Water Insecurity Indicators Are Associated with Lower Diet and Beverage Quality in a National Survey of Lower-Income United States Adults

Background: Tap water distrust and avoidance, indicators of water insecurity, are prevalent in marginalized United States populations. As future environmental challenges stress water resources, further understanding of the scope of water insecurity and its impact on diet quality is needed, particularly in vulnerable United States populations. Objectives: To evaluate associations between 3 potential indicators of water insecurity-1) perception of tap water safety for drinking, 2) perception of tap water safety for cooking, and 3) tap water avoidance-and dietary quality and beverage intake in lower-income United States adults.Methods: A cross-sectional, web-based survey was fielded to 1798 lower-income (<250% federal poverty guidelines) United States adults. Participants answered questions detailing tap water safety perceptions and avoidance, beverage intake, dietary intake (30-d prime diet quality score), and sociodemographic covariates. Sociodemographic differences in drinking water insecurity measures were evaluated using chi-square and Fisher-Freeman-Halton tests. Associations between water insecurity measures and dietary outcomes were assessed using generalized linear models adjusted for sociodemographic covariates, and effect modification by sociodemographic covariates was assessed.Results: Over half of the adults surveyed experienced some aspect of water insecurity. Measures of water security differed significantly by sociodemographic covariates (Ps < 0.05), with higher percentages of women and gender-nonconforming persons, minoritized racial and ethnic groups, lower-income groups, and food-insecure adults reporting indicators of water insecurity. Presence of any water insecurity was associated with lower diet quality (beta = -1.07; 95% CI: -2.11, -0.03; P = 0.04), lower tap water intake (relative difference [RD] = 0.35; 95% CI: 1.28, 2.12; P < 0.0001), higher bottled water intake (RD = 1.64; 95% CI: 1.28, 2.12; P = 0.0001), and higher sugar-sweetened beverages intake frequency (frequency ratio = 1.13; 95% CI: 1.01, 1.27; P = 0.03).Conclusions: Water insecurity indicators are associated with poorer diet quality and beverage intake in a population of United States adults with lower-incomes. Addressing the intersection of water insecurity, food security, environmental impacts, and nutrition may help to improve the well-being and resiliency of vulnerable populations.