Data and Safety Monitoring Board January 27, 2004

1
Bottled, Filtered or Tap? Implications for
Fluoridated Water Exposure
2

• Supported by NIH U54 DE14201
• Center to Address Disparities in Childrens Oral
  Health
• (CAN DO Center)
• University of California, San Francisco
• Jane A. Weintraub, DDS, MPH
• Sally Adams, RN, PhD
• Kristin Hoeft, MPH
• Rosalia Mendoza, MD, MPH
• Francisco Ramos-Gomez, DDS, MS, MPH
• Judith Barker, PhD

3
Bottled Water

• In F and non-F areas, growing use of drinking
  water in non-recyclable bottles.
• In 2003, bottled water became second largest
  American beverage category.
• (JADA Sept 2003 Americans consumed over 5
  billion gallons of bottled water in 2000, doubled
  from the decade earlier) update
• Per capita consumption rose almost 50 from 2001
  to 27.6 gallons in 2006.

4
Bottled Water

• Media attention on environmental impact of the
  plastic bottles and energy used to produce and
  transport bottles (i.e. from Fiji).
• Majority of water consumed this way is not
  optimally fluoridated for oral health.
• Some reports indicate that bottled water use is
  higher among Hispanic than non-Hispanic
  populations.
• Add references

5
Commercial Filtered Water

• In some towns, water kiosks are popular.
• People buy and fill their own jugs with filtered
  water.
• Water is also purchased at vending machines.

6
Home Filters

• Brita, Pur and most other home filters do not
  remove fluoride.

7

• October 14, 2006
• Health Claim Notification for
• Fluoridated Waterand Reduced Risk of Dental
  Caries
• The claim language is
• "Drinking fluoridated water may reduce the risk
  of dental caries or tooth decay." In addition,
  the health claim is not intended for use on
  bottled water products specifically marketed for
  use by infants.

The food eligible to bear the claim is bottled
water containing gt0.6 - 1.0 mg/L total fluoride,
and meeting all general requirements for health
claims... . "
8
Dental Caries Increase

• During this time period, there has been an
  increase in early childhood caries prevalence
  among 2-5 year olds from 24 to 28
  disproportionately affecting children living in
  poverty and children of color .
• (NHANES, Dye et al. 2007)
• Iowa study - no conclusive evidence of an
  association with increased caries with children
  who frequently drank bottled water but study
  not designed to study this issue.
• (JPHD 2007, Broffitt, Levy et al.)

9
OBJECTIVE
To assess sources of drinking water for children
in low-income, minority populations at risk for
high caries rates.
10
METHODS

• As part of UCSF CAN DO Center,
• studies pertaining to early childhood caries
  (ECC) were conducted in four low-income,
  primarily Hispanic communities.
• Questions about source of drinking water were
  asked as part of questionnaires or interviews
  being administered to parents of young children
  as part of these research projects.

11
4 Study Locations
San Francisco Oakland San Jose
Mendota (rural)
12
Community Fluoridation (F) Status

• San Francisco F since 1952
• Oakland F since 1976
• San Jose Some areas F, most not.
• Mendota Not fluoridated

13
San Francisco

• Questions were administered to 183 parents of 3-5
  year old children enrolled in 7 different Head
  Start programs in San Franciscos Mission
  neighborhood, a largely Hispanic community, as
  part of a larger study.

14
San Francisco

• Questions were administered by a family medicine
  physician (RM) to
• XX parents who brought their children to the San
  Francisco General Hospital Family Health Center
  for dental care.

15
Oakland, CA

• Questions were administered by 2 interviewers to
  110 parents of 3-5 year old Hispanic and
  African-American children enrolled in Head Start
  programs as part of a larger study.

16
Mendota, CA

• As part of a population-based study of
  agricultural worker families, 313 adults were
  asked about their usual source of drinking water.
  

17
San Jose and Mendota, CA

• As part of an ethnographic, qualitative study
  conducted in urban San Jose and rural Mendota, 65
  caregivers of young children were interviewed
  in-depth about their water use and drinking water
  safety.

18
Questions AdministeredSan Francisco Head
Start(need to confirm wording and add other
questions)

• Do you usually give your child water to drink
  from the tap in your home, from bottled water, or
  neither?
• ? Tap water
• ? Bottled water
• ? Both tap and bottled water
• ? I dont usually give my child water to drink

19
RESULTS

• In F San Francisco,
• 68 of Head Start parents
• 63 of Health Center parents
• were giving their children bottled water as the
  main water source.

20
Oakland, CA

• In F Oakland, among Head Start parents
• 23 used bottled water
• 41 used filtered water
• XX used tap water
• as the main water source.

21
Mendota and San Jose

• 97 of 313 Mendota adults surveyed reported
  buying filtered water from commercial water mills
  or kiosks.
• The majority of caregivers in San Jose and
  Mendota interviewed bought bottled or commercial
  water for their children.
• Many in Mendota thought the tap water was unsafe.

22
DISCUSSION

• These findings are from specific samples of
  low-income, primarily Hispanic parents of young
  children.
• The issues and policy implications for non-use of
  tap water is different for fluoridated and
  non-fluoridated communities.

23
Fluoridated Communities

• In San Francisco, Oakland and parts of San Jose,
  with high quality, fluoridated tap water,
  low-income families are spending money
  unnecessarily on bottled water which may or may
  not be fluoridated.

24
Non-fluoridated Mendota

• In Mendota, local stores could be encouraged to
  sell fluoridated bottled water and consumers to
  buy it.
• The Mayor of Mendota is interesting in pursuing
  fluoridation of the towns water because of the
  towns poor oral health.
• The water kiosks use city water
  and reverse osmosis which would remove any F from
  the water.

25
Water Safety Issues

• Erin Brockovitch Effect
• History of PGE, agriculture and other industries
  using water contaminants (i.e.
  fertilizers, nitrates, pesticides) causing
  groundwater pollution.

Picture from S.F Chronicle 8/27/07
26
Cultural Issues

• Many from Mexico, El Salvador and Central America
  where water may not be potable or trusted.
• Cultural factors and social history support not
  drinking the tap water.

27
Next steps

• Focus groups and in-depth interviews to examine
  beliefs regarding tap water safety and behaviors
  regarding water consumption among Hispanic
  caregivers in San Francisco and Mendota.
• Explore cultural context, immigrant and
  native-born experiences.
• Examine knowledge and beliefs regarding
  fluorides safety and acceptability of various
  means of fluoride consumption for their children.
• (J Barker, PI CAN DO Center project)

28
CONCLUSIONS

• These urban and rural low-income Hispanic parents
  reveal a pattern of buying bottled water or
  filtered water instead of using tap water.
• In both F and non-F communities, interventions
  are needed to increase exposure to F water to
  promote dental health.

29
Background Fluoridation

• Healthy People 2010 goal Increase the proportion
  of the U.S. population served by community water
  systems with optimally fluoridated water to 75.
• In 1992, California ranked 47th among 50 states
  in provision of fluoridated water with only 17
  of Californians receiving benefit.
• Californias Mandatory Fluoridation Law (AB733)
  was enacted in 1995 for all public water systems
  that have at least 10,000 service connections.
• With Sacramento, Los Angeles and other cities now
  fluoridated, CA ranks XX (?)