Water availability & promotion interventions

Evidence Rating  
Some Evidence
Evidence rating: Some Evidence

Strategies with this rating are likely to work, but further research is needed to confirm effects. These strategies have been tested more than once and results trend positive overall.

Health Factors  

Regular placement of drinking fountains, water coolers, or bottled water in vending machines can make water readily available in various settings. Remediating or replacing drinking water infrastructure such as plumbing and water fountains, and testing tap water quality can make water consumption more appealing. State legislation, school district wellness policies, and child care licensing rules can support water availability, restrict sales of sugar-sweetened beverages (SSBs), support water consumption campaigns, or require health education about the importance and benefits of water consumption1. Increased water consumption promotes healthy body systems2.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Increased water consumption

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Improved health outcomes

  • Improved dietary choices

  • Improved cognitive function

What does the research say about effectiveness? This strategy is rated some evidence.

There is some evidence that making water readily available and promoting its consumption increases water intake3, 4, 5, 6, 7. Frequent water consumption can also have positive effects on eating and drinking decisions8, 9, improve physical health and body functions2, and, potentially, reduce children’s risk of being overweight6. Increasing water availability is also a suggested strategy to improve nutrition and cognitive function in children and adolescents10, 11. Additional evidence is needed to confirm effects.    

Drinking water before meals can reduce energy (calorie) intake during meals and increase weight loss for overweight or obese middle-aged and older adults12, 13. When water consumption replaces sugar sweetened beverage (SSB) consumption it is linked with reduced energy intake2, 3, 14. However, increasing water availability and promotion can increase water consumption without changing SSB consumption4, 5, 6.

One study suggests that water consumption increases more with the introduction of alternative water delivery systems such as filtered water dispensers or water cooler stations, than with added traditional water fountains15. Alternative water delivery systems often cost less than improving or replacing deteriorating drinking water fountains and plumbing1, and in a New York City-based study, cafeteria workers reported that water dispensers are easy to operate and maintain7.  

How could this strategy impact health disparities? This strategy is rated no impact on disparities likely.
Implementation Examples

The Child Nutrition Reauthorization Act of 2010 requires schools to make water available during National School Lunch Program meal service16. As of the 2011-12 school year, 86% of elementary, 87% of middle, and 89% of high schools report meeting this drinking water requirement, most often through existing water fountains. In many of these schools, efforts to improve water quality, the condition of water fountains, and ease of water consumption with cups or recyclable bottles could help all students have water, especially during lunchtime17. State laws can strengthen requirements for healthy beverages and further increase water availability in schools and child care centers, for example the 2012 Healthy Beverages in Childcare law in California18, 19.

School districts across the country require water quality testing and have efforts underway to improve drinking water quality, for example, the Seattle Public Schools and the Los Angeles Unified School District. Some schools have installed alternative water delivery systems, as in Oakland, CA and New York City, NY. Public-private partnerships can support efforts to improve drinking water infrastructure, as in Utah1.

Implementation Resources

CDC-Adolescent health and water - Centers for Disease Control and Prevention (CDC). Adolescent and school health: Publications & resources.

CDC-School water toolkit 2014 - Centers for Disease Control and Prevention (CDC). Toolkit: Increasing access to drinking water in schools. 2014.

US EPA-Water quality funding 2006 - US Environmental Protection Agency (US EPA). Water quality funding sources for schools: A resource for K-12 schools and child care facilities. Washington, DC; 2006.

ChangeLab-Water - National Policy & Legal Analysis Network to Prevent Childhood Obesity (NPLAN). Water access in schools: Model wellness policy language. Oakland: ChangeLab Solutions; 2012.

Ritchie 2012 - Ritchie L, Rausa J, Patel AI, Braff-Guajardo E, Hecht K. Providing water with meals is not a concern for young children: Summary of the literature & best practice recommendations. Oakland: California Food Policy Advocates (CFPA); 2012.

Water in Schools-Resources - Water in Schools. Resources: Organizations, reports and toolkits, programs, and additional resources.

HOST-Healthy eating - Healthy Out-of-School Time (HOST) Coalition. Resources: Healthy eating.


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1 Patel 2011a - Patel AI, Hampton KE. Encouraging consumption of water in school and child care settings: Access, challenges, and strategies for improvement. American Journal of Public Health. 2011;101(8):1370-1379.

2 Popkin 2010 - Popkin BM, D'Anci KE, Rosenberg IH. Water, hydration and health. Nutrition Reviews. 2010;68(8):439-58.

3 Giles 2012 - Giles CM, Kenney EL, Gortmaker SL, et al. Increasing water availability during afterschool snack: Evidence, strategies, and partnerships from a group randomized trial. American Journal of Preventive Medicine. 2012;43(3 Suppl 2):S136-42.

4 Loughridge 2005 - Loughridge JL, Barratt J. Does the provision of cooled filtered water in secondary school cafeterias increase water drinking and decrease the purchase of soft drinks? Journal of Human Nutrition and Dietetics. 2005;18(4):281-6.

5 Patel 2011 - Patel AI, Bogart LM, Elliott MN, et al. Increasing the availability and consumption of drinking water in middle schools: A pilot study. Preventing Chronic Disease. 2011;8(3):A60.

6 Muckelbauer 2009 - Muckelbauer R, Libuda L, Clausen K, et al. Promotion and provision of drinking water in schools for overweight prevention: Randomized, controlled cluster trial. Pediatrics. 2009;123(4):e661-7.

7 Elbel 2015 - Elbel B, Mijanovich T, Abrams C, et al. A water availability intervention in New York City public schools: Influence on youths’ water and milk behaviors. American Journal of Public Health. 2015;105(2):365-372.

8 Popkin 2005a - Popkin BM, Barclay DV, Nielsen SJ. Water and food consumption patterns of US adults from 1999 to 2001. Obesity. 2005;13(12):2146-52.

9 French 2001 - French SA, Story M, Jeffrey RW. Environmental influences on eating and physical activity. Annual Review of Public Health. 2001;22:309-35.

10 IOM-Government obesity prevention 2009 - Institute of Medicine (IOM), National Research Council (NRC), Committee on Childhood Obesity Prevention Actions for Local Governments. Local government actions to prevent childhood obesity. (Parker L, Burns AC, Sanchez E, eds.). Washington, DC: National Academies Press; 2009.

11 CDC-Water access - Centers for Disease Control and Prevention (CDC). Water access in schools.

12 Dennis 2010 - Dennis EA, Dengo LA, Comber DL, et al. Water consumption increase weight loss during a hypocaloric diet intervention in middle-aged and older adults. Obesity. 2010;18(2):300-7.

13 Davy 2008 - Davy BM, Dennis EA, Dengo AL, Wilson KL, Davy KP. Water consumption reduces energy intake at breakfast meal in obese older adults. Journal of the American Dietetic Association. 2008;108(7):1236-9.

14 Daniels 2010 - Daniels MC, Popkin BM. Impact of water intake on energy intake and weight status: A systematic review. Nutrition Reviews. 2010;68(9):505-21.

15 Patel 2012 - Patel AI, Chandran K, Hampton KE, et al. Observations of drinking water access in school food service areas before implementation of federal and state school water policy, California 2011. Preventing Chronic Disease. 2012;9:E121. Epub 2012 Jul 5.

16 Child nutrition reauthorization 2010 - Let’s Move! Child nutrition reauthorization: Healthy, hunger-free kids act of 2010.

17 BTG-Colabianchi 2014 - Colabianchi N, Turner L, Hood NE, Chaloupka FJ, Johnston LD. Availability of drinking water in US public school cafeterias. Bridging the Gap (BTG) Research Brief. 2014.

18 Ritchie 2015 - Ritchie LD, Yoshida S, Sharma S, et al. Drinking water in California child care sites before and after 2011-2012 beverage policy. Preventing Chronic Disease. 2015;12(E89):1-9.

19 Ritchie 2015a - Ritchie LD, Sharma S, Gildengorin G, et al. Policy improves what beverages are served to young children in child care. Journal of the Academy of Nutrition and Dietetics. 2015;115(5):724-730.

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