and a statistically significant increase in students carrying a water bottle to school and filling it observed.

CONCLUSIONS

Both interventions were readily implemented with high levels of acceptability and impact on students' knowledge and SSB consumption. The study demonstrates how to promote water consumption in schools utilising two different interventions. SO WHAT?: Evidence regarding how to decrease SSB consumption amongst secondary school students has been strengthened.

Promoting water consumption among Dutch children: an evaluation of the social network intervention Share H2O

Background

There is a need to develop and improve interventions promoting healthy drinking behaviors among children. A promising method could be to stimulate peer influence within children’s social networks. In the Share H₂O social network intervention (SNI), peer influence was utilized by selecting a subset of influential children and training them as ‘influence agents’ to promote water consumption—as an alternative to SSBs. Previous research has mainly focused on the process of selecting influence agents. However, the process of motivating influence agents to promote the behavior has hardly received any research attention. Therefore, in the SNI Share H₂O SNI, this motivation process was emphasized and grounded in the self-determination theory (SDT). This study evaluated the implementation of the Share H₂O SNI, focusing on whether and how applying SDT-based techniques can motivate the influence agents and, indirectly, their peers.

Methods

This study included data collected in the Netherlands from both the influence agents (n = 37) and the peers (n = 112) in the classroom networks of the influence agents.

Self-reported measurements assessed the influence agents’ enjoyment of the training, duration and perceived autonomy support during the training, and changes in their intrinsic motivation and water consumption before and after the start of the intervention. Changes in the peers’ intrinsic motivation, perceived social support, and social norms were measured before and after the start of the intervention.

Results

The influence agents enjoyed the training, the duration was adequate, and perceived it as autonomy supportive. There was an increase in the influence agents’ intrinsic motivation to drink water and their actual water consumption. Providing personal meaningful rationales seemed to have motivated the influence agents. The intrinsic motivation and perceived descriptive norm of the peers remained stable. The peers reported an increase in their perceived social support and injunctive norm concerning water drinking after the intervention. Influence agents appeared to mainly use face-to-face strategies, such as modeling, talking to peers, and providing social support to promote the behavior.

Conclusions

The current findings provided preliminary evidence of the promising effects of using SDT-based techniques in an SNI to motivate the influence agents and, indirectly, their peers.

Trial registration

NTR, NL6905, Registered 9 January 2018, https://www.trialregister.nl/trial/6905

A cluster-randomized controlled trial of an elementary school drinking water access and promotion intervention: Rationale, study design, and protocol

INTRODUCTION

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.

METHODS

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.

DISCUSSION

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.

Promoting water consumption among children: a three-arm cluster randomised controlled trial testing a social network intervention

Objective:

To test the effectiveness of a social network intervention (SNI) to improve children’s healthy drinking behaviours.

Design:

A three-arm cluster randomised control trial design was used. In the SNI, a subset of children were selected and trained as ‘influence agents’ to promote water consumption–as an alternative to sugar-sweetened beverages (SSB)–among their peers. In the active control condition, all children were simultaneously exposed to the benefits of water consumption. The control condition received no intervention.

Setting:

Eleven schools in the Netherlands.

Participants:

Four hundred and fifty-one children (M_age = 10·74, SD_age = 0·97; 50·8 % girls).

Results:

Structural path models showed that children exposed to the SNI consumed 0·20 less SSB per day compared to those in the control condition (β = 0·25, P = 0·035). There was a trend showing that children exposed to the SNI consumed 0·17 less SSB per day than those in the active control condition (β = 0·20, P = 0·061). No differences were found between conditions for water consumption. However, the moderation effects of descriptive norms (β = –0·12, P = 0·028) and injunctive norms (β = 0·11–0·14, both P = 0·050) indicated that norms are more strongly linked to water consumption in the SNI condition compared to the active control and control conditions.

Conclusions:

These findings suggest that a SNI promoting healthy drinking behaviours may prevent children from consuming more SSB. Moreover, for water consumption, the prevailing social norms in the context play an important role in mitigating the effectiveness of the SNI.

Drinking Water in the United States: Implications of Water Safety, Access, and Consumption

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.

A systematic review of the effectiveness of promoting water intake to reduce sugar-sweetened beverage consumption

Objective

To examine whether the promotion of water intake could reduce sugar‐sweetened beverage (SSB) consumption or purchases independent of interventions that target SSBs.

Methods

Seven databases were systematically searched. Included studies used water promotion as the primary intervention; used a controlled trial, single group pre‐post, or prospective cohort study design; included a measure of SSB consumption or purchase; enrolled human participants of any age who lived in high‐income or middle‐income countries; contained original data; and appeared in a peer‐reviewed English‐language article published from 1 January 2000 to January 4, 2019. The search yielded 7068 publications, from which 108 were chosen for full‐text review. Seventeen were included in this review.

Results

Nine of the 17 studies were randomized controlled trials, six were nonrandomized controlled trials, and 2 were single‐group pre‐post studies. Participants were primarily children and adolescents. Interventions included water provision, education or promotion activities. Ten of 17 studies were at low or some/moderate risk of bias. Seven studies showed a statistically significant decrease in SSB consumption of which only 2 were at low or some/moderate risk of bias.

Conclusions

This review found limited evidence that interventions aimed solely at increasing water consumption reduce SSB intake. Further research is needed to investigate whether interventions that combine water promotion and SSB reduction strategies could be synergistic for reducing SSB intake.

Evaluation and Treatment of Primary Headaches in Adolescents

Headache is a common episodic and chronic pain syndrome in adolescents. Evaluation of headaches in primary care requires a comprehensive assessment including lifestyle behaviors and physical examination, as well as an understanding of when to pursue appropriate testing. Primary headache disorders seen in adolescents include migraine and tension-type headache. Pharmacologic management for primary headache includes both acute and prophylactic treatment strategies.

Providing Students with Adequate School Drinking Water Access in an Era of Aging Infrastructure: A Mixed Methods Investigation

Ensuring students’ access to safe drinking water at school is essential. However, many schools struggle with aging infrastructure and subsequent water safety problems and have turned to bottled water delivery systems. Little is known about whether such systems are feasible and effective in providing adequate student water access. This study was a mixed-methods investigation among six schools in an urban district in the U.S. with two types of water delivery systems: (1) tap water infrastructure, with updated water fountains and bottle fillers, and (2) bottled water coolers. We measured students’ water consumption and collected qualitative data from students and teachers about their perceptions of school drinking water. Student water consumption was low—between 2.0 (SD: 1.4) ounces per student and 2.4 (SD: 1.1) ounces per student during lunch. Students and teachers reported substantial operational hurdles for relying on bottled water as a school’s primary source of drinking water, including difficulties in stocking, cleaning, and maintaining the units. While students and teachers perceived newer bottle filler units positively, they also reported a distrust of tap water. Bottled water delivery systems may not be effective long-term solutions for providing adequate school drinking water access and robust efforts are needed to restore trust in tap water.

Cost-Effectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake

OBJECTIVE

This study aimed to estimate the cost-effectiveness and impact on childhood obesity of installation of chilled water dispensers ("water jets") on school lunch lines and to compare water jets' cost, reach, and impact on water consumption with three additional strategies.

METHODS

The Childhood Obesity Intervention Cost Effectiveness Study(CHOICES) microsimulation model estimated the cost-effectiveness of water jets on US childhood obesity cases prevented in 2025. Also estimated were the cost, number of children reached, and impact on water consumption of the installation of water jets and three other strategies.

RESULTS

Installing water jets on school lunch lines was projected to reach 29.6 million children (95% uncertainty interval [UI]: 29.4 million-29.8 million), cost $4.25 (95% UI: $2.74-$5.69) per child, prevent 179,550 cases of childhood obesity in 2025 (95% UI: 101,970-257,870), and save $0.31 in health care costs per dollar invested (95% UI: $0.15-$0.55). In the secondary analysis, installing cup dispensers next to existing water fountains was the least costly but also had the lowest population reach.

CONCLUSIONS

Installating water jet dispensers on school lunch lines could also save almost half of the dollars needed for implementation via a reduction in obesity-related health care costs. School-based interventions to promote drinking water may be relatively inexpensive strategies for improving child health.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption

BACKGROUND

Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers.

OBJECTIVES

1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches.

SELECTION CRITERIA

We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product.

DATA COLLECTION AND ANALYSIS

We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE.

MAIN RESULTS

We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias.

AUTHORS' CONCLUSIONS

The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption

BACKGROUND

Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers.

OBJECTIVES

1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches.

SELECTION CRITERIA

We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product.

DATA COLLECTION AND ANALYSIS

We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE.

MAIN RESULTS

We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias.

AUTHORS' CONCLUSIONS

The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

School Policy on Drinking and Toilets: Weaknesses and Relation With Children's Hydration Status

OBJECTIVE

To investigate school policies and practices related to drinking fluids and toileting and test their association with children's hydration status and toilet behaviors.

DESIGN

Cross-sectional study in 2014.

SETTING

Seventeen Belgian primary schools.

PARTICIPANTS

A total of 416 children (aged 7-13 years).

MAIN OUTCOME MEASURES

Hydration was measured by urinary osmolality in a pooled school-day sample and by impedance-based body water percentage. Children reported how much they liked school toilets. School policy and practices were reported by schools on 59 items over 10 policy components.

ANALYSIS

Multilevel logistic regression analyses adjusted for age, sex, region and socioeconomic status.

RESULTS

School's weaknesses were the lack of policy participation by parents and children; official agreements (only in 11%); organizing education on drinking and toilet visits; and toilet infrastructure. Children's hydration was higher in schools that (1) made water available, (2) organized toilet and drinking related education, (3) had formal agreements on drinking and toilet visits, and (4) had good toilet maintenance. Children liked school toilets more in schools that (1) organized toilet and drinking related education, (2) had an official policy on drinking, (3) had good toilet infrastructure, and (4) allowed policy participation by parents and children.

CONCLUSIONS AND IMPLICATIONS

Specific action points for school management and government to improve children's hydration at school were detected by focusing on both drinking and toilet practices/infrastructure.

Promoting Water Consumption on a Caribbean Island: An Intervention Using Children's Social Networks at Schools

Sugar-sweetened beverage (SSB) consumption and the associated childhood obesity are major concerns in the Caribbean, creating a need for interventions promoting water consumption as a healthy alternative. A social network-based intervention (SNI) was tested among Aruban children to increase their water consumption and behavioral intention to do so and, consequently, to decrease SSB consumption and the associated behavioral intention. In this study, the moderating effects of descriptive and injunctive norms were tested. A cluster randomized controlled trial was completed in schools (mean age = 11 years ± SD = 0.98; 54% girls). Children were assigned to the intervention group (IG; n = 192) or control group (CG; n = 185). IG children were exposed to peer influencers promoting water consumption and CG children were not. Regression analyses showed that water consumption increased for IG children with a high injunctive norm score (p = 0.05); however, their intention to consume more water remained unchanged (p = 0.42). Moreover, IG children showed a decrease in SSB consumption (p = 0.04) and an increase in their intention to consume less SSB (p = 0.00). These findings indicate that SNIs are a promising instrument for health behavioral changes for Aruba and other islands in the Caribbean region.

Effectiveness of school food environment policies on children's dietary behaviors: A systematic review and meta-analysis

Background

School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear.

Objective

To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children.

Methods

We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children’s dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg’s and Egger’s test evaluated potential publication bias.

Results

From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified.

Conclusions

Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.

College Cafeteria Signage Increases Water Intake but Water Position on the Soda Dispenser Encourages More Soda Consumption

OBJECTIVES

To evaluate the effects of improved water location visibility and water dispenser position on the soda dispenser on undergraduate students' beverage choices.

METHODS

Two focus groups with pilot intervention surveys before and after, adding a small sign above the soda dispensers' water button for 6 weeks in a large US university's all-you-can-eat, prepaid dining hall (measured with chi-square tests and logistic and ordinal logistic regression).

RESULTS

Focus groups included 15 students. Survey participants included 357 students before and 301 after the intervention. After the intervention, more students reported ever having drunk water with the meal (66.4% to 77.0%; P = .003) and water consumption frequency increased (P = .005). Postintervention, the odds of drinking water increased by 1.57. Preference for other drinks was the main reason for not drinking water. A total of 59% of students had ever changed their preference from water to soda.

CONCLUSIONS AND IMPLICATIONS

The clear indication of the water's location increased students' reported water consumption. Further investigation is needed into how a non-independent water dispenser influences students' beverage choice. Clearly labeled, independent water dispensers are recommended.

School beverage environment and children's energy expenditure associated with physical education class: an agent-based model simulation

BACKGROUND

Physical activity contributes to children's energy expenditure and prevents excess weight gain, but fluid replacement with sugar-sweetened beverages (SSBs) may diminish this benefit.

OBJECTIVE

The aim of this study was to explore the net energy expenditure (EE) after physical education (PE) class given the competition between water and SSB consumption for rehydration and explore environmental factors that may influence the net EE, e.g. PE duration, affordability of SSB and students' SSB preference.

METHODS

We built an agent-based model that simulates the behaviour of 13-year-old children in a PE class with nearby water fountains and SSB vending machines available.

RESULTS

A longer PE class contributed to greater prevalence of dehydration and required more time for rehydration. The energy cost of a PE class with activity intensity equivalent to 45 min of jogging is about 300 kcal on average, i.e. 10-15% of average 13-year-old children's total daily EE. Adding an SSB vending machine could offset PE energy expenditure by as much as 90 kcal per child, which was associated with PE duration, students' pocket money and SSB preference.

CONCLUSIONS

Sugar-sweetened beverage vending machines in school may offset some of the EE in PE classes. This could be avoided if water is the only readily available source for children's fluid replacement after class.

A Systematic Review to Assess Sugar-Sweetened Beverage Interventions for Children and Adolescents across the Socioecological Model

Sugar-sweetened beverage (SSB) consumption among children and adolescents is a determinant of childhood obesity. Many programs to reduce consumption across the socioecological model report significant positive results; however, the generalizability of the results, including whether reporting differences exist among socioecological strategy levels, is unknown. This systematic review aimed to examine the extent to which studies reported internal and external validity indicators defined by the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) model and assess reporting differences by socioecological level: Intrapersonal/interpersonal (Level 1), environmental/policy (Level 2), and multilevel (Combined Level). A systematic literature review was conducted in six major databases (PubMed, Web of Science, Cinahl, CAB Abstracts, Education Research Information Center, and Arcola) to identify studies from 2004-2015 meeting inclusion criteria (children aged 3 to 12 years, adolescents aged 13 to 17 years, and young adults aged 18 years, experimental or quasiexperimental, and substantial SSB component). Interventions were categorized by socioecological level, and data were extracted using a validated RE-AIM protocol. One-way analysis of variance assessed differences between levels. There were 55 eligible studies accepted, including 21 Level 1, 18 Level 2, and 16 Combined Level studies. Thirty-six studies (65%) were conducted in the United States, 19 studies (35%) were conducted internationally, and 39 studies (71%) were implemented in schools. Across levels, reporting averages were low for all RE-AIM dimensions (reach=29%, efficacy or effectiveness=45%, adoption=26%, implementation=27%, and maintenance=14%). Level 2 studies had significantly lower reporting on reach and effectiveness (10% and 26%, respectively) compared with Level 1 (44% and 57%, respectively) or Combined Level studies (31% and 52%, respectively) (P<0.001). Adoption, implementation, and maintenance reporting did not vary among levels. Interventions to reduce SSB consumption in children and adolescents across the socioecological spectrum do not provide the necessary information for dissemination and implementation in community nutrition settings. Future interventions should address both internal and external validity to maximize population influence.

CVD Prevention Through Policy: a Review of Mass Media, Food/Menu Labeling, Taxation/Subsidies, Built Environment, School Procurement, Worksite Wellness, and Marketing Standards to Improve Diet

Poor diet is the leading cause of cardiovascular disease in the USA and globally. Evidence-based policies are crucial to improve diet and population health. We reviewed the effectiveness for a range of policy levers to alter diet and diet-related risk factors. We identified evidence to support benefits of focused mass media campaigns (especially for fruits, vegetables, salt), food pricing strategies (both subsidies and taxation, with stronger effects at lower income levels), school procurement policies (for increasing healthful or reducing unhealthful choices), and worksite wellness programs (especially when comprehensive and multicomponent). Evidence was inconclusive for food and menu labeling (for consumer or industry behavior) and changes in local built environment (e.g., availability or accessibility of supermarkets, fast food outlets). We found little empiric evidence evaluating marketing restrictions, although broad principles and large resources spent on marketing suggest utility. Widespread implementation and evaluation of evidence-based policy strategies, with further research on other strategies with mixed/limited evidence, are essential “population medicine” to reduce health and economic burdens and inequities of diet-related illness worldwide.

A social network-based intervention stimulating peer influence on children's self-reported water consumption: A randomized control trial

The current pilot study examined the effectiveness of a social network-based intervention using peer influence on self-reported water consumption. A total of 210 children (52% girls; M age = 10.75 ± SD = 0.80) were randomly assigned to either the intervention (n = 106; 52% girls) or control condition (n = 104; 52% girls). In the intervention condition, the most influential children in each classroom were trained to promote water consumption among their peers for eight weeks. The schools in the control condition did not receive any intervention. Water consumption, sugar-sweetened beverage (SSB) consumption, and intentions to drink more water in the near future were assessed by self-report measures before and immediately after the intervention. A repeated measure MANCOVA showed a significant multivariate interaction effect between condition and time (V = 0.07, F(3, 204) = 5.18, p = 0.002, pη(2) = 0.07) on the dependent variables. Further examination revealed significant univariate interaction effects between condition and time on water (p = 0.021) and SSB consumption (p = 0.015) as well as water drinking intentions (p = 0.049). Posthoc analyses showed that children in the intervention condition reported a significant increase in their water consumption (p = 0.018) and a decrease in their SSB consumption (p < 0.001) over time, compared to the control condition (p-values > 0.05). The children who were exposed to the intervention did not report a change in their water drinking intentions over time (p = 0.576) whereas the nonexposed children decreased their intentions (p = 0.026). These findings show promise for a social network-based intervention using peer influence to positively alter consumption behaviors.

TRIAL REGISTRATION

This RCT was registered in the Australian New Zealand Clinical Trials Registry (ACTRN12614001179628). Study procedures were approved by the Ethics Committee of the Faculty of Social Sciences at Radboud University (ECSW2014-1003-203).

The effects of water and dairy drinks on dietary patterns in overweight adolescents

The aim was to investigate the effects of increased water or dairy intake on total intake of energy, nutrients, foods and dietary patterns in overweight adolescents in the Milk Components and Metabolic Syndrome (MoMS) study (n=173). Participants were randomly assigned to consume 1l/d of skim milk, whey, casein or water for 12 weeks. A decrease in the dietary pattern called Convenience Food, identified by principal component analysis, was observed during the intervention both in the water and dairy groups. Total energy intake decreased by 990.9 kJ/d (236.8 kcal/d) in the water group but was unchanged in the dairy group during intervention. To conclude, an extra intake of fluid seems to favourably affect the rest of the diet by decreasing the intake of convenience foods, including sugar-sweetened beverages. A low energy drink, such as water, seems advantageous considering the total energy intake in these overweight adolescents. This study is registered at clinicaltrials.gov (NCT00785499).

Grab a Cup, Fill It Up! An Intervention to Promote the Convenience of Drinking Water and Increase Student Water Consumption During School Lunch

OBJECTIVES

We evaluated a low-cost strategy for schools to improve the convenience and appeal of drinking water.

METHODS

We conducted a group-randomized, controlled trial in 10 Boston, Massachusetts, schools in April through June 2013 to test a cafeteria-based intervention. Signage promoting water and disposable cups were installed near water sources. Mixed linear regression models adjusting for clustering evaluated the intervention impact on average student water consumption over 359 lunch periods.

RESULTS

The percentage of students in intervention schools observed drinking water during lunch nearly doubled from baseline to follow-up compared with controls (+ 9.4%; P < .001). The intervention was associated with a 0.58-ounce increase in water intake across all students (P < .001). Without cups, children were observed drinking 2.4 (SE = 0.08) ounces of water from fountains; with cups, 5.2 (SE = 0.2) ounces. The percentage of intervention students observed with sugar-sweetened beverages declined (-3.3%; P < .005).

CONCLUSIONS

The current default of providing water through drinking fountains in cafeterias results in low water consumption. This study shows that an inexpensive intervention to improve drinking water's convenience by providing cups can increase student water consumption.

Plain water consumption is associated with lower intake of caloric beverage: cross-sectional study in Mexican adults with low socioeconomic status

BACKGROUND

Plain water (PW) should be the main beverage consumed by the population. However, consumption of caloric beverages (CB) has increased considerably worldwide. The purpose of this paper is to analyze the association between CB and PW intake in Mexican adults with a low socioeconomic status (SES).

METHODS

In a cross-sectional design, beverage consumption was evaluated with a 24-h beverages recall using the five-step multiple-pass method recommended by the U.S. Department of Agriculture. Physical activity, anthropometric and sociodemographic information were obtained. CB was defined as those beverages that provide energy, with the exception of low-fat milk and beverages with noncaloric sweeteners. Participants were classified into five groups according to their PW consumption (nondrinkers and four quartiles). Differences between groups were evaluated with ANOVA and Bonferroni tests for multiple comparisons among quartiles. A two-stage Heckman regression model was designed with robust standard errors, adjusting for potential confounders.

RESULTS

A total of 1108 adults between 21 and 59 years of age were evaluated. A negative association was noted between PW intake and CB consumption (p <0.001) with the exception of natural juice, which was positive (p <0.01) and sodas that no differences were found between quartiles. Specifically, for every milliliter of PW, the intake of CB was 3.4, 1.3, 0.68 and 0.38 mL in each quartile, respectively (p <0.001). In Heckman's model, PW consumers were 0.5 times less likely to consume CB (p = 0.029). This probability increased to 0.9 for low-fat milk, skim milk and beverages without added sugar (LFM-BWAS) consumers (p <0.001). Also, for every 100 mL of PW consumption, CB intake diminished by 20 mL (p <0.001). In turn, for every 100 mL of LFM-BWAS consumption, a reduction of 47 mL in CB was observed (p <0.001).

CONCLUSIONS

Higher PW consumption was associated with lower CB consumption. This association suggests that future studies are warranted to determine if increasing PW intake in a low SES Mexican population can reduce intake of CB.

Influence of school architecture and design on healthy eating: a review of the evidence

We examined evidence regarding the influence of school physical environment on healthy-eating outcomes. We applied a systems perspective to examine multiple disciplines' theoretical frameworks and used a mixed-methods systematic narrative review method, considering both qualitative and quantitative sources (published through March 2014) for inclusion. We developed a causal loop diagram from 102 sources identified. We found evidence of the influence of many aspects of a school's physical environment on healthy-eating outcomes. The causal loop diagram highlights multilevel and interrelated factors and elucidates the specific roles of design and architecture in encouraging healthy eating within schools. Our review highlighted the gaps in current evidence and identified areas of research needed to refine and expand school architecture and design strategies for addressing healthy eating.

A water availability intervention in New York City public schools: influence on youths' water and milk behaviors

OBJECTIVES

We determined the influence of "water jets" on observed water and milk taking and self-reported fluid consumption in New York City public schools.

METHODS

From 2010 to 2011, before and 3 months after water jet installation in 9 schools, we observed water and milk taking in cafeterias (mean 1000 students per school) and surveyed students in grades 5, 8, and 11 (n=2899) in the 9 schools that received water jets and 10 schools that did not. We performed an observation 1 year after implementation (2011-2012) with a subset of schools. We also interviewed cafeteria workers regarding the intervention.

RESULTS

Three months after implementation we observed a 3-fold increase in water taking (increase of 21.63 events per 100 students; P<.001) and a much smaller decline in milk taking (-6.73 events per 100 students; P=.012), relative to comparison schools. At 1 year, relative to baseline, there was a similar increase in water taking and no decrease in milk taking. Cafeteria workers reported that the water jets were simple to clean and operate.

CONCLUSIONS

An environmental intervention in New York City public schools increased water taking and was simple to implement.

A systematic review investigating interventions that can help reduce consumption of sugar-sweetened beverages in children leading to changes in body fatness

BACKGROUND

Both the prevalence of childhood obesity and the consumption of sugar-sweetened beverages (SSBs) have increased globally. The present review describes interventions that reduce the consumption of SSBs in children and determines whether this leads to subsequent changes in body fatness.

METHODS

Three databases were searched from 2000 to August 2013. Only intervention control trials, ≥6 months in duration, which aimed to reduce the consumption of SSBs in >100 children aged 2-18 years, and reporting changes in body fatness, were included. The quality of selected papers was assessed.

RESULTS

Eight studies met inclusion criteria. Six interventions achieved significant (P < 0.05) reductions in SSB intake, although this was not always sustained. In the two interventions providing replacement drinks, significant differences in body mass index (12- or 18-month follow-up) were reported (P = 0.001 and 0.045). The risk of being overweight/obesity was reduced (P < 0.05) in three of the five education programmes but in one programme only for girls who were overweight at baseline and in one programme only for pupils perceived to be at greater risk at baseline. In the one study that included both provision of water and education, the risk of being overweight was reduced by 31% (P = 0.04) in the intervention group.

CONCLUSIONS

The evidence suggests that school-based education programmes focusing on reducing SSB consumption, but including follow-up modules, offer opportunities for implementing effective, sustainable interventions. Peer support and changing the school environment (e.g. providing water or replacement drinks) to support educational programmes could improve their effectiveness. Home delivery of more suitable drinks has a big impact on reducing SSB consumption, with associated reductions in body weight.

Availability of drinking water in US public school cafeterias

This study examined the availability of free drinking water during lunchtime in US public schools, as required by federal legislation beginning in the 2011-2012 school year. Data were collected by mail-back surveys in nationally representative samples of US public elementary, middle, and high schools from 2009-2010 to 2011-2012. Overall, 86.4%, 87.4%, and 89.4% of students attended elementary, middle, and high schools, respectively, that met the drinking water requirement. Most students attended schools with existing cafeteria drinking fountains and about one fourth attended schools with water dispensers. In middle and high schools, respondents were asked to indicate whether drinking fountains were clean, and whether they were aware of any water-quality problems at the school. The vast majority of middle and high school students (92.6% and 90.4%, respectively) attended schools where the respondent perceived drinking fountains to be clean or very clean. Approximately one in four middle and high school students attended a school where the survey respondent indicated that there were water-quality issues affecting drinking fountains. Although most schools have implemented the requirement to provide free drinking water at lunchtime, additional work is needed to promote implementation at all schools. School nutrition staff at the district and school levels can play an important role in ensuring that schools implement the drinking water requirement, as well as promote education and behavior-change strategies to increase student consumption of water at school.

Middle school student attitudes about school drinking fountains and water intake

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Getting back on tap: the policy context and cost of ensuring access to low-cost drinking water in Massachusetts schools

BACKGROUND

Adequate water intake may have important health benefits for schoolchildren. Layers of federal, state, and local policy are relevant to provision of water within schools. Recently passed state and federal laws require free drinking-water access for students during mealtimes.

PURPOSE

To review Massachusetts local district wellness policies related to water access, provide estimates of costs for three water-provision strategies, and discuss implications for policy relevant to adequate drinking-water access.

METHODS

Legal research was conducted using the LexisNexis legal database and government websites. Local wellness policies were double-coded using existing research tools. Costs of three water-delivery options were estimated using a 10-year school-district perspective.

RESULTS

Prior to 2010, most Massachusetts public school district wellness policies (92%-94%) did not address access to free drinking water. Ten-year costs per school for providing water during mealtimes to students, including dispenser unit, installation, water testing, water, cups, and labor, range between $12,544 and $27,922 (depending on water-delivery option) assuming the average Massachusetts school enrollment. Water-provision strategies relying on tap water are more economical than bottled water in the long term.

CONCLUSIONS

Policy recommendations and cost considerations deserve attention at the local, state, and federal levels. Recommendations are discussed to ensure access to safe, free drinking water for all students.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Water and sanitation in schools: a systematic review of the health and educational outcomes

A systematic review of the literature on the effects of water and sanitation in schools was performed. The goal was to characterize the impacts of water and sanitation inadequacies in the academic environment. Published peer reviewed literature was screened and articles that documented the provision of water and sanitation at schools were considered. Forty-one peer-reviewed papers met the criteria of exploring the effects of the availability of water and/or sanitation facilities in educational establishments. Chosen studies were divided into six fields based on their specific foci: water for drinking, water for handwashing, water for drinking and handwashing, water for sanitation, sanitation for menstruation and combined water and sanitation. The studies provide evidence for an increase in water intake with increased provision of water and increased access to water facilities. Articles also report an increase in absenteeism from schools in developing countries during menses due to inadequate sanitation facilities. Lastly, there is a reported decrease in diarrheal and gastrointestinal diseases with increased access to adequate sanitation facilities in schools. Ensuring ready access to safe drinking water, and hygienic toilets that offer privacy to users has great potential to beneficially impact children's health. Additional studies that examine the relationship between sanitation provisions in schools are needed to more adequately characterize the impact of water and sanitation on educational achievements.

Encouraging consumption of water in school and child care settings: access, challenges, and strategies for improvement

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.

Enabling Hygienic Behavior among Preschoolers: Improving Environmental Conditions through a Multifaceted Intervention

Purpose.

Environmental conditions often serve as critical enabling factors for health promotion. This article describes the effect of a preschool hygiene intervention program on classroom environmental conditions.

Design.

Cluster randomized trial, with randomization at the level of the preschool.

Setting.

State-run preschools in Jerusalem.

Subjects.

Forty secular and religious Jerusalem preschools (including 1029 children).

Intervention.

A multidisciplinary hygiene intervention that included changes to the preschool environment.

Measures.

Presence of soap, soap dispenser, paper towel, paper towel dispenser, cloth towels, communal cup, or personal cups.

Analysis.

Generalized estimating equations and Fisher's exact test were used to estimate the effect of the intervention program on environmental conditions.

Results.

Information was obtained from most (97.9%) visits. Baseline environmental hygienic conditions were poor. Relative to the control group, the following environmental conditions were better in the intervention group after program implementation: soap (odds ratio [OR] = 14.7; p < .01), paper towels (OR = 13.5; p < .01), communal cups (OR = .05; p < .01), soap dispensers (secular preschools only, p < .01), individual cups (secular, p < .01; religious, OR = 18.7; p < .02).

Conclusions.

Environmental hygiene in the Israeli preschools studied was deficient at baseline but amenable to change. Improvement in environmental conditions was a necessary enabling factor for the changes in hand-washing behavior that were observed among the children. Sustained environmental change is possible in the preschool environment. (Am J Health Promot 2011;25[4]:248–256.)

The effects of the HEALTHY study intervention on middle school student dietary intakes

BACKGROUND

The HEALTHY study was designed to respond to the alarming trends in increasing rates of overweight, obesity, and type 2 diabetes mellitus in youth. The objective of this analysis was to examine the effects of the HEALTHY study on student self-reported dietary intakes (energy, macronutrients and grams consumed of selected food groups).

METHODS

HEALTHY was a cluster-randomized study in 42 public middle schools. Students, n=3908, self-reported dietary intake using the Block Kids Questionnaire. General linear mixed models were used to analyze differences in dietary intake at the end of the study between intervention and control schools.

RESULTS

The reported average daily fruit consumption was 10% higher at the end of the study in the intervention schools than in the control schools (138 g or approximately 2 servings versus 122 g, respectively, p=0.0016). The reported water intake was approximately 2 fluid ounces higher in the intervention schools than in the control (483 g versus 429 g respectively; p=0.008). There were no significant differences between intervention and control for mean intakes of energy, macronutrients, fiber, grains, vegetables, legumes, sweets, sweetened beverages, and higher- or lower-fat milk consumption.

CONCLUSION

The HEALTHY study, a five-semester middle school-based intervention program that integrated multiple components in nutrition, physical education, behavior change, and social marketing-based communications, resulted in significant changes to student's reported fruit and water intake. Subsequent interventions need to go beyond the school environment to change diet behaviors that may affect weight status of children.

Encouraging healthy beverage intake in child care and school settings

PURPOSE OF REVIEW

Inappropriate intake of sugar-sweetened beverages, fruit juice, and whole milk is associated with obesity and obesity-related comorbidities. As numerous children spend many hours in schools and child care, these settings provide a potential means for general pediatricians to reach children and their parents with interventions to encourage intake of guideline-recommended beverages. This review describes the beverages currently offered within child care facilities and schools and summarizes school and child care-based interventions and policies to encourage healthy beverage intake.

RECENT FINDINGS

The major sources of beverages available in schools and child care include beverages provided through federal programs, competitive beverages (e.g., beverages for purchase through vending machines), water from drinking fountains, and beverages brought into facilities. Policies governing the types of beverages available in schools and child care settings have increased, but still vary in scope and jurisdiction. Although there are no child care-based interventions that exclusively target beverage intake, there are examples of school-based interventions to encourage healthy beverage consumption.

SUMMARY

Although interventions and policies to encourage healthy beverage intake in schools and child care are increasing, there is a need for additional research, programs, and policies to guide beverage availability and intake in these settings.

Contributors of water intake in US children and adolescents: associations with dietary and meal characteristics--National Health and Nutrition Examination Survey 2005-2006

BACKGROUND

Little is known about the association of contributors of total water intake with dietary characteristics in US children.

OBJECTIVE

We examined intakes of total water and its contributors and their associations with diet and meal reporting in children and adolescents.

DESIGN

Dietary data for children 2-19 y of age (n = 3978) from the National Health and Nutrition Examination Survey 2005-2006 were used to compute usual intake of total water. The association of total water and its contributors with sociodemographic characteristics and dietary and meal attributes was examined by using multiple regression analysis.

RESULTS

The adjusted mean intakes of total water in Americans aged 2-5, 6-11, and 12-19 y were 1.4, 1.6, and 2.4 L, respectively. The mean usual intake of total water was generally less than the Adequate Intake; overall, more boys reported intakes of at least the Adequate Intake. The percentage of total water intake from plain water increased with age. Plain water intake was inversely associated with the intake of beverage moisture and the energy density of foods; conversely, beverage moisture was positively associated with dietary energy, fat, and the energy density of foods. Associations of water contributors with meal patterns (number of eating occasions, reporting of breakfast or snack) were inconsistent across age groups. Nearly 80% of food moisture, >66% of beverage moisture, and ≈30% of plain water were reported with main meals.

CONCLUSIONS

Intake of total water over 24 h from different contributors varied by age. Qualitative differences in dietary intake in association with the amount of plain water and beverage moisture in the recalls were observed. American children and adolescents consumed more than two-thirds of their daily beverages with main meals.

Effectiveness of school-based interventions in Europe to promote healthy nutrition in children and adolescents: systematic review of published and ‘grey’ literature

The objective of the present review was to summarise the existing European published and ‘grey’ literature on the effectiveness of school-based interventions to promote a healthy diet in children (6–12 years old) and adolescents (13–18 years old). Eight electronic databases, websites and contents of key journals were systematically searched, reference lists were screened, and authors and experts in the field were contacted for studies evaluating school-based interventions promoting a healthy diet and aiming at primary prevention of obesity. The studies were included if they were published between 1 January 1990 and 31 December 2007 and reported effects on dietary behaviour or on anthropometrics. Finally, forty-two studies met the inclusion criteria: twenty-nine in children and thirteen in adolescents. In children, strong evidence of effect was found for multicomponent interventions on fruit and vegetable intakes. Limited evidence of effect was found for educational interventions on behaviour, and for environmental interventions on fruit and vegetable intakes. Interventions that specifically targeted children from lower socio-economic status groups showed limited evidence of effect on behaviour. In adolescents, moderate evidence of effect was found for educational interventions on behaviour and limited evidence of effect for multicomponent programmes on behaviour. In children and adolescents, effects on anthropometrics were often not measured, and therefore evidence was lacking or delivered inconclusive evidence. To conclude, evidence was found for the effectiveness of especially multicomponent interventions promoting a healthy diet in school-aged children in European Union countries on self-reported dietary behaviour. Evidence for effectiveness on anthropometrical obesity-related measures is lacking.

Feasibility and impact of placing water coolers on sales of sugar-sweetened beverages in Dutch secondary school canteens

AIMS

The aim of this pilot study was to investigate the feasibility and effectiveness of placing water coolers on sugar-sweetened beverage sales at secondary schools (age 12-18 years) in the city of Zwolle, the Netherlands.

METHODS

Six schools, hosting 5,866 pupils, were divided in three intervention and three control schools. In the intervention schools, water coolers were placed in the canteen. Hidden observations were performed in one school to study the intervention's feasibility, and school personnel was interviewed. Beverage sales were monitored before and during the intervention. After the intervention period, 366 class 1 and 2 pupils completed a questionnaire about their drinking habits (response rate 81%).

RESULTS

Placement of water coolers appeared to be a feasible intervention at secondary schools. However, it did not affect sales of sugar-sweetened beverages at schools. Although mean intake of sugar-sweetened beverages at school was high, more than 500 ml/day for boys, and more than 250 ml/day for girls, only a minority of these quantities was purchased at school.

CONCLUSION

We conclude that placing water coolers as a single-issue intervention in secondary school canteens should not be prioritized in the combat against obesity.

Meta-Analysis of School-Based Childhood Obesity Interventions in the U.K. and U.S

This study conducted a meta-analysis on the outcome indicator of body mass index from published school-based childhood obesity interventions done in the United States and the United Kingdom between 2000 and 2007. Electronic databases were searched for school-based childhood obesity interventions and a total of five studies were analyzed. The results of the pooled estimate of reviewed studies were not significant for the outcome measure body mass index at p < 0.05 level for fixed (effect estimate –0.0649 (95% CI: –0.29, 0.16)) as well as random effects (effect estimate 0.179 (95% CI: –0.38, 0.72)) models. In conclusion, it can be said that current school-based childhood obesity interventions do not seem to modify body mass index.

Promotion and provision of drinking water in schools for overweight prevention: randomized, controlled cluster trial

OBJECTIVE

The study tested whether a combined environmental and educational intervention solely promoting water consumption was effective in preventing overweight among children in elementary school.

METHODS

The participants in this randomized, controlled cluster trial were second- and third-graders from 32 elementary schools in socially deprived areas of 2 German cities. Water fountains were installed and teachers presented 4 prepared classroom lessons in the intervention group schools (N = 17) to promote water consumption. Control group schools (N = 15) did not receive any intervention. The prevalence of overweight (defined according to the International Obesity Task Force criteria), BMI SD scores, and beverage consumption (in glasses per day; 1 glass was defined as 200 mL) self-reported in 24-hour recall questionnaires, were determined before (baseline) and after the intervention. In addition, the water flow of the fountains was measured during the intervention period of 1 school year (August 2006 to June 2007).

RESULTS

Data on 2950 children (intervention group: N = 1641; control group: N = 1309; age, mean +/- SD: 8.3 +/- 0.7 years) were analyzed. After the intervention, the risk of overweight was reduced by 31% in the intervention group, compared with the control group, with adjustment for baseline prevalence of overweight and clustering according to school. Changes in BMI SD scores did not differ between the intervention group and the control group. Water consumption after the intervention was 1.1 glasses per day greater in the intervention group. No intervention effect on juice and soft drink consumption was found. Daily water flow of the fountains indicated lasting use during the entire intervention period, but to varying extent.

CONCLUSION

Our environmental and educational, school-based intervention proved to be effective in the prevention of overweight among children in elementary school, even in a population from socially deprived areas.

International school-based interventions for preventing obesity in children

The purpose of this article was to review international (excluding the United States) school-based interventions for preventing obesity in children published between 1999 and 2005. A total of 21 such interventions were found from Australia (1), Austria (1), Canada (1), Chile (1), France (1), Germany (3), Greece (1), New Zealand (1), Norway (1), Singapore (1) and the United Kingdom (9). The grade range of these interventions was from pre-school to high school with the majority (17) from elementary schools. Nine of these interventions targeted nutrition behaviours followed by seven aiming to modify both physical activity and nutrition behaviours. Only five interventions in international settings were based on any explicit behavioural theory which is different than the interventions developed in the United States. Majority of the interventions (9) were one academic year long. It can be speculated that if the interventions are behavioural theory-based, then the intervention length can be shortened. All interventions that documented parental involvement successfully influenced obesity indices. Most interventions (16) focused on individual-level behaviour change approaches. Most published interventions (16) used experimental designs with at least 1-year follow-up. Recommendations from international settings for enhancing the effectiveness of school-based childhood obesity interventions are presented.