Water availability & promotion interventions

There is strong evidence that making water readily available and promoting its consumption increases water intake (Franse 2020, Cradock 2019, Lawman 2020, Patel 2016a, Muckelbauer 2009, Elbel 2015). Frequent water consumption can also have positive effects on eating and drinking decisions (Popkin 2005a, French 2001), improve physical health and body functions (Popkin 2010), and potentially reduce children’s overweight risk (Patel 2023, Schwartz 2016, Muckelbauer 2009). Increasing water availability is also a suggested strategy to improve nutrition and cognitive function in children and adolescents (IOM-Government obesity prevention 2009, CDC-Water access).

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 obesity (Dennis 2010, Davy 2008). When water consumption replaces sugar sweetened beverage (SSB) consumption it is linked with reduced energy intake (Daniels 2010, Popkin 2010, Giles 2012) and improved health outcomes among children, including reduced risk of overweight or obesity (Schwartz 2016, Muckelbauer 2009). Among children and adolescents, increasing water consumption through water provision, education, and promotion can reduce SSB consumption (Moghadam 2020, Grummon 2019, Kenney 2015).

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 fountains (Patel 2016a). Alternative water delivery systems often cost less than improving or replacing deteriorating drinking water fountains and plumbing (Patel 2011). 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 beverages (UCRCB&H-Sugary drinks). In a New York City-based study, cafeteria workers reported that water dispensers are easy to operate and maintain (Elbel 2015).

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 incomes (Cushing 2023). 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 people (Cushing 2023, Mueller 2021, Patel 2017b). Populations with lower levels of education and older adults may also experience hardships around water accessibility (Mueller 2021). 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 crisis (Cushing 2023).

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 authority (Cushing 2023). 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 incomes (US DHHS ATSDR-Drinking water, Cushing 2023). While some water-based contaminants are common across the U.S., others are more specific to certain regions or small communities (US DHHS ATSDR-Drinking water).

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 outcomes (Muckelbauer 2010).

In the 1800s, as American cities grew, water infrastructure was developed to supply urban residents with water from wells, lakes, and streams (Pew-Sedlak 2019). 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 neighborhoods (Kaplan 2007). 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 plumbing (Cushing 2023). 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 rights (Cushing 2023). 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 incomes (Cushing 2023).

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 service (Braveman 2022, Cushing 2023). 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 alike (CDC-Flint water crisis, Ruckart 2019). As of 2022, the city is still working to replace 30,000 lead pipes and reestablish safe access to drinking water (History-Flint).

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 fires (NYC DEP-Drinking water, Pew-Sedlak 2019). Water infrastructure requires constant monitoring and maintenance to prevent contamination (IWA-History of water and health); 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 century (Pew-Sedlak 2019).

Access to clean drinking water is important for everyday health and growth (CDC-Water and healthier drinks). 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 beverages (ChangeLab-Water).

• 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?

The Healthy, Hunger Free Kids Act of 2010 requires schools to make water available during National School Lunch Program meal service (Child nutrition reauthorization 2010). 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 lunchtime (BTG-Colabianchi 2014). 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 California (Ritchie 2015, Ritchie 2015a).

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 2016 (CPS-Water Quality Testing). 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 Utah (Patel 2011a).

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* Journal subscription may be required for access.

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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.

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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.

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UCRCB&H-Sugary drinks - University of California Research Consortium on Beverages and Health (UCRCB&H). The heavy environmental impact of sugary drinks.

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.

WI DPI-Water availability - Wisconsin Department of Public Instruction (WI DPI). Water availability: Water availability during National School Lunch Program and water access in schools.