Obesity: Increasing Water Access in Schools
Summary of CPSTF Finding
The CPSTF recommends the following related interventions in school settings:
Healthy Eating Interventions Combined with Physical Activity Interventions
- Meal or Fruit and Vegetable Snack Interventions Combined with Physical Activity Interventions in Schools
Healthy Eating Interventions Alone
- Meal or Fruit and Vegetable Snack Interventions to Increase Healthier Foods and Beverages Provided by Schools
- Multicomponent Interventions (Meal or Fruit and Vegetable Snack Interventions + Healthier Snack Foods and Beverages) to Increase Availability of Healthier Foods and Beverages in Schools
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.
- 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
Community Guide News
- Interventions to Get Healthier Foods and Beverages in Schools are Cost-Effective
- Obesity: Interventions to Support Healthier Foods and Beverages in Schools
The Community Preventive Services Task Force recommends three school-based intervention approaches to prevent childhood obesity. Drs. Jamie Chriqui and Ramona Finnie and Ms. Caitlin Merlo talk with CDC’s Dr. John Anderton about the systematic review evidence and how the CPSTF recommendations can be implemented in schools to improve children’s health.
Listen to the audio clip (6:55) [MP3 – 10 MB]
Read the audio transcript [PDF – 470 KB]
Recorded October, 2017
About The Systematic Review
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.
Summary of Results
The systematic review included 2 studies.
- 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)
- 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
- 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 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.
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.
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
Summary Evidence Table – Effectiveness Review [PDF – 405 kB]
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.
- Meal or fruit and vegetable snack interventions to increase healthier foods and beverages provided by schools
- Interventions supporting healthier snack foods and beverages sold or offered as a reward in schools
- Multicomponent interventions to increase availability of healthier foods and beverages in schools
- Interventions to increase water access 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
- (school or schools or afterschool or kindergarten or educational-setting*).ti,ot,sh,ab,tw.
- school/ or high school/ or kindergarten/ or middle school/ or primary school/
- exp obesity/
- exp body composition/
- waist hip ratio/ or waist to height ratio/
- (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.
- body weight/
- (normal weight or normal weights or hip circumference).ti,ot,sh,ab,tw.
- body fat/
- body mass index/
- skinfold thickness/
- waist circumference/
- 1 or 2
- 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12
- 13 and 14
- 2014*.em. or 2015*.em. or 2016*.em. [Individual update weeks were no longer available to be searched for 2014.]
- 15 and 16
- limit 17 to english language
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
Evidence-Based Cancer Control Programs (EBCCP)
Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)