Water availability & promotion interventions
Regular placement of drinking fountains, water coolers, or bottled or boxed 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, 2. Increased water consumption promotes healthy body systems3.
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?
There is strong evidence that making water readily available and promoting its consumption increases water intake4, 5, 6, 7, 8, 9. Frequent water consumption can also have positive effects on eating and drinking decisions10, 11, improve physical health and body functions12, and potentially reduce children’s overweight risk8, 13, 14. Increasing water availability is also a suggested strategy to improve nutrition and cognitive function in children and adolescents15, 16.
Drinking water before meals can reduce energy (calorie) intake during meals and increase weight loss for middle-aged and older adults affected by overweight or obesity17, 18. When water consumption replaces sugar sweetened beverage (SSB) consumption it is linked with reduced energy intake12, 19, 20 and improved health outcomes among children, including reduced risk of overweight or obesity8, 14. Among children and adolescents, increasing water consumption through water provision, education, and promotion can reduce SSB consumption21, 22, 23.
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 the addition of traditional water fountains7. Alternative water delivery systems often cost less than improving or replacing deteriorating drinking water fountains and plumbing24. Implementing water delivery systems that allow people to fill reusable stainless steel water bottles instead of offering single-use plastic water bottles reduces greenhouse gas emissions and plastic pollution, with even greater effects if people drink water instead of sugar-sweetened beverages25. In a New York City-based study, cafeteria workers reported that water dispensers are easy to operate and maintain9.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by expert opinion.
Experts suggest that interventions to increase and promote water availability, especially by addressing water infrastructure remediation or replacement, have the potential to reduce disparities in access to safe drinking water between communities of color, Native communities, and communities with lower incomes and white communities with higher incomes31. People with low incomes, people of color, and those living in rural areas are more likely to have limited access to clean, uncontaminated drinking water than people with higher incomes and white people31, 32, 33. Populations with lower levels of education and older adults may also experience hardships around water accessibility32. Historical discrimination, underinvestment in water infrastructure, lack of regulation enforcement, and failure to protect tribal water rights have resulted in Native American, Black, Hispanic, and other communities of color and residents with lower incomes shouldering the greatest health and economic burdens from water insecurity. Diminished federal investment in water infrastructure has shifted maintenance costs to state and local agencies, who pass them on to consumers, causing an affordability crisis31.
Water can become contaminated in countless ways; some examples include deteriorating systems of pipes and plumbing, naturally occurring elements and minerals (e.g., arsenic, radon, and uranium), and manufacturing or industrial processes. Individuals getting drinking water from private wells typically bear higher contamination risks as regulation of these water sources is outside of federal government authority31. In rural areas, livestock grazing and concentrated animal feeding operations along with the use of fertilizers or pesticides for agriculture, and manufacturing runoff can all contaminate drinking water, while sewer overflow and manufacturing runoff are often the culprits in more urban neighborhoods with residents with low incomes31, 34. While some water-based contaminants are common across the U.S., others are more specific to certain regions or small communities34.
Experts suggest using culturally meaningful and appropriate messaging when designing and implementing water availability and promotion interventions to reach all members of a community, including immigrants, and to avoid increasing disparities in effects on water consumption and health outcomes35.
What is the relevant historical background?
In the 1800s, as American cities grew, water infrastructure was developed to supply urban residents with water from wells, lakes, and streams36. Discriminatory housing, lending, and exclusionary zoning policies in the era of Jim Crow and government-sanctioned segregation led to the redlining practices of the Federal Housing Administration and concentrated poverty in designated neighborhoods37. Poverty levels in an area significantly impact the funding and infrastructure available to residents. These discriminatory practices have led to more than 20 million Americans being provided with water service from community water systems that are in violation of at least one health-based regulation standard and nearly two million individuals living without running water and indoor plumbing31. In the U.S., almost half of Native households are unable to access reliable water due to the neglect and failure of the U.S. government to protect water rights31. The federal government has also shifted maintenance costs of water supplies and wastewater treatment to states and local agencies; since 1990, costs for water rates have tripled and continue to rise faster than inflation and incomes31.
In the present day, formerly redlined neighborhoods are frequently near sources of pollution, toxins, and other health hazards, such as coal-fired power plants or hazardous waste disposal sites, which may contaminate water supplies and are more likely to include older homes in poorer condition often with lead pipes providing water service31, 38. Flint, Michigan, a community with high rates of poverty, unemployment, and racism, along with aging and deteriorating housing, is one of the most notable recent examples of contaminated drinking water in the U.S. In 2014, the water system became severely contaminated when the supply switched from Lake Huron to Flint River as a cost saving measure; the water distribution pipes corroded, leaching lead into the water and poisoning children and adults alike39, 40. As of 2022, the city is still working to replace 30,000 lead pipes and reestablish safe access to drinking water41.
Federal policies such as the Clean Water Act, passed in 1972, and technological advancements including the manufacturing of dams and reservoirs came about primarily in response to poor water quality and limited supply which had created disasters, like waterborne diseases and uncontrolled fires36, 42. Water infrastructure requires constant monitoring and maintenance to prevent contamination43; however, in the U.S., much of the water infrastructure is currently in dire need of replacement, with some cities’ systems dating back to the 19th century36.
Access to clean drinking water is important for everyday health and growth3. In 2010, the Healthy, Hunger-Free Kids Act was passed, federally mandating that all schools make fresh drinking water readily available to students during mealtimes; in addition to increasing access to drinking water, this law also promotes the importance of substituting water for other high calorie beverages44.
Equity Considerations
- Is clean drinking water accessible to all members of your community? Which neighborhoods lack access to clean drinking water or face barriers to accessing water?
- Can you partner with community organizations, schools, workplaces, and public health advocates to improve water availability? Who else can promote water access?
Implementation Examples
The Healthy, Hunger Free Kids Act of 2010 requires schools to make water available during National School Lunch Program meal service26. During the 2011-12 school year, 86% of elementary, 87% of middle, and 89% of high schools met 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 lunchtime27. 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 California28, 29.
School districts across the country require water quality testing and have efforts underway to improve drinking water quality, for example, Chicago Public Schools have been testing water quality on a regular schedule since 201630. Some schools have installed alternative water delivery systems, as in Oakland, California and New York City. Public-private partnerships can support efforts to improve drinking water infrastructure, as in Utah2.
Implementation Resources
‡ Resources with a focus on equity.
CDC-Data and research on water consumption - Centers for Disease Control and Prevention (CDC). Get the facts: Drinking water and intake.
CDC-School water toolkit 2014 - Centers for Disease Control and Prevention (CDC). Toolkit: Increasing access to drinking water in schools. 2014.
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.
National Drinking Water Alliance - National drinking water alliance. Access.
CDC-School water access - Centers for Disease Control and Prevention (CDC). Healthy schools. Water access microlearning videos.
Footnotes
* Journal subscription may be required for access.
1 Patel 2020 - Patel M, Donovan EM, Perks SN, et al. E-cigarette tobacco retail licensing laws: Variance across U.S. states as of January 1, 2020. American Journal of Public Health. 2020;110(9):1380-1385.
2 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.
3 CDC-Water and healthier drinks - Centers for Disease Control and Prevention (CDC). Water and healthier drinks.
4 Franse 2020 - Franse CB, Boelens M, Fries LR, et al. Interventions to increase the consumption of water among children: A systematic review and meta-analysis. Obesity Reviews. 2020;21(7):e13015.
5 Cradock 2019 - Cradock AL, Poole MK, Agnew KE, et al. A systematic review of strategies to increase drinking-water access and consumption among 0- to 5-year-olds. Obesity Reviews. 2019;20(9):1262-1286.
6 Lawman 2020 - Lawman HG, Henry KA, Scheeres A, et al. Tobacco retail licensing and density 3 years after license regulations in Philadelphia, Pennsylvania (2012–2019). American Journal of Public Health. 2020;110(4):547-553.
7 Patel 2016a - Patel AI, Grummon AH, Hampton KE, et al. A trial of the efficacy and cost of water delivery systems in San Francisco Bay Area middle schools, 2013. Preventing Chronic Disease. 2016;13(7):1-10.
8 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):e661-667.
9 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.
10 Popkin 2005a - Popkin BM, Barclay DV, Nielsen SJ. Water and food consumption patterns of U.S. adults from 1999 to 2001. Obesity. 2005;13(12):2146-2152.
11 French 2001 - French SA, Story M, Jeffrey RW. Environmental influences on eating and physical activity. Annual Review of Public Health. 2001;22:309-335.
12 Popkin 2010 - Popkin BM, D'Anci KE, Rosenberg IH. Water, hydration and health. Nutrition Reviews. 2010;68(8):439-458.
13 Patel 2023 - Patel AI, Schmidt LA, McCulloch CE, et al. Effectiveness of a school drinking water promotion and access program for overweight prevention. Pediatrics. 2023;152(3).
14 Schwartz 2016 - Schwartz AE, Leardo M, Aneja S, Elbel B. Effect of a school-based water intervention on child body mass index and obesity. JAMA Pediatrics. 2016;170(3):220-226.
15 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, D.C.: National Academies Press; 2009.
16 CDC-Water access - Centers for Disease Control and Prevention (CDC). Water access in schools.
17 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):300-307.
18 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):1236-1239.
19 Daniels 2010 - Daniels MC, Popkin BM. Impact of water intake on energy intake and weight status: A systematic review. Nutrition Reviews. 2010;68(9):505-521.
20 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.
21 Moghadam 2020 - Moghadam SD, Krieger JW, Louden DKN. A systematic review of the effectiveness of promoting water intake to reduce sugar-sweetened beverage consumption. Obesity Science and Practice. 2020;6(3):229-246.
22 Grummon 2019 - Grummon AH, Cabana MD, Hecht AA, et al. Effects of a multipronged beverage intervention on young children’s beverage intake and weight: A cluster-randomized pilot study. Public Health Nutrition. 2019;22(15):2856-2867.
23 Kenney 2015 - Kenney EL, Gortmaker SL, Carter JE, et al. Grab a cup, fill it up! An intervention to promote the convenience of drinking water and increase student water consumption during school lunch. American Journal of Public Health. 2015;105(9):1777-1783.
24 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.
25 UCRCB&H-Sugary drinks - University of California Research Consortium on Beverages and Health (UCRCB&H). The heavy environmental impact of sugary drinks.
26 Child nutrition reauthorization 2010 - Let’s Move! Child nutrition reauthorization: Healthy, hunger-free kids act of 2010.
27 BTG-Colabianchi 2014 - Colabianchi N, Turner L, Hood NE, Chaloupka FJ, Johnston LD. Availability of drinking water in U.S. public school cafeterias. Bridging the Gap (BTG) Research Brief. 2014.
28 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.
29 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.
30 CPS-Water Quality Testing - Chicago Public Schools (CPS). Water quality testing.
31 Cushing 2023 - Cushing L, et al. Water insecurity and population health: Implications for health equity and policy. Health Affairs. 2023.
32 Mueller 2021 - Mueller JT, Gasteyer S. The widespread and unjust drinking water and clean water crisis in the United States. Nature Communications. 2021;12:3544.
33 Patel 2017b - Patel AI, Schmidt LA, Lee PR. Water access in the United States: Health disparities abound and solutions are urgently needed. American Journal of Public Health. 2017;107(9):1354-1356.
34 US DHHS ATSDR-Drinking water - U.S. Department of Health and Human Services (U.S. DHHS), Agency for Toxic Substances and Disease Registry (ATSDR). Access to safe drinking water.
35 Muckelbauer 2010 - Muckelbauer R, Libuda L, Clausen K, et al. Immigrational background affects the effectiveness of a school-based overweight prevention program promoting water consumption. Obesity. 2010;18(3):528-534.
36 Pew-Sedlak 2019 - Sedlak D. How development of America’s water infrastructure has lurched through history. The Pew Charitable Trusts (Pew); 2019.
37 Kaplan 2007 - Kaplan J, Valls A. Housing discrimination as a basis for Black reparations. Public Affairs Quarterly. 2007;21(3):255-273.
38 Braveman 2022 - Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling. Health Affairs. 2022;41(2):171-178.
39 CDC-Flint water crisis - Centers for Disease Control and Prevention (CDC). Community assessment for public health emergency response (CASPER). Flint water crisis.
40 Ruckart 2019 - Ruckart PZ, Ettinger AS, Hanna-Attisha M, et al. The Flint water crisis: A coordinated public health emergency response and recovery initiative. Journal of Public Health Management and Practice. 2019;25(Suppl 1):S84-S90.
41 History-Flint - History. This day in history: April 25, 2014, the Flint water crisis begins.
42 NYC DEP-Drinking water - City of New York (NYC), Environmental Protection (DEP). Water Supply: History of New York City drinking water.
43 IWA-History of water and health - International Water Association (IWA). A brief history of water and health from ancient civilizations to modern times.
44 ChangeLab-Water - National Policy & Legal Analysis Network to Prevent Childhood Obesity (NPLAN). Water access in schools: Model wellness policy language. Oakland: ChangeLab Solutions; 2012.
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