Survey Study Explores Low-Income Parents’ Beliefs About Healthy Drinking Habits for Young Children

Educational Objectives

After reviewing this brief report, readers should be able to:

1. Illustrate that actual consumption and parental beliefs about age-appropriate intake levels are lower than clinical recommendations for water and milk and higher for flavored milk, juice, SSBs, and diet beverages.

2. Develop effective interventions to encourage healthy choices for beverage consumption in early childhood, including ongoing education about safe drinking water, clear instruction on beverage types and consumption amounts, and access to recommended beverages.

Introduction

Despite consensus by professional organizations about the beverage types and consumption amounts that promote healthy weight and good oral health, many US children’s habits do not follow these recommendations. Children frequently take in too much of the beverages that should be limited and consume too little of the recommended beverages. The American Academy of Pediatrics, American Academy of Pediatric Dentistry, and Centers for Disease Control and Prevention recommend that children under 1 year old should not consume juice, sugar-sweetened beverages (SSBs) or drinks with low-calorie sweeteners (diet beverages).^{1 -4} Children 1 year and older should drink 1 to 5 cups of water, 2 to 3 cups of milk, 4 oz (one-half cup) or less of 100% fruit juice daily, and receive no SSBs, toddler milk, or diet beverages.^{1 -4} The recommendations for milk consumption are inclusive of any non-drinkable forms of dairy (eg, yogurt or cheese products).

However, statistics show that beverage consumption among children in all age groups falls outside these recommendations. Less than one-third (30%) of 1-year-olds and 22% of 2- to 3-year-olds do not regularly drink plain water. ⁵ About one-half of 1- to 3-year-olds drink an average of 8 oz per day of juice, and between 30% and 46% drink 8 to 10 oz of SSBs. ⁵ Among children under 1 year, average consumption is as follows: 27% drink 5 oz of juice daily, and 9% drink 4.5 oz of SSBs. ⁵ The National Health and Nutrition Examination Survey 2005 to 2010 showed that beverages account for 18.7% of the total calories and 60% of added sugars consumed daily by children ages 2 to 18. ⁶ SSB intake is associated with overweight, obesity, and tooth decay,^7,8 all of which may increase risk of systemic chronic illnesses such as diabetes, heart disease, and certain cancers.

Studies on improving beverage habits of school-age children suggest that community-based interventions are more effective than home- or clinical-based interventions and need to include educational, behavioral, and environmental components. ⁹ Yet, little evidence exists about effective interventions for children younger than school age. This study builds upon a preliminary qualitative exploration of parental health beliefs about preventing obesity in early childhood ¹⁰ in which many participants mentioned beverage consumption as a contributing factor. The current study sought to further explore parental beliefs and beverage consumption habits of children in our health care service area to inform future interventions. The primary outcome assessed young children’s actual beverage consumption as compared with parent/guardian beliefs on appropriate intake, while secondary outcomes explored household beverage habits such as preferences and spending.

Methods

For this cross-sectional study, researchers recruited parents/guardians of children ages 0 to 5 years old through the local Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and the city Health Bureau between March 2022 and September 2022. Recruitment and data collection occurred using an anonymous survey (Supplemental A) provided on paper and via a QR code printed on business cards and flyers distributed throughout the city of Allentown, Pennsylvania. Participants included a convenience sample of urban/suburban community members who self-identified as parents/guardians of children ages 0 to 5 years old. Children in this age range comprise 7.1% of Allentown’s total population. Allentown is the third most populous city in Pennsylvania, where people primarily identify as White (51.3%) and Hispanic (56.2%), employment rate is at 57.2%, 15.5% do not have health insurance, and the median household income is $47 700 with 23.3% of households at or below the Federal Poverty Level.^{11 -13}

The study’s primary outcome assessed actual beverage consumption in children as compared with parent/guardian beliefs on what their children’s intake should be. Secondary outcomes of interest included questions about household water use, such as “What type of water does your family drink most of the time”; weekly spending on water, plain milk (cow, soy, almond), 100% juice, SSBs, and other drinks; beliefs about water safety; public water fountain use since the COVID-19 pandemic; and opinions on taste of water from the tap, public water fountains, and water bottle filling stations. Participants also were asked about the dollar amounts of WIC, Supplemental Nutrition Assistance Program (SNAP), and other benefits spent on specific beverage types. Data collected about children included age, WIC enrollment status, childcare use, child’s current beverage intake, and parent/guardian perspective on how much of each beverage type “should a child the same age as your child drink?”

The study team used a secure Research Data Electronic Capture (REDCap)^14,15 database to collect and store data and Microsoft Excel (version 2022) to analyze the data. Data analysis consisted of descriptive statistics (ie, calculating response frequencies and proportions) and data visualizations. The Lehigh Valley Health Network Institutional Review Board determined that this study (#STUDY00000280) met the requirements for approval of research under Exempt Category 3(i)(A) (Benign behavioral interventions [non-identifiable]). The data was collected using an anonymous survey, which included instructions indicating that completion was voluntary and implied consent in this research study.

Results

Participants included parents/guardians of 115 children from 83 households, with 98 (85.2%) of the children from households enrolled in WIC. Breakdown of respondents by children’s age group showed 16.5% with children 0 to 6 months; 12.7%, 6 to 12 months; 12.7%, 12 to 23 months; and 58.2% with children age 2 to 5 years. About half of households (41/83, 49%) reported that their child attends preschool, Head Start, or a similar childcare program. Just over half of households (48/83, 57.8%) most commonly drank bottled water at home.

As for beliefs and preferences about water safety and palatability, just over one-third (30/83, 36.1%) of households thought their tap water was safe to drink, and 30.1% (25/83) thought their tap water tasted good. While about half (43/83, 51.8%) of households drank from public drinking fountains before the COVID-19 pandemic, only 16.9% (14/83) continued to do so after the pandemic. Additional beliefs about water safety and palatability are shown in Table 1.

Table 1.

Parent/Guardian Beliefs About Water Safety and Palatability (N = 83 households).

Survey statement	“Agree” response, n (%)
Tap water in my home is safe.	30 (36.1%)
Tap water in my home tastes good.	25 (30.1%)
Before the pandemic, I drank from public drinking fountains.	43 (51.8%)
I currently drink from public drinking fountains.	14 (16.9%)
Water from public water fountains is safe.	16 (19.3%)
Water from public water fountains tastes good.	18 (21.7%)
Water from public water bottle filling stations is safe.	30 (36.1%)

The average WIC, SNAP, and other benefit program dollars spent by households on beverages included $17 per week on water, $22 per week on milk, $19 per week on juice, and $16 per week on SSBs. (Figure 1) Approximately 15% of households (13/83) reported spending more than $50 per week on SSBs. In terms of children’s beverage intake, 11% (3/28) of children under age 1 were consuming the recommended amount of water, and 18% (5/28) of parental beliefs were congruent with guideline recommendations. Parental beliefs and actual intake for all other beverage types aligned with recommendation that children in the <1 age group consume none of the other beverage types, except for juice, for which 18% (5/28) of children consumed some and 14% of parents believed it was appropriate for them to do so. (Figure 2) Among children aged 1 to 5, a large proportion (74/87, 85%) was consuming the recommended amounts of water, with 92% of parents agreeing they should be. Children in the older age group were drinking less plain milk (51/87, 59%) and more flavored milk (52/87, 60%), juices (39/87, 45%), and diet beverages (10/87, 11%) than recommended. Parental beliefs mostly aligned with their 1- to 5-year-olds’ consumption habits, except with SSBs: Most parents (61/87, 70%) believed this age group should not be drinking SSBs, despite 41% (36/87) of their children doing so (Figure 3).

Figure 1.

Household average weekly spending on beverages (N = 83 households).

Figure 2.

Actual beverage consumption versus parent/guardian beliefs on appropriate consumption for children aged < 1 year (n = 28 children)—[] indicate consumption recommendations.

Figure 3.

Actual beverage consumption versus parent/guardian beliefs on appropriate consumption for children aged 1 to 5 years (n = 87 children)—[] indicate consumption recommendations.

Discussion

Early childhood obesity is rising, ¹⁶ and it is crucial to address food and beverage consumption in young children to address this public health concern. Healthy beverage consumption, in particular, is one of many comprehensive options that can result in reducing excess calorie intake. ¹⁷ Consumption of SSBs, including flavored milk, are associated with increased risk for childhood obesity. ¹⁸ The inclusion of 100% juice in SNAP benefits was based on expert opinion with the intention of providing a substitute for daily fruit intake and associated micronutrients, ¹⁹ despite studies showing that consumption of fruit juices is associated with worsening BMI. ²⁰ Perhaps the harms of unhealthy excess calories from fruit juices and flavored milk may outweigh the intended benefits of supplemental nutrition provided by WIC’s inclusion of these beverages. ¹⁹

Our study aligns with the findings of Kay et al showing that young children do not regularly drink plain water, and their consumption of juice and SSBs is above guideline recommendations. ⁵ One solution to this may be to encourage water intake and discourage SSBs, which has been found to assist with promoting healthy weight in preschool children. ²¹ However, our study shows that actual beverage consumption in early childhood does not always align with parent/guardian beliefs about how much children should be drinking of various beverage types.

These findings suggest both a potential deficit in knowledge of beverage intake recommendations and potential barriers to applying consumption beliefs to children’s actual beverage intake. Milk, flavored milk, and 100% fruit juice are WIC-eligible, while SSBs, including “juice drinks” are not. ²² We agree with Rader et al, who suggested that the cost of purchasing juice and SSBs may be a leverage point to help families change behaviors. ¹⁷ Many families in our study reported significant spending on beverages, which aligns with the 2012 to 2013 national study showing that SNAP households spent 6% of their food allocation on SSBs. ²³ We suggest WIC re-evaluate its coverage of beverages and make changes, such as reducing juice and flavored milk benefits and adding bottled water and water filters. Doing so may support efforts to educate parents/guardians about recommended beverage intake, while making healthier beverage options more affordable and addressing tap water use hesitancy.

Another potential intervention centers on our finding that many families did not believe their tap water was safe to drink and were spending significant amounts to purchase bottled water. Only 36% believed their tap water was safe, which is significantly lower than the 87% who trusted their tap water found in a 2014 national study ²⁴ but closer to the 39% of Hispanic US adults in a 2019 study. ²⁵ In the same study, 69% agreed with a statement that knowing tap water is safe would make them less likely to consume bottled water. ²⁵ This indicates a need to educate residents of Allentown, a majority of whom are Hispanic, about the Safe Drinking Water provision in Title 25 of Pennsylvania Code ²⁶ that requires public tap water be safe for consumption.

Limitations and Opportunities for Future Study

Limitations of this study include the survey methodology, which requires participants to select from predetermined categorical responses, and parental self-report of their child’s beverage consumption. Utilizing convenience sampling also limits the diversity of the participant pool, as only those with direct access to the study team had an opportunity to be included. Self-reporting is inherently flawed by recall bias, cognitive bias, and social desirability bias, and responses cannot be validated. In addition, while parents of children under 5 will be primarily in control of beverage consumption, they may not be aware of beverages consumed when the child is under the care of another individual. In addition, the survey questions on cost of beverages did not separate flavored milk from milk, so the reported amounts spent in these categories may be conflated.

Conclusion

Key findings of this study included the identification of multiple barriers to healthier beverage consumption for young children, including parental beliefs about recommended intake and beliefs about water safety. An effective program to increase consumption of water and decrease consumption of SSBs and milk may include education about tap water safety and recommended consumption of all beverage types (particularly of 100% juice), along with changes to infrastructure to improve access to safe tap water. Cost reductions realized by drinking tap water rather than bottled water and drinking less juice and SSBs also may be a motivator for behavior change.