In a national survey of lower-income United States adults, indicators of water insecurity were found to be associated with lower diet and beverage quality.

Although water quality is regulated for public water systems in the United States (US), these systems are challenged with aging infrastructure, violations of health-based regulatory standards, and financial issues. These issues may disproportionately affect racially minoritized and low-resource, structurally marginalized communities fueling public tap water distrust and avoidance. Tap water avoidance has recently been proposed as a proxy for water insecurity in the United States. However, no known studies have evaluated how perceptions of drinking water safety and other measures of water insecurity are associated with overall dietary quality in the United States.

To bridge this knowledge gap, Drs. Slotnick and Leung (The University of Michigan School of Public Health and Harvard T.H. Chan School of Public Health, respectively) evaluated associations between 3 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 US adults.

A cross-sectional, web-based survey was sent to 1,789 US adults with incomes <250% federal poverty guidelines. Survey respondents answered questions detailing tap water safety perceptions and avoidance, beverage intake, dietary intake frequency, and sociodemographic information.

Over one-half of the adults reported some aspect of water insecurity, with 48% of participants reporting they did not agree that their tap water was safe to drink. Measures of water security differed significantly by sociodemographic variables, 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. Measures of water insecurity were associated with lower diet quality scores, lower tap water intake, higher bottled water intake, and higher sugar-sweetened beverage intake.

Proxies of water insecurity associated with poorer diet quality and beverage intake, provide insight into the possible role of water insecurity in the United States on dietary patterns and habits in lower-income adults. Although fueled by distrust and taste-focused concerns in this population, the extent of water insecurity in the United States is only beginning to emerge.

In comparing different previously used measures of water avoidance and trust, this research bridges the literature on water insecurity and nutritional research.

In a companion commentary, Drs. Rosinger and Broyles (Pennsylvania State University) further elaborate on the impact of water insecurity on diet quality and highlight future avenues to move water insecurity nutrition-related research forward.


Slotnick MJ and Leung CW. Water Insecurity Indicators Are Associated with Lower Diet and Beverage Quality in a National Survey of Lower-Income United States Adults. The Journal of Nutrition, Volume 153, Issue 11, November 2023, Pages 3308-3316,

Rosinger AY and Broyles LMT. Water Insecurity Is a Structural, Often Invisible Barrier to Healthy Beverage Patterns and Nutritious Diets. The Journal of Nutrition, Volume 153, Issue 11, November 2023, Pages 3153-3155,

Images via