Tap water stands at the intersection of multiple issue areas including water resources, the environmental impacts of beverage choices, and infrastructure needs. Tap water is also a public health issue. COVID-19, for example, has elevated the need for tap water access for basic hygiene such as handwashing.
The University of California, Agriculture and Natural Resources Nutrition Policy Institute (NPI), coordinator of the National Drinking Water Alliance, puts a focus on plain water as a healthy replacement for sugar-sweetened beverages. These beverages are the largest single source of added sugars in the American diet, a top source of calories, and a risk factor for numerous chronic diseases. However, concerns about tap water safety and barriers to access present challenges to making water the beverage of choice.
Lorrene Ritchie and Christina Hecht of NPI are among the co-authors of “Drinking Water in the United States: Implications of Water Safety, Access, and Consumption,” a new paper published online in Annual Review of Nutrition. The authors use a socioecological lens – considering the complex web of individual, relationship, community, and societal factors – to review the dynamics of drinking water consumption. This socioecological framework elucidates myriad factors that bear on the ability to drink tap water, including disparities in safety, access, and consumption.
A brief review of the evidence comparing current trends in drinking water intake in the U.S. to requirements across age and racial/ethnic groups reveals that most people do not drink enough plain water. While fluids can come from a variety of sources, there are many benefits of choosing water over sugar-sweetened beverages. Primary among these are the health benefits. Consumption of sugar-sweetened beverages increases the risk of cardiovascular diseases, type 2 diabetes, fatty liver disease and other metabolic diseases, dental decay, certain cancers, and risk of mortality. In addition, water, especially tap water, is not only a healthy form of hydration but is affordable, has a smaller environmental footprint, and, often, is fluoridated to strengthen and protect tooth enamel.
However, to enable tap water consumption, U.S. tap water safety must be ensured. While most U.S. tap water meets federal and state standards, there are times and places where it does not. The paper makes policy recommendations to improve tap water safety in the U.S. For example, lead in drinking water remains a concern. As the authors note, “drinking water can represent 20% or more of an individual's total lead exposure” and the potential lead exposure for infants fed with formula made of powder reconstituted with tap water is a particular concern.
Regulatory mechanisms to reduce lead in drinking water include federal, such as the Lead and Copper Rule, and state, such as mandates for testing for lead in school or childcare tap water. Challenges to detecting and reducing lead in tap water range from the building-specific nature of lead in plumbing to the lack of consensus on an acceptable level of lead in drinking water. Strategies to reduce drinking water exposure to lead include, as examples, the San Francisco Public Utilities Commission program to provide no-charge home tap water lead testing for families in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC, a federal child nutrition program) and efforts in cities to remove and replace both the utility-owned and privately-owned portions of all lead service lines.
Crucially, the authors' advance the concept of “effective access” to drinking water, which includes not only physical elements but also strategies for drinking water education and promotion. They write: “Effective drinking water access is necessary to maximally promote consumption. Key components include safety and aesthetics of drinking water; characteristics, features, location, and placement of drinking water sources; upkeep and maintenance; availability of drinking vessels; and water-related education and promotion.”
Each of these components is reviewed with a discussion of strategies to achieve effective access across the lifecourse from pregnancy and infancy to older adulthood, focusing primarily on U.S. settings but including approaches from other countries. Recommendations for research, policies, and practices needed to ensure optimal water intake by all include protecting watersheds and sourcewater from contamination by industry, agriculture, and other human activities; enhancing oversight of public water systems; and supporting increased capacity among small and rural water systems.
It is also important to improve infrastructure from public water systems to taps; establish a health-based standard for lead from taps in homes, schools, and childcare facilities; issue U.S. Department of Agriculture (USDA) guidance for monitoring tap water safety and remediation in schools and childcare facilities that participate in federal nutrition programs; and disseminate best practices for school districts and childcare providers to resolve water quality issues. Furthermore, there is a need to counter misperceptions of tap water safety and place accurate information about water quality within a broader context of costs and relative risks so that consumers can make more informed beverage choices.
Access to appealing drinking water can be improved by strategies including requiring USDA monitoring of effective access to water in schools and childcare facilities that participate in federal nutrition programs (rather than simply the presence of a water dispenser); ensuring effective water access in all public settings (e.g., public buildings, parks) in addition to workplaces and restaurants; and reducing access to unhealthy beverages (e.g., sugar-sweetened beverages).
Finally, there is a need to emphasize drinking water in the Dietary Guidelines for Americans, including prominently featuring water on public-facing nutrition materials such as the MyPlate graphic, the ubiquitous nutrition-education tool in U.S. The new 2020-2025 Dietary Guidelines for Americans are currently in development. Enabling consumption of water – that is, making tap water safe, accessible, and appealing -- is an essential complement to work to discouraging consumption of sugar-sweetened beverages.
The review was published online in September 2020 by the journal Annual Review of Nutrition. Authors are Anisha Patel of Stanford Medicine Division of General Pediatrics, Christina Hecht and Lorrene Ritchie of University of California Nutrition Policy Institute, Angie Cradock of Harvard T.H. Chan School of Public Health, and Marc Edwards of Virginia Polytechnic Institute and State University. For more drinking water information and resources, visit the National Drinking Water Alliance, coordinated by the Nutrition Policy Institute.