Obesity: Increasing Water Access in Schools

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) finds insufficient evidence to determine the effectiveness of interventions to increase water access in schools. Evidence is considered insufficient because there were too few studies.

The CPSTF recommends the following related interventions in school settings:

Healthy Eating Interventions Combined with Physical Activity Interventions

Healthy Eating Interventions Alone

Physical Activity Interventions

The CPSTF finds insufficient evidence for two other intervention approaches that focus on healthy eating in schools alone and two other intervention approaches that focus on healthy eating combined with physical activity in schools. Read a summary of the findings from all eight reviews of school-based interventions to prevent obesity.

Intervention

Interventions to increase water access in schools ensure students have access to safe, free drinking water during the school day. Interventions may include one or more of the following:
  • Procedures to ensure water fountains are clean and maintained
  • Availability of water fountains and hydration stations throughout the school
  • Policies allowing students to have water bottles in class

Interventions may also include healthy eating learning opportunities, such as nutrition education and other strategies that give children knowledge and skills to help choose and consume healthier foods and beverages.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

About The Systematic Review

In 2013, the Agency for Healthcare Research and Quality (AHRQ) conducted a meta-analysis on the effectiveness of childhood obesity prevention programs implemented in 6 intervention settings. The CPSTF finding is based on a subset of studies from the review that focused on dietary-only approaches in schools (Wang et al., 2013; 15 studies, search period through August 2012) combined with more recent evidence (36 additional studies, search period August 2012 to January 2017).

This review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to obesity prevention and control.

Context

Healthy eating during childhood is important (CDC, 1998; Dietary Guidelines Advisory Committee, 2010). Schools can play an important role in preventing obesity by providing nutritious and appealing foods and beverages (CDC, 2016a; CDC, 2011).

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 2 studies.

Weight-Related Outcomes

  • Overweight/Obesity Prevalence significant decrease (1 study)
  • The risk of overweight was significantly reduced in the intervention group compared to the control group (1 study)

Diet-Related Outcomes

  • Sugar-sweetened beverage intake no intervention effect (1 study)
  • Water intake significant increase of 1.1 glasses per day; p<0.001 (1 study)
  • Fruit juice intake decrease of 0.1 glasses per day (1 study)

Summary of Economic Evidence

An economic review of this intervention was not conducted because the CPSTF did not have enough information to determine if the intervention works.

Applicability

Applicability of this intervention across different settings and populations was not assessed because the CPSTF did not have enough information to determine if the intervention works.

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)
  • Which intervention activities, such as allowing water bottles in class, adding water fountains or dispensers, or combinations of these activities are most effective? Which activities are critical to success?
  • What are the cumulative effects of adding intervention components? Is a single component equally effective?
  • In order to increase comparability what are the “best measures” for dietary intake outcomes?
  • Do children act as agents of change by discussing changes in the school environment with parents? Do parents incorporate healthier dietary habits at home?
  • How often do schools implement interventions with fidelity? What amount of training is needed for faculty?
  • Does effectiveness vary by age group?
  • Are national, state, or local policies most effective?
  • Approximately half of the studies reported on weight outcomes; future studies should report weight-related outcomes to increase understanding of intervention effectiveness.
  • For studies reporting on milk products and alternatives to dairy, what is the fat content of these foods and beverages?
  • Do interventions lead to other health benefits such as improvements in cholesterol or blood pressure?

Study Characteristics

  • Study designs included group randomized trial (1 study) and repeat cross-sectional with concurrent comparison group (1 study).
  • Studies were conducted in the United States (1 study) and Germany (1 study).
  • Both studies evaluated interventions conducted in schools alone.
  • One study was implemented in elementary and middle schools and 1 study was implemented in an elementary school only.
  • Both studies were set in urban areas.
  • One study was implemented in a lower socioeconomic population.

Publications

Wethington HR, Finnie RKC, Buchanan LR, et al. Healthier food and beverage interventions in schools: four Community Guide systematic reviews. American Journal of Preventive Medicine 2020;59(1):e15-26.

Community Preventive Services Task Force. Healthier food and beverage interventions in schools: recommendation of the Community Preventive Services Task Force. American Journal of Preventive Medicine 2020;59(1):e11-4.

Analytic Framework

Effectiveness Review

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Analytic Framework [PDF – 293 kB]

Summary Evidence Table

Effectiveness Review

Summary Evidence Table – Effectiveness Review [PDF – 405 kB]

Included Studies

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Muckelbauer R, Libuda L, Clausen K, Toschke AM, Reinehr T, Kersting M. Promotion and provision of drinking water in schools for overweight prevention: randomized, controlled cluster trial. Nutrition Today 212;47:S27-34.

Schwartz AE, Leardo M, Aneja S, Elbel B. Effect of a school-based water intervention on child body mass index and obesity. JAMA Pediatr 2016;170(3):220-6.

Search Strategies

The search strategy described below was used for the following reviews of interventions to support healthier foods and beverages in schools:

The CPSTF findings are based on evidence from a systematic review published in 2013 (Wang et al, 2013) combined with more recent evidence. Wang et al. searched five bibliographic databases: MEDLINE , EMBASE , PsychInfo , CINAHL , and the Cochrane Library for relevant studies from their inception through April 22, 2013. The Community Guide systematic review team conducted an updated search for evidence through January 4, 2017. In the updated search for evidence, PubMed was used instead of MEDLINE , and a search was conducted using Clinicaltrials.com.

Search terms and search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. Once the literature search was completed, Community Guide staff reviewed the citations using inclusion and exclusion criteria to narrow down the publications to be included.

Search Strategy – Effectiveness Review

Database: Embase (OVID)

Date Searched: 1/04/2017

Search Strategy:

  1. (school or schools or afterschool or kindergarten or educational-setting*).ti,ot,sh,ab,tw.
  2. school/ or high school/ or kindergarten/ or middle school/ or primary school/
  3. exp obesity/
  4. exp body composition/
  5. waist hip ratio/ or waist to height ratio/
  6. (bmi or healthy weight or body weight or adiposity or body mass index or skinfold thickness or body fat or waist circumference or waist hip ratio or waist to height ratio or body composition or overweight or obese or obesity or over weight).ti,ot,sh,ab,tw.
  7. body weight/
  8. (normal weight or normal weights or hip circumference).ti,ot,sh,ab,tw.
  9. body fat/
  10. body mass index/
  11. skinfold thickness/
  12. waist circumference/
  13. 1 or 2
  14. 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12
  15. 13 and 14
  16. 2014*.em. or 2015*.em. or 2016*.em. [Individual update weeks were no longer available to be searched for 2014.]
  17. 15 and 16
  18. limit 17 to english language

Review References

Centers for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. MMWR 1998;47: 1-29.

Centers for Disease Control and Prevention. School health guidelines to promote healthy eating and physical activity. MMWR 2011;60(5):1-76.

Centers for Disease Control and Prevention. School Nutrition Environment. Atlanta (GA): 2016 [cited 2017 Jan 4]. Available from: https://www.cdc.gov/healthyschools/nutrition/schoolnutrition.htm.

Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010 (Report to the Secretary of Agriculture and the Secretary of Health and Human Services). Washington (DC): 2010 [cited 2017 Jan 4]. Available from: http://www.nutriwatch.org/05Guidelines/dga_advisory_2010.pdf.

Wang Y, Wu Y, Wilson RF, Bleich S, Cheskin L, et al. Childhood Obesity Prevention Programs: Comparative Effectiveness Review and Meta-Analysis. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2013. Report No.: 13-EHC081-EF.

Considerations for Implementation

The CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.

Crosswalks

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)