Sociodemographic Characteristics and Beverage Intake of Children Who Drink Tap Water

  • Anisha I. Patel
    Correspondence
    Address correspondence to: Anisha I. Patel, MD, MSPH, MSHS, Department of Pediatrics, University of California at San Francisco, 3333 California Street, Suite 245, Mailbox 0503, San Francisco CA 94118
    Affiliations
    Department of Pediatrics, Columbia Mailman School of Public Health, New York, New York

    Philip R. Lee Institute for Health Policy Studies, Columbia Mailman School of Public Health, New York, New York
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  • Daniel J. Shapiro
    Affiliations
    Philip R. Lee Institute for Health Policy Studies, Columbia Mailman School of Public Health, New York, New York
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  • Y. Claire Wang
    Affiliations
    Department of Health Policy and Management, Columbia Mailman School of Public Health, New York, New York
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  • Michael D. Cabana
    Affiliations
    Department of Pediatrics, Columbia Mailman School of Public Health, New York, New York

    Philip R. Lee Institute for Health Policy Studies, Columbia Mailman School of Public Health, New York, New York

    Epidemiology and Biostatistics, University of California, San Francisco, California
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      Background

      Tap water provides a calorie-free, no-cost, environmentally friendly beverage option, yet only some youth drink it.

      Purpose

      To examine sociodemographic characteristics, weight status, and beverage intake of those aged 1–19 years who drink tap water.

      Methods

      National Health and Nutrition Examination Survey data (2005–2010) were used to examine factors associated with tap water consumption. A comparison was made of beverage intake among tap water consumers and nonconsumers, by age, race/ethnicity, and income.

      Results

      Tap water consumption was more prevalent among school-aged children (OR=1.85, 95% CI=1.47, 2.33, for those aged 6–11 years; OR=1.85, 95% CI=1.32, 2.59, for those aged 12–19 years) as compared to those aged 1–2 years. Tap water intake was less prevalent among girls/women (OR=0.76, 95% CI=0.64, 0.89); Mexican Americans (OR=0.32, 95% CI=0.23, 0.45); non-Hispanic blacks (OR=0.48, 95% CI=0.34, 0.67); and others (OR=0.50, 95% CI=0.36, 0.68) as compared to whites; Spanish speakers (OR=0.72, 95% CI=0.55, 0.95); and among referents with a lower than Grade-9 education (OR=0.52, 95% CI=0.31, 0.88); Grade 9–11 education (OR=0.50, 95% CI=0.32, 0.77); and high school/General Educational Development test completion (OR=0.50, 95% CI=0.33, 0.76), as compared to college graduates. Tap water consumers drank more fluid (52.5 vs 48.0 ounces, p<0.01); more plain water (20.1 vs 15.2 ounces, p<0.01); and less juice (3.6 vs 5.2 ounces, p<0.01) than nonconsumers.

      Conclusions

      One in six children/adolescents does not drink tap water, and this finding is more pronounced among minorities. Sociodemographic disparities in tap water consumption may contribute to disparities in health outcomes. Improvements in drinking water infrastructure and culturally relevant promotion may help to address these issues.

      Introduction

      Water is a no-calorie alternative to sugar-sweetened beverages (SSBs) such as soda and sports drinks. Drinking plain water instead of SSBs may help prevent obesity and obesity-related comorbidities.
      • Stookey J.D.
      • Constant F.
      • Popkin B.M.
      • Gardner C.D.
      Drinking water is associated with weight loss in overweight dieting women independent of diet and activity.
      • Dennis E.A.
      • Dengo A.L.
      • Comber D.L.
      • et al.
      Water consumption increases weight loss during a hypocaloric diet intervention in middle-aged and older adults.
      • Ebbeling C.B.
      • Feldman H.A.
      • Osganian S.K.
      • Chomitz V.R.
      • Ellenbogen S.J.
      • Ludwig D.S.
      Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study.
      • Muckelbauer R.
      • Libuda L.
      • Clausen K.
      • Toschke A.M.
      • Reinehr T.
      • Kersting M.
      Promotion and provision of drinking water in schools for overweight prevention: randomized, controlled cluster trial.
      • Stookey J.D.
      • Constant F.
      • Gardner C.D.
      • Popkin B.M.
      Replacing sweetened caloric beverages with drinking water is associated with lower energy intake.
      According to estimates from the National Health and Nutrition Examination Survey (NHANES), if children and adolescents substitute SSB intake with plain water, they can reduce their daily caloric intake by ~235 kilocalories.
      • Wang Y.C.
      • Ludwig D.S.
      • Sonneville K.
      • Gortmaker S.L.
      Impact of change in sweetened caloric beverage consumption on energy intake among children and adolescents.
      Drinking fluoridated plain water also can reduce dental caries, one of the most common chronic conditions among children and adolescents.
      • Armfield J.M.
      Community effectiveness of public water fluoridation in reducing children's dental disease.
      • Lee M.
      • Dennison P.J.
      Water fluoridation and dental caries in 5- and 12-year-old children from Canterbury and Wellington.
      • McDonagh M.S.
      • Whiting P.F.
      • Wilson P.M.
      • et al.
      Systematic review of water fluoridation.
      In the U.S., in most cases, individuals historically have consumed water directly from the tap (e.g., faucet, sink), as it provides a clean and low-cost beverage option. Over the past several decades, however, bottled water consumption has increased because of active marketing in conjunction with escalating consumer concerns regarding water quality, taste preferences for bottled water, and convenience (i.e., portability of bottled water).
      • Doria M.F.
      Bottled water versus tap water: understanding consumers' preferences.
      • Napier G.L.
      • Kodner C.M.
      Health risks and benefits of bottled water.
      Unfortunately, unlike most tap water, the majority of bottled water does not contain sufficient fluoride to prevent dental caries.
      • Johnson S.A.
      • DeBiase C.
      Concentration levels of fluoride in bottled drinking water.
      • Steinmetz J.E.
      • Martinez-Mier E.A.
      • Jones J.E.
      • et al.
      Fluoride content of water used to reconstitute infant formula.
      • Bullers A.C.
      Bottled water: better than the tap?.
      • Sriraman N.K.
      • Patrick P.A.
      • Hutton K.
      • Edwards K.S.
      Children's drinking water: parental preferences and implications for fluoride exposure.
      Moreover, intake of bottled water may pose a financial burden for families, particularly families who drink bottled water exclusively.
      • Gorelick M.H.
      • Gould L.
      • Nimmer M.
      • et al.
      Perceptions about water and increased use of bottled water in minority children.
      Bottled-water containers also adversely affect the environment.
      • Napier G.L.
      • Kodner C.M.
      Health risks and benefits of bottled water.
      • Bullers A.C.
      Bottled water: better than the tap?.
      There is limited information regarding the sources of drinking water that U.S. children and adolescents consume. Previous studies, including several regional surveys
      • Gorelick M.H.
      • Gould L.
      • Nimmer M.
      • et al.
      Perceptions about water and increased use of bottled water in minority children.
      • Huerta-Saenz L.
      • Irigoyen M.
      • Benavides J.
      • Mendoza M.
      Tap or bottled water: drinking preferences among urban minority children and adolescents.
      • Hobson W.L.
      • Knochel M.L.
      • Byington C.L.
      • Young P.C.
      • Hoff C.J.
      • Buchi K.F.
      Bottled, filtered, and tap water use in Latino and non-Latino children.
      • Williams B.L.
      • Florez Y.
      • Pettygrove S.
      Inter- and intra-ethnic variation in water intake, contact, and source estimates among Tucson residents: implications for exposure analysis.
      • Weissman A.M.
      Bottled water use in an immigrant community: a public health issue?.
      and a brief report using national data,

      Sebastian RS, Wilkinson Enns C, Goldman JD. Drinking water intake in the U.S.: What We Eat In America, NHANES 2005-2008. Food Surveys Research Group dietary data brief no. 7. September 2011. ars.usda.gov/Services/docs.htm?docid=19476.

      suggest that tap water intake is less common among low-income populations and of individuals of Latino and black race/ethnicity. It is unclear whether real problems or perceived concerns about water quality are driving low tap-water intake among these groups.
      The current study was designed to augment this previous work by conducting a more comprehensive analysis of NHANES data spanning a lengthier time frame of 2005–2010. Specifically, in this study, an examination was made of whether sociodemographic characteristics and weight status of children and adolescents aged 1–19 years in the U.S. are associated with intake of plain tap water. Investigation also was made of whether beverage consumption patterns, including intake of bottled water, which typically is not fluoridated, differed between tap water consumers and nonconsumers, stratified by age, race/ethnicity, and income level.
      Based on prior literature,
      • Gorelick M.H.
      • Gould L.
      • Nimmer M.
      • et al.
      Perceptions about water and increased use of bottled water in minority children.
      • Huerta-Saenz L.
      • Irigoyen M.
      • Benavides J.
      • Mendoza M.
      Tap or bottled water: drinking preferences among urban minority children and adolescents.
      • Hobson W.L.
      • Knochel M.L.
      • Byington C.L.
      • Young P.C.
      • Hoff C.J.
      • Buchi K.F.
      Bottled, filtered, and tap water use in Latino and non-Latino children.
      • Williams B.L.
      • Florez Y.
      • Pettygrove S.
      Inter- and intra-ethnic variation in water intake, contact, and source estimates among Tucson residents: implications for exposure analysis.
      • Weissman A.M.
      Bottled water use in an immigrant community: a public health issue?.

      Sebastian RS, Wilkinson Enns C, Goldman JD. Drinking water intake in the U.S.: What We Eat In America, NHANES 2005-2008. Food Surveys Research Group dietary data brief no. 7. September 2011. ars.usda.gov/Services/docs.htm?docid=19476.

      the current authors hypothesized that children from under-represented minority backgrounds and in families of lower income and lower educational levels would be less likely to drink tap water. Additionally, it was postulated that children who did not drink tap water would drink more SSBs and fruit juice and would be more likely to be overweight than children who drink tap water. Study results can be used to further understand and eliminate disparities in tap water intake, and potentially associated health conditions, among U.S. children and adolescents.

      Methods

      Data Source, Design, and Study Population

      From 2011 to 2012, an analysis was made of dietary and physical examination data from NHANES (2005–2010) including dietary and physical examination data. The NHANES is administered continuously by the National Center for Health Statistics (NCHS) through a series of interviews, physical examinations, and questionnaires that is described on the NCHS website.

      National Health and Nutrition Examination Survey. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm.

      Dietary data are collected using a multiple-pass 24-hour dietary interview method described elsewhere.
      • Pereira M.A.
      • Fulgoni 3rd, V.L
      Consumption of 100% fruit juice and risk of obesity and metabolic syndrome: findings from the national health and nutrition examination survey 1999-2004.
      • Wang Y.C.
      • Bleich S.N.
      • Gortmaker S.L.
      Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among U.S. children and adolescents, 1988-2004.
      During the interviews, respondents are asked to recall all foods and beverages consumed during the prior 24 hours. Demographic information and data regarding respondents’ typical diet also are collected. Interview participants vary by age; participants aged ≥12 years completed interviews on their own; interviews for children aged ≤5 years were completed by a proxy; and interviews with children aged 6–11 years were proxy-assisted. Thorough physical examinations, including anthropomorphic measurements, also are included in NHANES data collection procedures.
      In order to collect nationally representative data, the NCHS administers the NHANES using a complex, four-stage, probability sampling procedure. The NCHS samples counties, segments within counties, households within segments, and individuals within households. The NHANES oversamples certain population groups (e.g., African Americans and adolescents) who may be of particular public health interest. For the current study, the sample weights provided by the NCHS were applied, in order to account for the unequal probability of selection and nonresponse. The current analysis used data from three NHANES releases (2005–2006, 2007–2008, and 2009–2010) for which data on the water-intake outcomes of interest were first available. Individuals with incomplete or unreliable dietary data, as coded by NHANES staff, were excluded from the analysis.

      Outcome Variables

      The primary outcome was the proportion of children and adolescents aged 1–19 years who drank tap water. As part of the household interview, respondents or their proxy (for children aged <6 years) were asked: When you drink tap water, what is the main source of the tap water? Responses were categorized as: (1) community supply; (2) well or rain cistern; (3) spring; (4) don’t drink tap water; or (5) other. Children aged <1 year were excluded, as infants’ fluid intake consists of breast milk or infant formula.
      A comparison was made of the following sociodemographic characteristics of respondents who drank tap water versus those who did not: age (1–2 years, 3–5 years, 6–11 years, 12–19 years); gender; race/ethnicity (Mexican American, non-Hispanic white, non-Hispanic black, other); ratio of monthly family income to the poverty level based on the DHHS poverty guidelines (0%–129%, 130%–349%, 350%–499%, ≥500%); survey year (2005–2006, 2007–2008, 2009–2010); language of the interview (English, Spanish); and education level of a household reference person (<Grade 9; Grades 9–11; high school graduate/General Educational Development test [GED] equivalent; some college or another advanced degree; college graduate or above).
      An examination also was made of how weight status varied among tap water consumers and nonconsumers. Children were categorized as obese, overweight, or normal weight based on CDC-recommended BMI % cutoffs.

      CDC. A SAS program for CDC growth charts. www.cdc.gov.laneproxy.stanford.edu/nccdphp/dnpao/growthcharts/resources/sas.htm.

      For children aged ≥2 years, height and weight were used to calculate BMI% based on gender- and age-specific growth charts. Children in the 85%–95% were categorized as overweight, children ≥95% were categorized as obese, and children <85% were categorized as normal weight.
      Finally, in order to examine differences in beverage intake by tap water consumers and nonconsumers, estimates were made of the mean daily ounces of beverages consumed by children in each group. Using U.S. Department of Agriculture’s Food and Nutrient Database codes,

      U.S. Department of Agriculture. National nutrient database for standard reference, Release 24. ndb.nal.usda.gov/

      beverages were categorized into one of seven groups: (1) plain water, including tap and noncarbonated bottled water without sweeteners or other additions; (2) milk (including flavored milk); (3) 100% fruit/vegetable juice (including nectars); (4) SSBs (sodas, sports/energy drinks, fruit drinks, sweetened coffee/tea, other sweetened beverages); (5) low-calorie beverages (diet sodas, other beverages sweetened with low-calorie sweeteners); (6) unsweetened coffee/tea; and (7) other beverages. Similar to previous studies,
      • Wang Y.C.
      • Ludwig D.S.
      • Sonneville K.
      • Gortmaker S.L.
      Impact of change in sweetened caloric beverage consumption on energy intake among children and adolescents.
      • Wang Y.C.
      • Bleich S.N.
      • Gortmaker S.L.
      Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among U.S. children and adolescents, 1988-2004.
      estimates were made of both the mean daily volumetric intake and the mean daily caloric intake of beverages from each of these categories.

      Data Analysis

      A chi-square test was used to assess the association between each variable and whether the respondent drank tap water. Multivariable logistic regression was used, including all variables, to examine factors associated with tap water intake. Differences in the mean consumption of beverages between tap water consumers and nonconsumers stratified by age, race/ethnicity, and income were assessed using a Student’s t-test. All analyses were performed using survey commands in Stata 11 to adjust for survey design, including sample weights, primary sampling units, and strata.

      Results

      The final data set includes 10,470 children and adolescents aged 1–19 years. Although a total of 12,043 children and adolescents were surveyed; 1573 were excluded because either their dietary recall status was not reliable or there were missing data with regard to the current outcome of interest (i.e., source of water consumed). Study sample characteristics did not differ by 2-year release increments (Table 1).
      Table 1Characteristics of the study sample, by survey year, %
      Weighted to be nationally representative
      ,
      Data regarding weight status were available for 9536 of the 10,470 children in the study sample. Overweight was defined as BMI ≥85th percentile for age and gender; obese was defined as ≥95th percentile for age and gender (according to 2000 CDC growth charts). GED, General Educational Development test
      Characteristic2005–20062007–20082009–20102005–2010p
      (n=3984)(n=3152)(n=3334)(n=10,470)2)
      Age (years)0.97
       1–211111211
       3–516161616
       6–1132323332
       12–1941414041
      Gender0.93
       Male51505051
       Female49505049
      Race/ethnicity0.90
       Mexican American13131413
       Non-Hispanic white62615860
       Non-Hispanic black15141314
       Other11121412
      Poverty level, %0.32
       0–13027333431
       131–35039343636
       351–49918161416
       ≥50015171616
      Language of sample person interview0.36
       English94929192
       Spanish6898
      Household reference person’s education level0.33
       <Grade 95776
       Grade 9–1113131313
       High school graduate/GED26262124
       Some college/associate’s degree34303131
       College graduates23242825
      Birth country0.89
       U.S.95949595
       Mexico2222
       Other3433
      Weight status
      Data regarding weight status were available for 9536 of the 10,470 children in the study sample. Overweight was defined as BMI ≥85th percentile for age and gender; obese was defined as ≥95th percentile for age and gender (according to 2000 CDC growth charts). GED, General Educational Development test
       Overweight313132310.96
       Obese161617170.82
      a Weighted to be nationally representative
      b Data regarding weight status were available for 9536 of the 10,470 children in the study sample. Overweight was defined as BMI ≥85th percentile for age and gender; obese was defined as ≥95th percentile for age and gender (according to 2000 CDC growth charts).GED, General Educational Development test
      Of the 83% of children and adolescents who drank tap water, 67% drank water from a community supply, 15% from a well/rain cistern, and 2% from a spring. Of those who did not drink tap water, 59% reported that they drank bottled water. During the study period (2005–2010), plain water intake did not change; tap water intake decreased (20.0 to 19.1 ounces; p-value=0.05); and bottled water consumption increased (7.1 to 9.1 ounces; p=0.03).
      In multivariable analysis adjusting for sociodemographic characteristics, weight status, and survey year, tap water consumption was more likely among school-aged children as compared to those aged 1–2 years (Table 2). Tap water consumption was less likely among girls; Mexican Americans, non-Hispanic blacks, and other race/ethnicity as compared to whites; Spanish speakers as compared to English speakers; and among households in which referents had less than a Grade-9 education, a Grade-9–11 education, or high school/GED completion as compared to college graduates.
      Table 2Factors associated with tap water consumption in children and adolescents aged 1–19 years (2005–2010; N=9536)
      Weighted to be nationally representative
      ,
      Adjusted for age, gender, race/ethnicity, poverty level, survey year, language of interview, household reference education level, and child weight status.
      CharacteristicProportion reporting tap water consumption, %p 2)AOR (95% CI) for reporting tap water consumption
      Age (years)<0.01
       1–2761.00
       3–5761.00 (0.77, 1.31)
       6–11851.85 (1.47, 2.33)
       12–19871.85 (1.32, 2.59)
      Gender<0.01
       Male861.00
       Female820.76 (0.64, 0.89)
      Race/ethnicity<0.01
       Mexican American650.32 (0.23, 0.45)
       Non-Hispanic white901.00
       Non-Hispanic black780.48 (0.34, 0.67)
       Other790.50 (0.36, 0.68)
      Poverty level, %<0.01
       0–129750.63 (0.38, 1.05)
       130–349860.85 (0.52, 1.38)
       350–499890.82 (0.51, 1.32)
       ≥500921.00
      Survey year0.20
       2005–2006871.00
       2007–2008830.72 (0.48, 1.09)
       2009–2010820.72 (0.45, 1.15)
      Language of sample  person interview<0.01
      English861.00
      Spanish590.72 (0.55, 0.95)
      Household reference  person’s education level<0.01
       <Grade 9670.52 (0.31, 0.88)
       Grade 9–11750.50 (0.32, 0.77)
       High school graduate/GED or equivalent820.50 (0.33, 0.76)
       Some college or associate’s degree870.67 (0.45, 1.00)
       College graduates or  above921.00
      Weight status
      Data regarding weight status was available for 9,536 of the 10,470 children in the study sample. Overweight was defined as BMI ≥85th percentile for age and gender (according to 2000 CDC growth charts). GED, General Educational Development test
       Normal841.00
       Overweight830.491.03 (0.82, 1.29)
      a Weighted to be nationally representative
      b Adjusted for age, gender, race/ethnicity, poverty level, survey year, language of interview, household reference education level, and child weight status.
      c Data regarding weight status was available for 9,536 of the 10,470 children in the study sample. Overweight was defined as BMI ≥85th percentile for age and gender (according to 2000 CDC growth charts).GED, General Educational Development test
      Total mean intake of all beverages was 51.8 (0.8) ounces. Total beverage intake consisted primarily of three beverages: plain water (19.2 [0.6] ounces); SSBs (14.7 [0.5] ounces); and milk (10.6 [0.2] ounces). Appendix A (available online at www.ajpmonline.org) shows the mean consumption of beverages among tap water consumers and nonconsumers stratified by age group. Tap water consumers drank on average 4.9 ounces more of plain water per day, 7 ounces less of bottled water per day, and 1.6 ounces less of juice per day than nonconsumers. Overall, tap water consumers drank a greater average volume of all beverages than nonconsumers; however, there were no significant differences across groups in the average caloric intake from all beverages. Results stratified by race/ethnicity and income are shown in Appendixes B and C (available online at www.ajpmonline.org).

      Discussion

      This is the first comprehensive, national study to examine the sociodemographic characteristics of U.S. children and adolescents who drink tap water. This study showed disparities in tap water consumption related to age, gender, education, language, and race/ethnicity. As in a previous national data brief and smaller regional studies,
      • Sriraman N.K.
      • Patrick P.A.
      • Hutton K.
      • Edwards K.S.
      Children's drinking water: parental preferences and implications for fluoride exposure.
      • Gorelick M.H.
      • Gould L.
      • Nimmer M.
      • et al.
      Perceptions about water and increased use of bottled water in minority children.
      • Huerta-Saenz L.
      • Irigoyen M.
      • Benavides J.
      • Mendoza M.
      Tap or bottled water: drinking preferences among urban minority children and adolescents.
      • Hobson W.L.
      • Knochel M.L.
      • Byington C.L.
      • Young P.C.
      • Hoff C.J.
      • Buchi K.F.
      Bottled, filtered, and tap water use in Latino and non-Latino children.
      • Williams B.L.
      • Florez Y.
      • Pettygrove S.
      Inter- and intra-ethnic variation in water intake, contact, and source estimates among Tucson residents: implications for exposure analysis.

      Sebastian RS, Wilkinson Enns C, Goldman JD. Drinking water intake in the U.S.: What We Eat In America, NHANES 2005-2008. Food Surveys Research Group dietary data brief no. 7. September 2011. ars.usda.gov/Services/docs.htm?docid=19476.

      whites in the current study were more likely to drink tap water as compared to under-represented minority children. In a 2011 data brief that examined national trends in the mean amount of bottled and tap water consumption (in cups) among U.S. adults and children using 2005–2008 NHANES data, non-Hispanic white teens (aged 12–19 years) drank more tap water than Hispanic and non-Hispanic black teens.

      Sebastian RS, Wilkinson Enns C, Goldman JD. Drinking water intake in the U.S.: What We Eat In America, NHANES 2005-2008. Food Surveys Research Group dietary data brief no. 7. September 2011. ars.usda.gov/Services/docs.htm?docid=19476.

      In a study conducted of parents of children presenting to pediatric clinics in Salt Lake City UT, twice as many Latinos as whites reported never giving their child tap water (44% vs 21%).
      • Hobson W.L.
      • Knochel M.L.
      • Byington C.L.
      • Young P.C.
      • Hoff C.J.
      • Buchi K.F.
      Bottled, filtered, and tap water use in Latino and non-Latino children.
      Similarly, in a study of parents of pediatric patients presenting to emergency departments in an urban/suburban location in Milwaukee WI, the percentage of Latino and African-American parents who reported exclusive bottled-water intake was double that of non-Latino whites.
      • Gorelick M.H.
      • Gould L.
      • Nimmer M.
      • et al.
      Perceptions about water and increased use of bottled water in minority children.
      Perceptions of tap water as a health risk and taste preferences may contribute to racial/ethnic disparities in tap water consumption.
      • Gorelick M.H.
      • Gould L.
      • Nimmer M.
      • et al.
      Perceptions about water and increased use of bottled water in minority children.
      The finding that Spanish speakers are less likely to drink tap water than English speakers supports the hypothesis that immigrants may perceive water in the U.S. as unsafe due to contaminants in their “home” country water supply.
      • Hobson W.L.
      • Knochel M.L.
      • Byington C.L.
      • Young P.C.
      • Hoff C.J.
      • Buchi K.F.
      Bottled, filtered, and tap water use in Latino and non-Latino children.
      Alternatively, preference for bottled water may stem from poor water quality/safety in the current communities in which they live. Indeed, minority populations may be more likely to live in older homes in which water has elevated levels of lead, is discolored, or is not palatable due to antiquated or poorly maintained plumbing.
      • Hood E.
      Dwelling disparities: how poor housing leads to poor health.
      In order to reduce such disparities in tap water intake, it is critical to first ensure equal access to safe and potable drinking water. In locations where drinking water is safe, culturally specific messaging may help increase intake of tap water instead of bottled water or non-nutritive beverages.
      The current study also demonstrates that independent of income, a lower educational status of the household referent is negatively associated with tap water intake. To our knowledge, no previous studies have found such a relationship. Even in communities where tap water is safe to drink, there may be negative perceptions regarding the safety of tap water. Efforts to educate families, particularly those of lower educational status, about the health and financial benefits of tap water consumption, may help to improve intake among youth.
      In areas where water is unsafe to drink directly from the tap (e.g., as a result of lead leaching from old plumbing, groundwater nitrate contamination), there should be a concerted effort by communities and the government to improve the drinking water infrastructure so that families do not have to bear the burden of purchasing bottled water or filtration devices to ensure access to safe drinking water.
      • Cradock A.L.
      • Wilking C.L.
      • Olliges S.A.
      • Gortmaker S.L.
      Getting back on tap: the policy context and cost of ensuring access to low-cost drinking water in Massachusetts schools.
      • Giles C.M.
      • Kenney E.L.
      • Gortmaker S.L.
      • et al.
      Increasing water availability during afterschool snack: evidence, strategies, and partnerships from a group randomized trial.
      In the short term, public health officials and local community agencies can inform families of the most cost-effective ways to provide safe drinking water when potable water is unavailable (e.g., filtering water rather than purchasing individual-use disposable bottles).
      In the current study, older children were more likely to drink tap water as compared to younger children. A previous NHANES study of water intake among adults, children, and adolescents found that mean intake of plain water (including tap and bottled water) was higher among older children, after adjusting for child and household sociodemographic characteristics, child BMI, physical activity, and screen time behaviors.
      • Kant A.K.
      • Graubard B.I.
      Contributors of water intake in U.S. children and adolescents: associations with dietary and meal characteristics—National Health and Nutrition Examination Survey 2005-2006.
      Because of concerns regarding water intoxication, a condition in which water can dilute a baby's sodium levels leading to seizures, coma, brain damage, and death, many pediatricians do not recommend that children aged <1 year drink water.
      • Scariati P.D.
      • Grummer-Strawn L.M.
      • Fein S.B.
      Water supplementation of infants in the first month of life.
      • Gartner L.M.
      • Morton J.
      • Lawrence R.A.
      • et al.
      Breastfeeding and the use of human milk.
      Further, popular parenting books suggest that parents boil or use purified water when infants are young.
      • Jana L.
      • Shu J.
      Heading home with your newborn: from birth to reality.
      It is possible that the age differences in tap water intake observed in this study may be due to messages parents receive from healthcare providers and parenting sources that discourage plain water consumption in the early years and encourage purified or bottled water use for young children. Because of the numerous topics that need to be covered during the well-child visit,
      clinicians may not revisit the importance of water intake at health maintenance visits. Pediatricians and public health officials should increase efforts to educate families about the importance of encouraging tap water intake in toddlers, school-aged children, and adolescents.
      Overall consumption of plain water in this study was low as defined by previous studies (<3 glasses/day). As would be expected, children and adolescents who drank tap water drank less bottled water than nonconsumers. Tap water consumers also drank half a cup more of plain water overall (i.e., from bottled and/or tap water sources) and consumed less juice than nonconsumers. Moreover, children who drank tap water drank more fluid overall than children who did not drink tap water. No previous studies have examined differences in beverage intake in terms of volume and kilocalories among tap water consumers and nonconsumers.
      A previous study of beverage intake patterns among adults based on 1999–2001 NHANES data demonstrated that among water consumers (including tap and bottled water) there was a lower overall intake of kilocalories from nondairy caloric beverages (namely juice and soda) than among adults who did not consume water.
      • Lasater G.
      • Piernas C.
      • Popkin B.M.
      Beverage patterns and trends among school-aged children in the U.S., 1989-2008.
      In a study of children and adolescents using NHANES data, plain water intake was not associated with energy intake but was associated with intake of foods of lower energy density.
      • Kant A.K.
      • Graubard B.I.
      Contributors of water intake in U.S. children and adolescents: associations with dietary and meal characteristics—National Health and Nutrition Examination Survey 2005-2006.
      In the current study, no significant difference was found in SSB intake or weight status among tap water consumers and nonconsumers overall. However, given that consumption of SSBs is associated with adverse health effects (e.g., dental caries and obesity),
      • Wang Y.C.
      • Bleich S.N.
      • Gortmaker S.L.
      Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among U.S. children and adolescents, 1988-2004.
      • Malik V.S.
      • Popkin B.M.
      • Bray G.A.
      • Despres J.P.
      • Hu F.B.
      Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk.
      • Malik V.S.
      • Schulze M.B.
      • Hu F.B.
      Intake of sugar-sweetened beverages and weight gain: a systematic review.
      • Ismail A.I.
      • Sohn W.
      • Lim S.
      • Willem J.M.
      Predictors of dental caries progression in primary teeth.
      • Marshall T.A.
      • Broffitt B.
      • Eichenberger-Gilmore J.
      • Warren J.J.
      • Cunningham M.A.
      • Levy S.M.
      The roles of meal, snack, and daily total food and beverage exposures on caries experience in young children.
      • Marshall T.A.
      • Levy S.M.
      • Broffitt B.
      • et al.
      Dental caries and beverage consumption in young children.
      and overall hydration status is associated with cognitive functioning in children and adolescents,
      • D'Anci K.E.
      • Constant F.
      • Rosenberg I.H.
      Hydration and cognitive function in children.
      • Edmonds C.J.
      • Jeffes B.
      Does having a drink help you think? 6-7-year-old children show improvements in cognitive performance from baseline to test after having a drink of water.
      it is important to encourage consumption of water in lieu of SSBs, and in particular tap water (a low-cost and often fluoridated beverage), among children and adolescents.

      Limitations

      Several limitations to this study are acknowledged. Although several sociodemographic factors were controlled for in the analyses, there may be unmeasured confounders that were not possible to account for in the current study. For example, because there may be geographic variability in the safety and quality of tap water, future studies should examine how tap water intake varies by geographic locale (e.g., region, urban-centric locale).
      Despite variability in dietary intake for 1-day, 24-hour dietary recall, the 1-day recall provides unbiased estimates of population-level intake. Because the survey respondent interviewed varies by age (i.e., surveys are proxy-completed for younger children), this could have led to differential reporting by age. For example, perhaps adolescents are more likely to report tap water intake as compared to proxies such as parents. Finally, because this study relies on closed-ended survey data, it is not possible from the current results to fully understand the reasons that children and adolescents do not drink tap water. An in-depth qualitative study may be a better methodology for examining why younger children and children and adolescents from underserved backgrounds are least likely to drink tap water.

      Conclusion

      Although tap water is a readily accessible and low-cost beverage with health benefits, approximately one in six U.S. children and adolescents do not drink tap water. Children who are from underserved backgrounds (minority, low-education, and immigrant) are least likely to drink tap water; only one in three Mexican-American youth in the U.S. drink tap water. Although efforts increasingly discourage consumption of non-nutritive, energy-dense beverages, greater emphasis should be placed on increasing intake of water, and especially tap water, which is typically fluoridated and of low cost. A first step toward this goal is to ensure equal access to safe tap water, particularly in low-income and minority communities. In addition to drinking-water infrastructure improvements, it is also important to develop and disseminate culturally relevant messages to promote tap water intake among low-income and minority families.

      Acknowledgments

      Dr. Patel was supported in part by grant no. 1 K23 HD067305-01A1 from the NIH. The views expressed in this paper do not reflect those of the NIH. Dr. Wang was supported in part by the Robert Wood Johnson Foundation, grant No. 68162.
      No financial disclosures were reported by the authors of this paper.

      Appendix A. Supporting information

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