Poor children used to boost vending machine sales
Children from socially deprived areas — 1,641 elementary students in all — were specifically targeted by a government-funded study that promoted a large drink vendor. The experimental intervention, which had no scientific basis and is known to put children at risk for harm, involved compulsory lessons of mythologies designed to scare these youngsters...thin. Medical ethics is, indeed, a fragile thing.
How did this study pass an Institutional Review Board? There are ethical guidelines on human experimentation which especially safeguards the welfare of under-age children and other vulnerable populations who are not in positions to give voluntary, informed consent. Yet, no medical professional has spoken up on behalf of these underprivileged children.
Mainstream media has heralded the program, inaccurately reporting that the intervention is harmless and could be the answer to childhood obesity and help kids fight fat, and even that it had proven effective and able to “prevent obesity in kids.” In actuality, it had failed and wasn’t harmless, either.
Why has no health writer reported what was actually happening to these young disadvantaged children? It would have taken just minutes to go beyond the abstract and read the actual study, to look up the registered clinical trial protocol and Google the curriculum to learn what was being done to these children. It would have taken just one health reporter who understood science… for the world to have learned the truth. Yet, no journalist did..
What the public heard
The health writer at the New York Times led the way in touting this study as the possible answer to childhood obesity and describing its lesson plans as “health messages.” In “School Water Fountains to Prevent Obesity,” reporter Tara Parker-Pope wrote:
Adding school water fountains, distributing water bottles in classrooms and teaching kids about the health benefits of water can lower a child’s risk for becoming overweight, a new study shows. The findings, published in today’s Pediatrics, are based on a unique intervention in 32 German grade schools. In the study, about 3,000 second and third graders were weighed and quizzed about their beverage consumption. In some of the schools, water fountains were added and children were given personal water bottles they could fill at the beginning of the school day. Teachers were also given lesson plans that included health messages about the benefits of water consumption...
Even the writer at the misnamed Scientific American reported:*
Here's something to drink to: easy access to water fountains and a nudge from teachers to use them might help kids stay lean. A new study published today in Pediatrics suggests that installing fountains in elementary schools and pushing students to drink more water may reduce their risk of being plump by as much as a third. "Drinking fountains won't solve the obesity epidemic, but they could be effective components of the solution," says study co-author Rebecca Muckelbauer, a nutritionist at the Research Institute of Child Nutrition Dortmund in Dortmund, Germany...
Study overview
This week’s online issue of Pediatrics, the journal of the American Academy of Pediatrics, published the report of this study. It was led by Rebecca Muckelbauer in the department of dietary behavior at the Research Institute of Child Nutrition Dortmund in Germany. They identified 32 elementary schools in socially deprived areas — as defined by disproportionate numbers of parents who were “non-German” born, unemployed or on government welfare — and randomly selected 17 of those schools to test a program of promoting water and use of water bottles for preventing overweight in children.
The explanation given for why minority and poor children were selected was that they were most likely to have poor diets that put them at risk for obesity. This comes from two unscientific premises. The belief that parents of poor children feed their children less nutritionally than those of high socioeconomic status, as numerous international studies have found, is not supported by the evidence. Nor does any sound evidence support dietary or behavioral interventions in children for the prevention of obesity, because fat and thin children eat no differently to explain the diversity of their sizes.
These 1,721 disadvantaged children, average 8 years of age, were subjected to a comprehensive intervention that “concentrates on a single obesity-related behavior.” The authors stated that their “sole intention was to promote water consumption for overweight prevention, specifically targeting children in elementary schools in deprived urban areas…The study was approved by the ethics committee of the University of Bonn (Bonn, Germany).”
“Pure water does not contain energy and thus may support a healthy weight status if it replaces sugar containing beverages,” the authors said. Water could fill children up so that they eat less in meals or promote weight loss through thermogenesis, they said.
In addition to the unsupported claim of fattening sugary drinks, they added the myth of thermogenesis for weight loss: the belief that drinking cold water burns significantly more calories.**
In each school, a vending machine that delivered cold, filtered water was installed and each child was given a plastic water bottle. 
Teachers were instructed to organize the children to fill their water bottles each morning.
The educational program consisted of four 45-minute prepared lessons on the body’s need for water that the teachers were to incorporate into the formal school curriculum. Booster sessions were included beginning three months later. The lessens were “intended to improve the constructs of intention, attitudes, and perceived behavioral control, on the basis of the theory of planned behavior.”
The height and weight of the children in the intervention school and control schools were measured and their BMIs SD scores were determined. [As we’ve covered before, since children are growing, researchers use the z score (also called SD score) which accounts for a child’s age and gender and compares their BMI with average children of the same age and gender.] The children also self-reported the beverages (water, juice and soda) they drank, and the water consumption from the vending machines was monitored with flow meters.
Findings: It didn’t work
At the end of the school year, the 1,641 children who completed the program were compared with 1,309 children in control schools. The authors concluded “the estimated group difference in BMI SD score changes (-0.004) was not significant.” While the authors failed to report any actual weights or heights, clearly this program was unable to demonstrate a significant effect on the children’s size or any long-term effect. The study also failed to recruit enough children to be sufficiently powered to statistically detect even a 4% difference in weight status between the intervention and control group.
Nor did the study prove to have any effect on reducing the consumption of caloric beverages measured. The estimated increase in water consumption was 1.1 glass a day among the intervention students, but there was no statistically significant difference in juice or soft drink consumption. Whether water displaced nutrient-rich milk was not even examined in this study, which is significant when you learn what the children were taught.
In fact, missing from this clinical trial was an examination of any potential harms resulting from the intervention. The study design didn’t include any examinations of the children’s nutritional status, disordered eating or unhealthful weight concerns and weight control behaviors — adverse effects which have been shown to increase in other studies of childhood anti-obesity dietary interventions.
About three-quarters of the school classes organized the entire class to fill their drinking bottles from the vending machine each day. But about half of the teachers (51%) reported that the water bottles were disruptive of classroom education, with 15% of the teachers prohibiting them in class.
Despite the authors’ own findings, they concluded:
Our environmental and educational, school-based intervention, with the single focus on the promotion and provision of drinking water, proved to be effective in the prevention of childhood overweight. It was effective even with a population from socially deprived areas, which encourages introduction in the general population.
The full study as published in Pediatrics already reveals the discrepancy from the actual findings and the favorable portrayal to the public. But this is only part of the story. To understand what the children were actually being subjected to requires going to the registered study.
What you didn’t hear
This study was registered at clinicaltrials.gov (NCT00554294) and called Trinkfit. This program is probably unfamiliar to most American readers, but is the “Trinkfit—mach mit!” anti-obesity initiative being directed to school children in both Denmark and Germany. 
It promotes a new vending machine cooler, invented and patented by Juul & Partners, which made the vending machines and water bottles for this program and this study. “This new Vending machine will be the 21st century’s answer to the old water fountains in the cities,” states the company’s marketing.
How many of the poor parents knew what their children would be taught in the Trinkfit—mach mit! curriculum and freely gave their informed consent? The intense lessons and complex health concepts being given to their children would frighten and be misconstrued by most adults, let alone young children. How many parents would want their children exposed to these lessons, reinforced every school day, to have their children herded down the hall to fill bottles every class and be instructed to record the water they drink?
"Wer regelmäßig trinkt, hat mehr Kraft und Vitalität."
[Those who regularly drink, have more strength and vitality.]
Regular consumption of fresh water is stressed in the Trinkfit curriculum 
as critical for the body to function, keep from overheating, facilitate the removal of metabolic end products in the urine, transport nutrients in the blood, and work with enzyme-dependent metabolic processes.
“Water is the most important nutrient for the human body,” children are taught. They are told that their body is about two-thirds water and that they need to drink much more water than adults. Youngsters age 7-10 years old are instructed that they should drink at least one liter of fresh water a day and teens 1.5 liters. It they are active and play sports or are outside in the heat, they should drink three to four times that. Water, mineral water and teas are the best drink even at meals and even for young children, the program says.
Drinking water regularly enough has to be learned, says the curriculum. Most children don’t drink enough water and are dehydrated, it claims, because thirst is not a sufficiently strong signal to let them know when they need to drink.
“By the time children perceive thirst, it’s too late,” the children are told.
Drinking too little water sets the entire body off: the blood is thickened and makes the heart work harder. Losing just 5% of water can be life threatening. Children are told that it’s not only severe, acute water shortages that can threaten their health, but that even slight dehydration of 1-2% causes them to lose 20% of their physical and mental capacities and result in health problems like urinary tract infections, constipation, asthma and heart stress. At a loss of just 2.2%, short-term memory and concentration is impaired.
Children who don’t drink enough water, they’re taught, don’t concentrate well, learn poorly and been shown to have lower academic performance.
“Improper drinking habits” also cause weight gain, the lessons stress: “Above all, water contains no calories.”
Such complex health concepts — beyond the abilities of children to comprehend, critically process, or put into perspective — leave them anxious and more vulnerable to unhealthful reactions. 
But the inappropriateness of these lessons is overshadowed by the fact that they also indoctrinate children with popular water myths. [If these lessons sounded credible or in any way like “health messages about the benefits of water,” you’ll find some science here.]
Under the guise of preventing childhood obesity and “healthy” diets, beliefs are overriding science and ethics in increasingly disturbing ways. Using health scares to compel little kids to guzzle water isn’t science. We don’t know what affect this program had on the health and well-being of these underprivileged children, or their worries about their body, health and diet. This study wasn’t designed to find out.
It was designed to create a fear of thirst and hunger… and teach young poor children that both could be deadly.
© 2009 Sandy Szwarc
* To embellish this story, writer Coco Ballantyn added her own spin, warning consumers that “what's good for kids in Germany may not be good for kids in the U.S., where school drinking fountains may expose them to dangerous concentrations of lead (linked to brain damage).” The origin of this legendary scare are reports detecting lead in school drinking water, such as Seattle and New York. But, school drinking fountains are not exposing children to dangerous levels of lead and the miniscule amounts detected in the water have not been shown to put children at risk. New York City Department of Education (with technical support from the Departments of Health and Mental Hygiene and Environmental Protection) tested drinking water in all 990 public elementary schools and proceeded to conduct tests at all public middle and high schools. It found that 85% of the faucets failed to exceed EPA’s safety cushions (which, as readers know, are at least ten times the benchmark dose: the lowest dose considered safe from any effect over a lifetime of daily exposure in the most sensitive population of children). Of the 3% of nearly 20,000 outlets that had levels above this safety cushion, most were in sinks used for handwashing, not drinking. It concluded:
The U.S. Centers for Disease Control and Prevention reported of tests done of school drinking water in Seattle, Washington. To better understand the potential blood levels in elementary school children to identify any potential health risks of the levels found, they projected the worst-case scenarios, as well as the typical case. They concluded: Our modeling suggests drinking water exposures up to 10–15 times the Environmental Protection Agency guideline are unlikely to result in [blood lead levels] exceeding the current guidelines of the Centers for Disease Control and Prevention in the absence of other significant exposure sources. In Seattle,
** Eating disorder specialists know this behavior well: water for weight control is not only unsound, it’s an eating disorder behavior.
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