Lack of in-home piped water and reported consumption of sugar-sweetened beverages among adults in rural Alaska

Abstract

Introduction:

According to the World Health Organization, 29% of people in the world did not have access to safely managed drinking water in 2015.⁽¹⁾ In low- and middle- income countries, lack of access to improved water sources and sanitation has been associated with infectious disease and poor child growth.^{(2, 3)} Even in the United States, some areas do not have full coverage of in-home piped water. In 2017, at least 15% of occupied housing units in rural Alaska lacked in-home plumbing. ⁽⁴⁾ The lack of access to piped water service is a particular problem in remote communities that are reachable only by airplane or boat. In these communities, not having piped water has been associated with added risk of numerous infectious diseases, including respiratory hospitalizations in children, skin infections, gastrointestinal infections, and invasive pneumococcal disease.^(5-7) In addition to infectious diseases, there may be additional unknown health risks associated with not having access to in-home drinking water. Studies in other regions have found associations between inadequate water supply and stress,⁽⁸⁾ musculoskeletal injuries,⁽⁹⁾ and gastric cancer risk. ⁽¹⁰⁾

Qualitative research has shown that individuals experiencing water scarcity may conserve water by consuming sugar-sweetened beverages (SSBs).⁽¹¹⁾ SSBs are defined as any beverage with added caloric sweetener, including regular soda, sweetened juices (eg. Tang® or Kool-Aid®), sweet tea and sports/energy drinks. ^{(12, 13)} In the United States, 30.1% of respondents report consuming at least one SSB per day, with the prevalence ranging from under 20% in some states in the northeast to over 40% in the southeast. ⁽¹⁴⁾ In several large and repeated studies, frequent consumption of SSBs has been associated with obesity, cardiovascular disease, metabolic disorders, dental decay, and other chronic conditions. ^(15-18)

In rural Alaska, studies have found that over 50% of adults consume sugar sweetened beverages at least once per week.⁽¹⁹⁾ However, to our knowledge, the association between lack of water access and SSB consumption has not been studied quantitatively. In this analysis of Behavioral Risk Factor Surveillance System (BRFSS) and water utility data, we evaluated whether rural Alaska residents in communities without in-home piped water service reported different frequencies of SSB consumption than residents of communities with in-home service. We also assessed if residents without in-home piped water service had a different prevalence of health outcomes that could be related to SSB consumption, including obesity or self-reported poor health.

Methods:

Results:

After excluding urban areas, hub communities, and communities on the statewide road or marine highway system, 887 rural Alaskans over age 25 years participated in the 2013 and 2015 BRFSS. Slightly more participants were female (430, 52%) and the mean age was 48 years. Of these participants, 733 (83%) lived in 102 zip codes with piped water and 154 (17%) lived in 28 zip codes without piped water. Among participants with in-home piped water, 43% reported completing some college or higher and 39% reported household annual income of over $50,000 (Table 1). Among participants without in-home piped water, 27% reported completing some college or higher and 22% reported household annual income of over $50,000 (Table 1).

Overall, 37% of participants reported drinking SSBs at least once per day, and participants reported drinking SSBs a mean of 8.5 times per week. Participants in communities with in-home piped water reported a mean SSB consumption frequency of 7.8 times per week while participants in communities without in-home piped water reported a mean frequency of 12.5 times per week. Overall, those who reported higher frequency of SSB consumption were younger, had lower household income, and lower formal education (Table 2).

In the unadjusted model, respondents who lived in a community without in-home piped water reported consuming SSBs 46% more often than those who lived in a community with in-home piped water (unadjusted exp β 1.46, 95% CI 1.29, 1.67, p=0.02). After adjustment for age, income, and education, the size of the effect decreased (adjusted exp β 1.29, 95% CI 1.00, 1.67, p=0.05; Table 3).

In an unadjusted overall model, residence in a community without in-home piped water was not associated with obesity (adjusted exp β 1.22, 95% CI 0.81, 1.83, p=0.36; Table 3). This did not change after adjustment for confounders. In unadjusted and adjusted models, participants in communities without in-home piped water were significantly more likely to report fair/poor general health (adjusted exp β 1.63, 95% CI 1.05, 2.54, p=0.04).

Three zip codes with 31 participants were considered to have “mixed” service. All three were coded as having in-home piped water based on the criteria listed above, but included some participants in communities with washeterias or watering points. In sensitivity analyses where we removed these zip codes, no meaningful changes were observed in the models described above (data not shown).

Discussion:

Within the United States, rural Alaskans have the lowest access to in-home piped water service and experience a concordantly high burden of infectious disease.⁽⁶⁾ However, the burden of infectious disease might not capture the full picture of the outcomes of lack of water access within rural Alaska or elsewhere. We evaluated whether a lack of water service in rural Alaska was also associated with frequency of SSB consumption and other chronic disease outcomes. We found that rural Alaskans who lived in communities without in-home piped water may consume SSBs more frequently than those who lived in communities with in-home piped water service. Our findings contribute to the growing literature on the non-infectious disease risk factors associated with inadequate access to reliable, clean, water within the home^(8,9,27)

The linkage between lack of in-home water service and infectious disease risk in Alaska has been well described.⁽²⁸⁾ However, the relationship between in-home water service and SSB consumption is not well documented. There are several potential reasons that residents of communities without in-home piped water service might drink SSBs more often than those in communities with in-home piped water. Self-hauling water is time-consuming, and the amount brought into the home is often directly related to a household’s access to a vehicle and the presence of an able-bodied male household member.^{(29, 30)} If water is not easily accessible, people may decrease their water consumption and increase their consumption of other beverages. Recently a quasi-experimental study in schools in New York City showed that providing accessible water jet dispensers led to decreases in student BMI, ostensibly due to the consumption of water rather than other beverages.⁽³¹⁾ However, more research is necessary to evaluate the precise reasons that residents of communities without in-home piped water service consumed SSBs more frequently than those in communities with in-home piped water.

In this analysis, frequency of SSB consumption was associated with age, household income, and education level. Other studies of SSBs have found similar patterns, demonstrating that younger people, men, those with lower income, and those with less formal educational attainment are likely to drink SSBs more frequently.^{(14, 32, 33)} In rural Alaska, several factors could also influence the choice to drink SSBs, regardless of water accessibility. For example, prior studies have shown that some residents in these communities distrust the safety of treated water and/or are not satisfied with its quality (including color and taste).^{(20, 21)} Across the United States, trust of water sources has been shown to impact behavior around water consumption, especially among minorities ^(34-36). Therefore, rural residents might perceive that consuming beverages from bottles or cans is safer than consuming tap water. The use of sugar-sweetened mixes such as Tang ® could offer a more palatable way to consume treated water. Further, SSBs may be cheaper than bottled water in these communities, possibly contributing to higher consumption.

Not having in-home piped water service was not significantly associated with obesity in this analysis. Although the association between drinking SSBs and obesity has been well-described in other contexts,⁽¹⁵⁾ there could be aspects of living in communities without piped water that are protective against weight gain. For example, in Yupik communities, hauling water is conducted primarily by men and boys and could serve as a form of physical activity.⁽²⁰⁾ Communities without piped water could also differ from those with piped water by other activities related to exercise and diet, such as the types and frequencies of hunting or other physically-demanding subsistence activities. Unfortunately we were not able to assess these other factors in the current analysis. Further research on obesity in communities without piped water is warranted.

Living in a community without in-home water was associated with a higher proportion of respondents reporting fair or poor general health in this analysis. This association could reflect that residents experienced a variety of poor health outcomes associated with lack of water access, including infectious diseases.

This analysis has a few limitations. First, these data sources are cross sectional, which affects the interpretability of temporal associations. Second, there may be some misclassification of water service exposure on the individual level. For example, in communities that have a piped water system, some households might still use point water sources. Therefore, the exposure in this analysis only represents a community-wide exposure to water service infrastructure. Additionally, the BRFSS data are self-reported, so responses are subject to inaccuracies. For example, self-reported height and weight often result in an underestimate of obesity.⁽³⁷⁾ However, we would not expect this underestimate to be differential between communities with and without piped water. Furthermore, the BRFSS requests information on the frequency of SSB consumption, but does not include an estimate of volume. Similarly, sugar-sweetened coffee drinks are not included in the measure. These issues could lead to a misrepresentation of the amount of SSBs consumed, although we also do not expect this to be differential between communities. Additionally, although rural Alaska was oversampled in the BRFSS, the number of participants who were classified as living in a community without piped water was small. The small sample size likely resulted in insufficient power to detect some significant differences, and possibly the borderline significance in the overall result.

Confounding is an important consideration illuminated by this analysis. Respondents from communities with and without piped water were markedly different according to their reported demographics. Furthermore, the changes to the effect estimates after adjustment demonstrated that confounding by socio-economic status, age, and race existed in the association between piped water and drinking SSBs. There may be residual confounding or additional confounding by other factors that were not measured. Accordingly, the associations seen here warrant further investigation in other datasets and prospective analyses.

Conclusions

Recent studies have shown that disparities exist across the United States in terms of clean tap water access and consumption.^{(38, 39)} Our analysis suggests that residents who lived in communities without in-home piped water may drink SSBs more frequently than those who lived in communities with in-home piped water. Although lacking piped water was not significantly associated with obesity in this analysis, a higher frequency of SSB consumption could lead to a number of other chronic disease outcomes and may have contributed to the association between lack of water and reported poor health. Access to in-home clean water is a key component to maintain optimal health in rural Alaska.

Acknowledgments

Footnotes

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