The Relationship of Perceptions of Tap Water Safety with Intake of Sugar Sweetened Beverages and Plain Water among U.S. Adults

Abstract

Objective

Research is limited on whether mistrust of tap water discourages plain water intake and leads to greater intake of sugar-sweetened beverages (SSB). The objective of this study is to examine demographic differences in perceptions of tap water safety and determine if these perceptions are associated with intake of SSB and plain water

Design

The study examined perceptions of tap water safety and their cross-sectional association with intake of SSB and plain water. Racial/ethnic differences in the associations of tap water perceptions with SSB and plain water intake were also examined.

Setting

Nationally weighted data from 2010 HealthStyles Survey (n=4184)

Subjects

United States adults ≥18 years

Results

Overall, 13.0% of participants disagreed that their local tap water was safe to drink and 26.4% of participants agreed that bottled water was safer than tap water. Both mistrust of tap water safety and favoring bottled water differed by region, age, race/ethnicity, income, and education. The associations of tap water mistrust on intake of SSB and plain water were modified by race/ethnicity (p<0.05). Non-white racial/ethnic groups who disagreed that their local tap water was safe to drink were more likely to report low intake of plain water. The odds of consuming ≥1 SSB/day among Hispanics who mistrusted their local tap water was twice that of Hispanics who did not (OR = 2.0; 95% CI: 1.2, 3.3).

Conclusions

Public health efforts to promote healthy beverages should recognize the potential impact of tap water perceptions on water and SSB intake among minority populations.

Introduction

At present approximately half of adults in the United States consume sugar sweetened beverages (SSB) on any given day¹ and SSB intake is higher among Mexican Americans and blacks than among non-Hispanic whites.¹ Consumption of SSB has been associated with adverse health consequences including obesity ^{2, 3}, poor mental health⁴, and type 2 diabetes.⁵ Increasing intake of plain drinking water has been recommended by the Institute of Medicine to prevent dehydration and suggested as a means to prevent weight gain by reducing energy intake through displacement of SSB.⁶ Furthermore, drinking plain water as part of an overall healthy diet can help weight management.⁷ However, based on the 2005–2006 National Health and Nutrition Examination Survey (NHANES), the average plain water intake was about 1.06 L/day and plain water intake was negatively associated with water intake from other beverages among adults aged ≥20 years.⁸

A national poll conducted in the 1990's suggests that approximately one third of Americans may mistrust their tap water.⁹ Mistrust of tap water may be even more common among Hispanics, leading them to avoid drinking tap water for themselves as well as for their children.¹⁰ When people do not trust the quality of their tap water, they may be more likely to purchase and consume bottled beverages, including bottled water and SSB. For example, a perception that bottled water is safer than tap water was significantly associated with primarily bottled water use among parents¹¹ and concerns about water quality were found to be more common among college students and adults who drank primarily bottled water.^{12, 13} Furthermore, in a focus group conducted in a rural region of California's central valley, Hispanic participants reported that they regularly consumed SSB and other beverages when bottled or filtered water were not available.¹⁴ However, the relationship between trust of tap water and intake of SSB has not been quantitatively examined to date.

If mistrust of tap water is associated with increased intake of SSB, it would represent a modifiable community risk factor of considerable public health importance. Understanding the relationship between trust in tap water safety, plain water intake, and SSB intake will help to inform public health efforts to reduce SSB intake through promotion of drinking water. This study examines whether reported mistrust of tap water is associated with intake of plain water and SSB among U.S. adults and whether this association differs according to race/ethnicity.

Experimental Methods

Study Population

This cross-sectional study was based on the HealthStyles Survey conducted in the fall of 2010. The HealthStyles Survey is a national mail survey of U.S. adults (≥18 years) and is designed to assess a wide variety of respondents' health-related knowledge, attitudes, behaviors, and conditions surrounding important public health issues, including dietary behaviors. The HealthStyles Survey is sent to the same individuals who complete and return the ConsumerStyles Survey, which is a consumer mail panel survey. The sampling and data collection are conducted by Synovate, Inc., a market research firm.¹⁵ The Synovate, Inc. consumer mail panel consists of about 328,000 potential respondents throughout the United States; this is a convenience sample based on their respondents on previous survey over the years. Respondents are asked to join the mail panel through a recruitment survey and received a small gift. The ConsumerStyles Survey is sent to a stratified random sample drawn from the potential respondents. Although this survey is administered to a convenience sample, it was stratified on region, household income, population density, age, and household size to create a sample distribution similar to the national distribution. Low-income and minority groups are oversampled to have sufficient representation of these subgroups. In 2010, a total of 10,328 people completed the ConsumerStyles survey, yielding a response rate of 51.6%. A total of 6,255 HealthStyles Surveys were sent to a stratified random sample of households that returned the ConsumerStyles Survey. Responses were received from 4,184 HealthStyles participants, yielding a response rate of 66.9%. Compared to non-respondents, respondents included a somewhat higher percentage of older participants, non-Hispanic whites, and lower income individuals. Participants in HealthStyles Survey are assigned sample weights based upon sex, age, income, race, and household size to match U.S. Current Population Survey (CPS) proportions¹⁶ and to adjust for demographic differences that result from differences in sampling and response rates. For this cross-sectional analyses, a total of 397 participants with missing data were excluded; 100 for missing data on water perceptions; 132 for missing data on SSB or water intake; 27 for missing data on education status, and 138 for missing data on physical activity status. This left a final analytic sample size of 3,787 (90.5% of all HealthStyles respondents).

This analysis was exempt from the Centers for Disease Control and Prevention (CDC) Institutional Review Board process because personal identifiers were not included in the data provided to the CDC.

Study Variables

Perceptions of Tap Water

Participants were asked to rate their agreement with the following statements: “My local tap water is safe to drink” and “Bottled water is safer than tap water”. Response choices available for both of these items were “strongly disagree”, “some what disagree”, “neither agree nor disagree”, “somewhat agree”, and “strongly agree”. For bivariate analysis, three categories were created for each water perception variable: strongly/somewhat agree, neutral, and strongly/somewhat disagree. For logistic regression analysis, water perception variables were dichotomized. Participants were classified as having mistrust of tap water if they strongly or somewhat disagreed that their local tap water was safe to drink and not having mistrust of tap water if they responded “neither agree nor disagree”, “somewhat agree”, and “strongly agree”. Participants were classified as favoring bottled water if they strongly or somewhat agreed that bottled water was safer than tap water and not favoring bottled water if they responded “neither agree nor disagree”, “somewhat disagree”, and “strongly disagree”.

Outcome Variables for Plain Water and SSB Intake

Plain water intake was based upon the following question: “On a typical day, how many times do you drink a glass or bottle of plain water? Count tap, water fountain, bottled, and unflavored sparking water.” Response choices for water intake were “none”, “1 time per day”, “2 times per day”, “3 times per day”, “4 times per day”, or “5 times or more per day”. Participants were classified as having low intake of plain water if they drank ≤1 time/day because it is likely these individuals derive little of their total water intake (water from all dietary sources) from plain water. SSB intake was based upon the following question: “During the past 7 days, how many times did you drink sodas, fruit drinks, sports or energy drinks or other sugar-sweetened drinks? Do not include 100% fruit juice, diet drinks, or artificially sweetened drinks.” Response choices for SSB intake were “none”, “1 to 6 times per week”, “1 time per day”, “2 times per day”, “3 times per day”, or “4 or more times per day”. Participants were classified as daily SSB consumers if they responded that they consumed SSB ≥1 time/day.

Demographic Variables

Mutually exclusive categories were created for each covariate. Race/ethnicity was classified as non-Hispanic white, non-Hispanic black, Hispanic, or non-Hispanic other. Participants were classified into three age categories: 18–34, 35–54, and ≥55 years. Household income was classified into three categories: <$25,000, $25,000–<$60,000, and ≥$60,000. Education was classified according to four categories: <high school, high school, some college, and college graduate. Because individuals may be instructed to alter their dietary intake of SSB after diagnosis of diabetes, participants were classified as having diabetes based upon self-report of ever receiving treatment by a physician or health care provider. Geographic regions of the country were classified according to the following nine categories: East North Central, West South Central, East South Central, Middle Atlantic, Mountain, New England, Pacific, South Atlantic, and West North Central. Physical activity level was measured in adults using four questions that asked about the number of days and minutes per day of moderate physical activity and number of days and minutes per day of vigorous physical activity during a usual week. To categorize PA level, the total moderate intensity-equivalent minutes were calculated for each participant by summing the weekly minutes of moderate physical activity and two times the number of minutes of vigorous activity. Adults were classified as being either “inactive” (0 weekly moderate intensity-equivalent minutes), “insufficiently active” (1–150 weekly moderate intensity-equivalent minutes), or “active” (≥150 minutes weekly moderate intensity-equivalent minutes).¹⁷

Analysis

The FREQ and LOGISTIC procedures with appropriate weight statements in SAS version 9.2 were used for analysis. Weighted frequencies of mistrust of tap water and favoring bottled water according to age, sex, race/ethnicity, income, education, diabetes, physical activity level, and region were compared using chi-square tests. Chi-square analysis and multivariable logistic regression was used to assess the association of mistrust of tap water and favoring bottled water with daily SSB intake and low plain water intake. Two separate models were fit for each outcome (daily SSB intake and low water intake). Both models included mistrust of tap water and favoring bottled water as the primary exposure variables and age, sex, income, education, race/ethnicity, regions of country, physical activity level, and diabetes as covariates. Because previous studies have observed racial/ethnic differences in perceptions of tap water safety and because of qualitative evidence that tap water mistrust may be a unique risk factor for SSB intake among Hispanic populations¹⁴, interactions between race/ethnicity and mistrust of tap water and favoring bottled water were also assessed. Wald type-three analysis of effect tests with alpha level of 0.05 were used to assess the significance of interaction terms. Separate chi-square analysis to assess the association of mistrust of tap water and favoring bottled water with daily SSB intake and low plain water intake was also performed for each racial/ethnic group. In supplementary analysis, the relationship between low plain water intake with SSB intake was also assessed in a multivariable model with the same covariables as used in the primary analysis.

To assess the appropriateness of the dichotomous classification of water perception variables, sensitivity analysis was performed by refitting the models with separate variables corresponding to neutral and negative water perceptions as compared to positive water perceptions. The resulting race/ethnicity-specific odds ratios corresponding to negative water perceptions were then compared to original estimates where the response category “neither agree nor disagree” was included in the reference categories.

Results

Water Perceptions According to Sociodemographic Characteristics

Overall, 13.0% of participants either somewhat or strongly disagreed that their local tap water was safe to drink and 26.4% of participants somewhat or strongly agreed that bottled water was safer than tap water. Both mistrust of tap water safety and favoring bottled water significantly differed by age, race/ethnicity, income, and education, with mistrust of tap water and favoring bottled water tending to be more prevalent among younger adults, non-whites, and participants having lower income and less education (Table 1). Mistrust of tap water safety also tended to be more prevalent among those who were less active (Table 1). Favoring bottled water was more prevalent among persons with diabetes. Both mistrust of tap water and favoring bottled water also differed significantly by region, with mistrust of tap water ranging among regions from 4.2% to 20.1% and favoring bottled water ranging from 13.4% to 35.1% (Table 1). Mistrust of local tap water safety and favoring bottled water were also positively associated with each other such that 21.4% of those who favored bottled water did not agree that their local tap water was safe compared to 6.8% among those who disagreed bottled water was safer than tap water.

Table 1. Prevalence of tap water and bottled water safety perceptions according to survey respondent characteristics.

	Local tap water perceptions “My local tap water is safe to drink”				Bottled water perceptions “Bottled water is safer than tap water”
	Disagree	Neutral	Agree	p-value	Agree	Neutral	Disagree	p-value
n (weighted %a)	456 (13.0)	679 (19.2)	2,652 (67.9)	-	960 (26.4)	1,365 (37.4)	1,462 (36.2)	-
Age
18–34 y	14.9	23.5	61.6	<0.0001	29.6	40.5	29.9	<0.0001
35–54 y	15.1	19.0	65.9		26.9	36.5	36.6
55+ y	8.3	15.1	76.6		22.6	35.5	41.9
Sex
Male	12.3	19.9	67.1	0.5	27.0	37.3	35.8	0.8
Female	13.5	19.4	67.1		26.0	37.6	36.5
Race/ethnicity
Non-Hispanic white	10.8	16.9	72.4	<0.0001	21.8	38.0	40.2	<0.0001
Non-Hispanic black	19.9	24.5	55.6		40.0	34.6	25.4
Hispanic	16.0	24.9	59.2		34.1	38.0	28.0
Non-Hispanic other	18.0	22.4	59.6		36.6	34.6	28.8
Income
<$25,000	15.3	25.4	59.4	<0.0001	34.3	38.6	27.1	<0.0001
$25,000–$59,999	14.1	17.1	68.8		22.9	41.3	35.9
≥$60,000	10.8	17.4	71.8		24.8	33.9	41.3
Education
<High school	17.0	19.7	63.3	<0.0001	40.0	28.6	31.4	<0.0001
High school	15.1	19.4	65.5		27.5	41.7	30.8
Some college	16.1	21.9	62.1		29.5	39.4	31.1
College graduate	7.1	15.4	77.5		19.9	33.4	46.7
Self-reported diabetes
Diabetes	11.2	20.0	66.8	0.5	33.3	37.9	28.8	0.0001
No diabetes	13.2	19.1	67.8		25.4	37.4	37.2
Physical activity level
Inactive	16.5	21.1	62.5	0.004	28.2	36.6	35.2	0.3
Insufficiently active	13.3	18.3	68.4		28.2	35.7	36.1
Active	11.6	18.9	69.5		25.1	38.4	36.5
Region
New England	4.2	18.5	77.4	<0.0001	35.1	31.5	33.4	<0.0001
Middle Atlantic	15.5	20.3	64.2		22.9	40.6	36.5
South Atlantic	11.6	21.6	66.8		27.1	35.6	37.4
East North Central	14.6	14.5	70.9		27.2	38.5	34.2
East South Central	8.1	23.2	68.7		25.0	32.6	42.3
West North Central	5.6	17.1	77.3		13.4	48.7	37.9
West South Central	20.1	20.9	59.0		34.6	33.0	32.4
Mountain	13.7	15.3	71.0		24.1	36.6	39.2
Pacific	14.3	20.2	65.6		30.5	35.1	34.4
Agree bottled water is safer than tap	21.5	31.2	47.4	<0.0001	-	-	-	-
Neutral bottled water is safer than tap	12.9	20.8	66.3		-	-	-	-
Disagree bottled water is safer than tap	6.8	8.7	84.5		-	-	-	-
Disagree home tap water is safe	-		-	-	43.8	37.2	19.0	<0.0001
Neutral home tap water is safe					42.9	40.6	16.5
Agree home tap water is safe	-		-	-	18.5	36.6	45.0

^aAll percentages weighted based upon sex, age, income, race, and household size; because of rounding, weighted percentages may not add up to 100%.

Association of Mistrust of Tap Water with SSB and Plain Water Intake

Overall, 29.9% of participants reported drinking at least one SSB daily. Results of the association of tap water perceptions with SSB and plain water intake are shown in Table 2. The percentage of participants consuming ≥1 SSB/day differed significantly according to mistrust of local tap water only among Hispanics. Specifically, 45.6% of Hispanics who mistrusted the safety of their local tap water consumed ≥1 SSB/day compared to 28.8% of Hispanics who believed their local tap water was safe or were neutral regarding the safety. When the data were fitted to a multivariable model, the relationship between mistrust of local tap water with daily SSB intake was significantly modified by race/ethnicity (p=0.007 for tap water/race interaction). The adjusted odds of consuming ≥1 SSB/day among Hispanics who mistrusted their local tap water was twice that of Hispanics who did not (Odds Ratio [OR]=2.0) and mistrust of local tap water was negatively associated with SSB intake among those of non-Hispanic other races. Overall, 18.5% of participants reported drinking ≤1 glass or bottle/day of plain water. Hispanics, blacks, and those of non-Hispanic other races who disagreed that their local tap water was safe to drink were all significantly more likely to drink ≤1 glass or bottle/day of plain water (22.8% vs. 12.3% among Hispanics; 45.3% vs. 15.1% among blacks; 52.5% vs. 17.5% among other races). This relationship was not seen among non-Hispanic whites. When the data were fitted to a multivariable model, the relationship between mistrust of local tap water with low water intake was significantly modified by race/ethnicity (p<0.0001 for interaction). The adjusted odds of low plain water intake was approximately twice as high (OR=1.9) among Hispanics who disagreed their local tap water was safe and over four times as high among blacks (OR=4.2) and those of Non-Hispanic other races (OR=4.7) who disagreed their local tap water was safe.

Table 2. Associations of perceptions of tap and bottled water safety with daily intake of sugar-sweetened beverages and low intake of plain drinking water^a.

	Local tap water perceptions “My local tap water is safe to drink”		Bottled water perceptions “Bottled water is safer than tap water”
	Disagree	Agree/neutral	Agree	Disagree/neutral
	Prevalence of daily SSB intake (≥1 time/day)
All respondents	34.7%*	29.1% *	33.2% *	28.7% *
Hispanic	45.6%*	28.8%*	36.2%	29.5%
White, non-Hispanic	30.0%	27.2%	30.6%	26.6%
Black, non-Hispanic	43.1%	37.3%	31.5%*	43.1%*
Other, non-Hispanic	24.2%	39.2%	46.9%*	30.4%*
	Multivariable ORs for daily SSB intake (≥1 time/day)b
All Respondents	1.1 (0.9, 1.4)	1.0 (Reference)	1.1 (0.9, 1.3)	1.0 (Reference)
Hispanic	2.0 (1.2, 3.3)	1.0 (Reference)	1.3 (0.9, 1.9)	1.0 (Reference)
White, non-Hispanic	1.0 (0.7, 1.3)	1.0 (Reference)	1.1 (0.9, 1.4)	1.0 (Reference)
Black, non-Hispanic	1.3 (0.8, 2.1)	1.0 (Reference)	0.6, (0.4, 0.8)	1.0 (Reference)
Other, non-Hispanic	0.4 (0.2, 0.9)	1.0 (Reference)	2.0 (1.1, 3.8)	1.0 (Reference)
	Prevalence of low plain water intake (≤1 time/day)
All Respondents	25.8%*	17.4%*	19.5%	18.1%
Hispanic	22.8%*	12.3%*	12.1%	15.0%
White, non-Hispanic	16.7%	18.8%	18.1%	18.7%
Black, non-Hispanic	45.3%*	14.1%*	22.5%	18.8%
Other, non-Hispanic	52.5%*	17.5%*	37.4%*	15.9%*
	Multivariable ORs for low plain water intake (≤1 time/day)b
All Respondents	1.5 (1.2, 1.9)	1.0 (Reference)	1.0 (0.8, 1.2)	1.0 (Reference)
Hispanic	1.9 (1.1, 3.5)	1.0 (Reference)	0.7 (0.4, 1.3)	1.0 (Reference)
White, non-Hispanic	0.8 (0.6, 1.2)	1.0 (Reference)	0.9 (0.7, 1.2)	1.0 (Reference)
Black, non-Hispanic	4.2 (2.4, 7.3)	1.0 (Reference)	1.1 (0.6, 1.9)	1.0 (Reference)
Other, non-Hispanic	4.7 (2.2, 10.1)	1.0 (Reference)	1.8 (0.9, 3.6)	1.0 (Reference)

^*Chi-square p<0.05 for difference in proportions in SSB or water intake according to water perception.

^aAll interactions between race and tap water and between race and bottled water were significant except for interaction between race and bottled water perception on low water intake.

^bORs where the CI does not include 1.0 denote significant findings based on the 95% CI. ORs are adjusted for age, sex, income, education, race/ethnicity, regions of country, physical activity level, and diabetes. Odds ratios for “All Respondents” are derived from adjusted models that do not include interaction terms.

Association of Bottled Water Perceptions with SSB and Plain Water Intake

Results of the association of bottled water perceptions with SSB and plain water intake are shown in Table 2. The percentage of participants who consumed ≥1 SSB/day was significantly greater among those of non-Hispanic other races who believed bottled water was safer than tap water (46.9% vs. 30.4%, p=0.01) but lower among blacks who believed bottled water was safer than tap water (31.5% vs. 43.1%, p=0.02). These relationships remained significant after adjustment and there was significant effect modification of favoring bottled water on SSB intake by race/ethnicity (p=0.002). The belief that bottled water is safer than tap water was not significantly associated with low intake of plain water and this relationship was not modified significantly by race/ethnicity (p=0.2 for interaction).

In supplemental analysis, low intake of plain water was significantly associated with consumption of ≥1 SSB/day (adjusted OR=1.5; 95% CI: 1.2, 1.8) (data not shown). In sensitivity analysis of the classification of water perceptions, the direction of race-specific odds ratios for SSB intake and low plain water intake were unchanged and the magnitude of odds ratios were similar when neutral responses for water perception questions were removed from reference categories (results not shown).

Discussion

The results of this study suggest that 1 in 8 Americans disagree that their local tap water is safe to drink and 1 in 4 believe that bottled water is safer than tap water. Both disagreement with the safety of local tap water and the belief that bottled water is safer than tap water varied by region of the country and were more common among younger adults, lower socioeconomic status populations and non-white racial/ethnic groups. The study also found significant racial/ethnic differences in how water safety perceptions relate with consumption of plain water and SSB. Specifically, disagreement with the safety of local tap water was associated with low intake of plain water among all non-whites, including Hispanics, blacks, and those of non-Hispanic other races but was associated with greater probability of SSB intake only among Hispanics. However, the belief that bottled water is safer than tap water was not associated with low plain water intake and was associated with greater probability of SSB intake only among those of non-Hispanic other racial/ethnic groups.

Previous studies have suggested that concerns regarding tap water safety vary significantly by region¹² and are more common among young adults¹² and minority populations.^{11, 18, 19} In particular, Hobson et al. found that among those surveyed, 42% of low-income Latinos served by a public health clinic in Salt Lake city avoided tap water because they believed it caused illness compared to only 12% of non-Latinos served by the same clinic.¹⁸ Likewise, Gorelick et al. found that perceptions of bottled water being cleaner and safer than tap water were two to three times more common among blacks and Latinos as compared to non-Hispanic whites surveyed at a pediatric hospital in Wisconsin.¹¹ Finally, a survey of predominantly black adolescents and caregivers at pediatric practices in Philadelphia, found that study participants rated the taste, clarity, purity, and safety of bottled water higher than tap water.¹⁹ According to the United States Environmental Protection Agency, approximately 96% of Americans are served by community water systems.20 Of the population served by these systems, fewer than 10% are served by systems that report health-based violations in any given year.²⁰ Unfortunately, although there are several case reports of water infrastructure disparities, there is a paucity of data regarding systematic disparities in drinking water access and quality.²¹ To our knowledge, this is the first study to examine the relationship between perceptions of tap water safety and intake of SSB and plain water. However, there is qualitative evidence to suggest that water safety concerns may lead Hispanics to consume more SSB when filtered or bottled water is not available.²² and previous studies have shown that water quality concerns are associated with bottled water use^{12, 13} Regarding the association between water intake and SSB intake, previous research using NHANES data has shown that intake of plain water, as measured by in-person interview using measurement guides, is inversely correlated with intake of other beverages and added sugar intake⁸ but did not find significant differences in plain water intake according to racial/ethnic group.⁸

There are several limitations to this cross-sectional study. First, the findings may not be generalizable nationally because of selection bias associated with the use of a convenience sample from a mail panel survey with a relatively low response rate. However, a previous study has shown that certain items from HealthStyles (e.g., health conditions, attitudes, and behaviors) are comparable to the Behavioral Risk Factor Surveillance System, which uses probability-sampling technique.²³ Second, the HealthStyles data are self-reported and the SSB and water intake data used in this study are based upon single question survey items, which may result in misclassification. Furthermore, measurement of water intake remains a challenge for all researchers and there is a lack of validated instruments for this purpose.²⁴ We also did not have specific data on intake of bottled water or artificially sweetened beverages, which would have been useful in further exploring how tap water perceptions impact beverage choices. Third, because of the somewhat limited number of categories of race/ethnicity, it is also difficult to interpret associations observed with subjects whose ethnicity was classified as non-Hispanic other. Similarly, it was not possible to ascertain if racial/ethnic differences in associations observed were further modified by country of birth or acculturation because this information was not collected in the survey. Finally, our research highlights the importance of how perceptions of tap water are ascertained and classified. Specifically, large differences were observed in the prevalence of local tap water safety mistrust (13% overall) and prevalence of the belief that bottled water was safer than tap water (26% overall) as well as differences in the associations of these variables with SSB and water intake. Clearly, methodological research on the measurement of tap water safety perceptions is warranted.

In conclusion, our study suggests that mistrust of local tap water safety is common and varies by age, income, education, region, and race/ethnicity. Mistrust of tap water safety could be a risk factor for SSB intake among Hispanics and may result in low intake of plain water among many minority populations. Given the relatively common prevalence of this belief among Hispanics suggested by this and other studies,^{10, 11} concerns regarding tap water safety may be an important determinant of SSB intake among Hispanics. Public health efforts to decrease intake of SSB through promotion of plain drinking water should recognize the role of perceptions regarding tap water safety on water and SSB intake among minority populations.

Abbreviations

SSB

Sugar Sweetened Beverages

NHANES

National Health and Nutrition Examination Survey

OR

Odds Ratio

CI

Confidence Interval