Gulp

It was a few vocal middle-schoolers who set the course for Anisha Patel’s research career.

In late 2006, Patel, MD, then a brand-new physician scientist, was working in Los Angeles middle schools to gather ideas for reducing childhood obesity. As part of a fellowship training program in community-based participatory research, she mapped barriers to obesity prevention — what food was available, how school cafeterias were set up, where and how much students could be physically active.

Patel planned to take this information back to a community advisory board and her mentor at UCLA to develop an obesity-prevention strategy they could test.

But a few middle school students had a different idea for the young scientist.

“It was a really hot day out in the schools — these were low-income schools in low-income areas of Los Angeles — and we were observing the school cafeteria and the lunch line,” Patel, now a Stanford School of Medicine associate professor of pediatrics, said in a recent interview for a Stanford School of Engineering podcast, The Future of Everything. “Students came up to us, and they said, ‘You know what? What we really need is, we need water.’”

Patel was taken aback. Students didn’t have water?

The nearest place to get a drink of water, she soon learned, was a porcelain fountain outside the cafeteria. It was not easily accessible to kids eating indoors, produced a feeble stream of lukewarm water and was clogged with leaves.

Even on a hot day, she thought, who would want to drink from that?

With that observation, Patel launched more than a decade of research and initiatives to improve access to a vital but overlooked component in children’s health: drinking water.

When she started, no one was aware that about half of California public school cafeterias lacked a place for students to get a free drink of water — and that was just one example of the problem. Safe, free, appealing tap water can help combat childhood obesity and dental cavities because water can replace sugary drinks kids otherwise consume, as Patel’s research is now demonstrating.

To make sure their findings have the maximum benefit, especially for vulnerable kids in low-income areas and communities of color, Patel and her collaborators have formed close ties with community members to inform the research, and with health policy and legislative experts to help translate their solutions into reality.

Community members as experts

During her pediatric residency at Stanford Medicine, in the early 2000s, Patel realized she wanted to tackle kids’ health challenges at a larger scale than one-on-one doctor’s visits allow. Her fellowship training at UCLA was the logical next step.

Community-based participatory research, which she was learning to conduct, takes scientists outside ivory-tower isolation. Instead, researchers partner with community organizations to identify and articulate problems that affect real people. They collect data on the issues and solutions that community members suggest and promote their discoveries to people who have the power to change things.

It’s a method especially suited to investigating social drivers of health — poverty, racism, and the like — because it allows scientists to build studies that, from the start, account for insider knowledge in the communities where they work.

“The ideal scenario would be the community coming to us to say, ‘We want your help evaluating X,’ and then you work together to design the study you’re going to conduct,” Patel said. “It’s always action-oriented; communities don’t want you to just describe the problem over and over. They want us to help them fix it.”

Traditional research takes, on average, 17 years to be translated into clinical practice, she noted. The goal of her work is to make changes much faster.

Not a drop to drink

After hearing students’ insider knowledge — “Hey, we don’t have water” — Patel and her colleagues began examining water access in Los Angeles schools.

“A lot of the fountains were not in great shape, and students didn’t want to drink the water because of taste or quality concerns, or even safety concerns,” she said. “Bottled water was there for purchase, but it was next to all these more-enticing beverages, so even if you had the dollar to spend, you probably wouldn’t be getting water.”

At the time, vending machines in California schools were still selling beverages with added sugar, including juice, sodas and sports drinks. (Selling these drinks in schools has since been outlawed.) Sugary drinks increase the risk for obesity and dental cavities and cost money students don’t necessarily have.

Kids asked Patel’s team for free bottles of water with lunch, but a school district beverage contract with PepsiCo Inc. prohibited offering students free bottles of beverages they might otherwise buy. To get around this restriction, Patel and her team designed a research project to test schools’ water for lead contamination, enlisting cafeteria staff to serve free, chilled tap water in dispensers at lunch. Kids could use cups or refillable water bottles to help themselves.

“Bottled water was there for purchase, but it was next to all these more-enticing beverages, so even if you had the dollar to spend, you probably wouldn’t be getting water.”

Anisha Patel, MD, associate professor of pediatrics

Patel refined the project with input from a community advisory board that included school district staff, teachers, parents, youth, the local public health department and others. At one of her presentations, Matt Sharp, who worked at a nonprofit then called California Food Policy Advocates, now known as Nourish California, heard her describe the dismal state of water access in Los Angeles schools.

“He said, ‘This is crazy,’” Patel recalled. Sharp enlisted Ken Hecht, LLB, a founder of the nonprofit, to raise the issue with state legislators he knew. Hecht is now policy director at the University of California Agriculture and Natural Resources’ Nutrition Policy Institute.

The nonprofit sponsored a bill requiring California schools to offer water in their cafeterias, which passed both houses of the legislature but was vetoed by then-Gov. Arnold Schwarzenegger, who said the problem should be fixable without legislation, Hecht recalled.

The veto prompted Hecht to call a colleague at the California Department of Education to ask for hard numbers on water access in school cafeterias. The department added a question about water to a school survey they were already conducting, and Hecht quickly had data to take back to lawmakers: About half of California school cafeterias had no place for students to get a free drink of water.

The data changed Schwarzenegger’s mind; among other details, Hecht recalls the governor saying in his famous Terminator accent, “I love water.”

Schwarzenegger signed a new bill, CA SB 1413, into law in 2010. It reads, in part: “Schools participating in the school lunch program under this Act shall make available to children free of charge, as nutritionally appropriate, potable water for consumption in the place where meals are served during meal service.”

The bill became a template for water provisions in the federal Healthy, Hunger-Free Kids Act of 2010, the first major revision to school food programs in more than 30 years. Both California and federal laws have also been changed to require free water in centers that participate in the Child and Adult Care Food Program, a federal program that funds food for child care and adult day care facilities.

Patel has collaborated with other researchers including Hecht and his wife, Christina Hecht, PhD, senior policy adviser at the University of California Agriculture and Natural Resources’ Nutrition Policy Institute, to track how much the legislative changes improved students’ water access.

For instance, in a 2020 scientific paper in Preventive Medicine Reports, they showed that between 2010-11 and 2016-18, California schools doubled or tripled the number of water sources in key locations such as food service areas, outdoor physical activity areas and classrooms; had more bottled water access; installed more fountains with appealing features such as refrigeration and filtration; and had more drinking fountains per student.

Tackling contaminants

At UC San Francisco, where Patel took her first faculty job, she launched a collaboration in 2014 with the Rural Community Assistance Corp., a national network of nonprofits that aid people in rural areas, to promote use of clean-water stations in California’s San Joaquin Valley.

The valley, one of the state’s most important agricultural regions, has some of California’s worst drinking water, caused by naturally occurring contaminants such as arsenic and by introduced pollutants such as fertilizer nitrates and coliform bacteria in agricultural runoff.

In some cases, public health advisories about how to make water safer (by boiling it to get rid of bacteria, for instance) can worsen other contamination concerns (boiling concentrates nitrates). Many households resort to buying bottled water.

To compound the problem, average per capita incomes among the region’s residents are about $7,000 per year less than the state average. Every dollar residents spend to buy bottled water reduces their ability to meet other needs.

In a project called Agua4All, Patel and her colleagues tested two approaches for getting people to use free water stations, set up around their communities, that provided clean, uncontaminated drinking water.

“The goal was to saturate a community with safe public water sources so families could go and fill up there,” Patel said. The researchers compared one town that used minimal promotion of the stations, such as posters, to a second town where the community also implemented activities from a tool kit of promotional ideas. The larger package of community-driven promotion increased water-station use, the research showed. The work was published in Preventing Chronic Disease in 2019.

“We’re big believers in the human right to water; everyone should have affordable access to safe drinking water,” said Sarah Buck, Patel’s research partner at the Rural Community Assistance Corp. and a co-author on the scientific paper. The need is especially acute for kids because they’re small, growing, and thus especially susceptible to contaminated water, she added.

Since the project was completed, Buck has moved to the national office of the Rural Community Assistance Partnership, where she lobbies for water-system improvements in rural communities nationwide. The research she conducted with Patel has been valuable for securing funding for these projects from the Environmental Protection Agency and the private sector.

“We utilized the study as part of an example of what could potentially be done and why the EPA should be helping pay for it as part of the WIIN program,” said Buck, referring to the Water Infrastructure Improvements for the Nation Act of 2016’s Reducing Lead in Drinking Water grant program. “It has been a feather in our cap as far as proof of concept.”

Water first

Patel hasn’t lost sight of her early goals to reduce childhood obesity and, since arriving at Stanford Medicine in 2018, has built the evidence base for water’s role, especially around boosting kids’ water intake at school.

With a large NIH grant, Patel’s team has been conducting a study, called Water First, at 26 low-income elementary schools in the San Francisco Bay Area. Developed in concert with a community advisory board that included policy advocates, the California Department of Education, schools, parents and teachers, it provided participating schools with upgrades to their drinking water facilities and a six-month educational program about the health benefits of water for all fourth-grade students.

As part of the study, after randomly assigning the schools to act as intervention or control sites, each school in the intervention arm received three water fountains that deliver chilled, filtered water and serve as water-bottle filling stations. Often, the new fountains replaced old, poorly functioning porcelain models.

The entire school participated in a kick-off assembly, usually including a live performance by a local musician who had written a children’s song, with actions, about the benefits of drinking water. The students also learned about orderly use of the water fountains.

Research staff led eight weekly lessons for fourth-grade students about health, environmental and financial benefits of drinking water. Fourth-graders also received reusable water bottles to drink from at school, and presented projects — including posters, skits and puppet shows — to describe what they had learned. Family-engagement activities, such as worksheets to complete with a parent or guardian, were also part of the study.

“We’re big believers in the human right to water; everyone should have affordable access to safe drinking water.”

Sarah Buck, Patel’s research partner at the Rural Community Assistance Corp.

The researchers conducted measurements at baseline, seven and 15 months later. They measured students’ body mass index, an obesity measure, as well as calorie intake from foods and beverages in 24-hour food diaries. Researchers also collected data on kids’ water intake at school during lunch, recess and PE and used the volume of water dispensed at the new fountains to estimate changes in students’ water consumption over time.

The study ran into challenges because participation by some schools was interrupted by the beginning of the COVID-19 pandemic in early 2020. But so far, the data indicates that the work achieved some degree of overweight prevention, Patel said. Water intake increased, too. The report is currently under peer-review for publication. Patel has also shared data from the study in testimony for new California legislation that will require water bottle filling stations in public schools undergoing modernization or new construction.

Making a difference

Students and school officials report seeing benefits from participating in the study. Before Bay Elementary School, in San Lorenzo, California, joined the Water First study in the fall of 2019, the school had only old porcelain fountains, many of which didn’t function, said Principal Bethannee Witczak. Students mostly drank water or juice from single-use plastic bottles, generating a lot of waste.

The water bottle filling stations changed that. Once the stations were installed, school leaders encouraged students to bring reusable bottles and started talking about the health and environmental benefits of doing so.

“Now it’s just part of the culture,” Witczak said. “When I walk into a classroom, at least 85 to 90% of kids have water bottles on their desks.”

Parents get information about reusable water bottles in beginning-of-the-year information packets, and Witczak describes the water bottle filling stations at Back to School Night. In her slide show explaining to students how to behave at school, proper use of the water stations is part of the material, just like the rules about lining up when the bell rings.

The stations make filling water bottles fun, Witczak said, adding with a chuckle that it’s become trendy: “It’s this positive space, like, ‘Oh, I’m going to go fill my water bottle!’ ‘You are?’ ‘Yeah!’ ‘Me, too!’ And kids bring water bottles that are representative of themselves as humans; it’s very sweet.”

While the research was underway, students participating in water lessons frequently chatted with Witczak on the playground about what they’d learned, or she overheard them reminding each other to drink less juice so they wouldn’t get cavities.

As for Patel, she’s planning how to translate the study’s findings into still more action to build healthier communities.

The research shows that in addition to other strategies to improve children’s health and reduce childhood obesity — fixing playgrounds, encouraging physical activity, providing free school meals for everyone — details like water fountains matter, just as the Los Angeles middle-schoolers told Patel years ago, she said.

“It’s the combination of access, structural changes in the school and home environments and our neighborhoods, and education that makes a difference for kids’ health,” Patel said.

“You can’t just educate this problem away without making investments in policies, school and home environments to make sure healthy options are accessible.”