Research Article

Associations Among Chronic Disease Status, Participation

in Federal Nutrition Programs, Food Insecurity, and
Sugar-Sweetened Beverage and Water Intake Among
Residents of a Health-Disparate Region
Brenda M. Davy, PhD, RD1; Jamie M. Zoellner, PhD, RD1; Clarice N. Waters, PhD2;
Angela N. Bailey, MA1; Jennie L. Hill, PhD1

ABSTRACT
Objective: To determine whether sociodemographic characteristics, food security status, participation in
federal nutrition programs (Supplemental Nutrition Assistance Program [SNAP] or Special Supplemental
Nutrition Program for Women, Infants, and Children [WIC]), and chronic disease status were associated
with adherence to water and sugar-sweetened beverage (SSB) intake recommendations.
Design: Cross-sectional, random-digit phone survey with questions from the Behavioral Risk Factor
Surveillance System and beverage intake questionnaire.
Participants: Residents of a medically underserved, rural area.
Main Outcome Measures: Water and SSB intake.
Analysis: Descriptive statistics, chi-square and 1-way ANOVA, and linear and logistic regression.
Results: The sample consisted of 930 respondents (aged 56
17 years; 35% non-white); reported food
insecurity and SNAP and WIC participation were 37%, 29%, and 8%, respectively. Prevalent health con-
ditions included overweight/obesity (69%), diabetes (19%), and hypertension (45%). Water recommen-
dations were more likely to be met (72%; mean intake, 31
19 fluid oz) than SSB (41%; mean intake,
246
297 kcal). Food insecurity and SNAP/WIC participation were not associated with meeting recom-
mendations, but those reporting $ 1 chronic disease were more likely to meet SSB recommendations (odds
ratio, 2.42; P ¼ .02).
Conclusions and Implications: Odds of achieving SSB but not water recommendations were greater
among individuals with a chronic disease. Efforts to communicate beverage recommendations to at-risk
groups are needed.
Key Words: rural, health disparities, diabetes, beverages, water (J Nutr Educ Behav. 2015;47:196-205.)
Accepted January 2, 2015. Published online February 9, 2015.

INTRODUCTION Healthy and Fit Nation recommends which could represent a barrier to
that individuals drink more water adhering to the DGA. Yet the recom-
Increased water consumption is instead of SSB.4 ‘‘Drink water instead mendation to consume water in place
associated with healthier weight sta- of sugary drinks’’ is 1 of the 7 key of SSB could represent a cost savings
tus, and sugar-sweetened beverage selected messages for consumers by for individuals with access to potable
(SSB) (eg, soda, sweetened tea, juice the Dietary Guidelines for Americans tap water (ie, tap water has little or
drinks) consumption is associated (DGA), 2010.5 There is evidence6 no cost). Targeted dietary messages,
with increased risk of diabetes and supporting the perception that particularly those that are sensitive
other obesity-related diseases.1-3 consuming a healthy diet is more to social and economic issues, are crit-
The Surgeon General’s Vision for a expensive than the alternative,7 ical to promoting lifestyle changes
that reduce the risk of obesity and
related chronic diseases.8
1
Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, VA The Institute of Medicine has
2
Saw Swee Hock School of Public Health, National University of Singapore, Singapore acknowledged the importance of ad-
Conflict of Interest Disclosure: The authors’ conflict of interest disclosures can be found online dressing disparities in obesity rates
with this article on www.jneb.org. among population subgroups9 such
Address for correspondence: Brenda M. Davy, PhD, RD, Department of Human Nutri- as rural, low–socioeconomic status
tion, Foods, and Exercise, 221 Wallace Hall 0430, Virginia Tech, Blacksburg, VA 24061; (SES) populations. Higher risk of heavy
Phone: (540) 231-6784; Fax: (540) 231-3916; E-mail: bdavy@vt.edu SSB consumption occurs among low-
Ó2015 Society for Nutrition Education and Behavior. Published by Elsevier, Inc. All rights SES populations10 and subgroups at
reserved. greatest risk of obesity and diabetes
http://dx.doi.org/10.1016/j.jneb.2015.01.001 (ie, blacks, Mexican Americans), and

196 Journal of Nutrition Education and Behavior  Volume 47, Number 3, 2015

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Journal of Nutrition Education and Behavior  Volume 47, Number 3, 2015
those with lower health literacy and
education level are more frequent SSB
consumers.11-13 Higher rates of SSB
consumption have also been reported
among males compared with females
and among young adults compared
with older adults.14 Studies of nation-
ally representative samples have asso-
ciated low water consumption with
older age (ie, $ 55 years) and less
healthy lifestyle behaviors.15 Others
have reported that low-income urban
populations consume about 33 and
20 fluid oz of water and SSB,
respectively, and that rural adults
consume more SSB than their urban
counterparts.16,17 Tap water quality
may have a role; concerns about tap
water safety have been reported
among rural, low-SES populations.18
However, water consumption has
been associated with numerous
health benefits19 including reductions
in fasting glucose and a greater odds
of achieving clinically meaningful
(ie, 5%) weight loss,20 and less weight
gain over time when consumed
instead of juices or SSB.21
Related to demographic influences,
participation in the Supplemental
Nutrition Assistance Program (SNAP)
may affect beverage consumption pat-
terns, and differences by sex and race
have been reported. Specifically, fe-
male SNAP participants consumed
about 60% more SSB than low-
income female non-participants, but
SNAP participation was positively
associated with water consumption
among males and blacks.22 Yet find-
ings may differ among nationally
representative samples compared
with rural, health-disparate popula-
tions. Participation in SNAP was not
associated with SSB consumption but
it was associated with a higher
Healthy Eating Index score among
those living in a rural, health dispa-
rate region.12 Food insecurity could
influence SSB consumption.17 The
extent to which chronic disease status
is associated with adherence to wa-
ter23 and SSB intake guidelines is also
unclear. Understanding these associa-
tions at a regional level may assist in
developing targeted intervention
strategies that extend beyond
individual-level consumers, to pro-
mote awareness of beverage recom-
mendations among health care
providers who are treating those
with chronic diseases, or among pub-
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lic health nutritionists who provide
nutrition education to individuals
receiving public assistance (ie, SNAP,
Special Supplemental Nutrition Pro-
gram for Women, Infants, and Chil-
dren [WIC] benefits). Hospitals and
health care providers are considered
important partners in promoting
healthy eating behaviors in rural
communities.24 Although water and
SSB intake has been reported in na-
tionally representative samples,15,25
few studies have addressed water and
SSB consumption among rural adults
in health-disparate regions. The extent
that current beverage intake recom-
mendations are being met has not
been evaluated in this population
segment. Although national epidemi-
ological data are important in identi-
fying broad health concerns, these
data often hold little relevance to local
stakeholders, health professionals,
and workers in community-based ini-
tiatives who are trying to prioritize
strategies aimed at improving health.
The Dan River Region, an educa-
tionally and economically disadvan-
taged region in south central Virginia
and north central North Carolina, is
characterized by high rates of unem-
ployment, low educational attain-
ment, and high indices of chronic
disease.26 This predominantly rural re-
gion includes 3 counties (about 1,800
square miles [4.7 billion square me-
ters]) anchored by a regional city (44
square miles [114 million square me-
ters]; population of 45,000) and it is a
federally designated medically under-
served area/population. Since 2009,
a community–academic partnership,
the Dan River Partnership for Healthy
Communities (DRPHC) has been work-
ing in the region using a community-
based participatory process. After the
development of locally developed
ecological models defining causal links
to regional obesity problems,27 an
ecological perspective was also used to
develop a regional surveillance survey.
This surveillance survey was conducted
in the region to aid coalition partners in
developing and delivering interven-
tions focused on obesity and health be-
haviors. The ecological perspective of
health recognizes multiple levels of
influences for health-related behaviors,
such as beverage consumption.28
These levels typically include at least 5
factors: intrapersonal or individual,
interpersonal factors, institutional,
Davy et al 197
community, and public policy. Ecolog-
ical perspectives recognize the inter-
dependence of these multiple levels of
influence on health behavior and
emphasize their interactions. Although
it is not practical to assess each of these
levels in depth for a surveillance survey;
according to the ecological perspective
and prior literature, the authors hy-
pothesized that both intrapersonal
and individual and public policy factors
could influence beverage consumption.
Therefore, the purpose of this investiga-
tion was to determine whether sociode-
mographic characteristics, food security
status, participation in federal nutrition
programs, and self-reported chronic
disease status were associated with
adherence to water and SSB intake rec-
ommendations among individuals
from the rural, health-disparate Dan
River Region.
METHODS
Study Area and Population
Since 2009, a community–academic
partnership, DRPHC, has been working
in the region using a community-based
participatory process. To aid coalition
partners in developing and delivering
interventions focused on obesity and
health behaviors, a surveillance survey
was conducted in the region. Before
its initiation, this project was approved
by the Virginia Tech institutional
review board. A professional survey
unit was contracted to conduct a tele-
phone survey of residents using 2
sampling frames including listed and
unlisted landlines and cell phone
numbers: (1) a random proportional
sampling frame based on the popula-
tion of the 3 counties and the regional
city, and (2) a targeted nonrandom
sample recruited from residents living
in government-sponsored housing. A
toll-free number was provided for pub-
lic housing residents to call into the
survey unit at their convenience to
complete the survey. The survey was
conducted in English and took approx-
imately 25 minutes to complete. All par-
ticipants received a $20 gift card for
completing the telephone survey. The
survey unit conducted a pretest of the
survey within the region (n ¼ 22). Feed-
back from the pilot test resulted in mi-
nor adaptations to the wording and
flow of the survey and clarifications to
instructions for the survey unit staff,
198 Davy et al
but no changes to survey content. Re-
sults from the pilot test were not signif-
icantly different from the full sample;
therefore, the pilot respondents were
included in the current analysis.
Measures
Modeled after the Behavioral Risk
Factor Surveillance System, the tele-
phone survey consisted of 10 modules
that included questions on health
status, food security/food assistance,
water and SSB consumption, and socio-
demographic characteristics. Survey
questions applied to the respondent
and not other household members. A
description of the modules used is
detailed below.
Sociodemographics module. The re-
searchers included 10 questions to
obtain demographic information (ie,
age, gender, race [white, black, Asian,
Native Hawaiian, or American Indian],
education, income, employment, and
marital status).29 Age categories were
determined using a tertile split. Race
was dichotomized as white and
black/other to account for empty or
very low counts in cells among other
racial categories within the region
(eg, Asian, Native American). Analyses
were conducted with no difference in
interpretation using the categorical
or dichotomized version of race and
the dichotomized version reported.
Based on geocoded street addresses,
participants were categorized as living
in public housing, living in urban
areas within the city limits but not in
public housing, or living in a rural
area outside city limits.
Food security and food assistance
module. The validated, 6-item, short
form of the US Household Food Secu-
rity Survey Module assessed food inse-
curity during the past year.30 For
analyses, household food security was
dichotomized, combining very low
and low food security as food inse-
cure.30 Two single item questions
from the Current Population Survey
Food Security Supplement were used
to assess the use of food and nutrition
assistance programs in the past year,
including SNAP and WIC.
Weight status. Body mass index
(BMI) was calculated from
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Journal of Nutrition Education and Behavior  Volume 47, Number 3, 2015
reported height and weight converted
to kilograms per square meter.
Normal weight was categorized as
BMI ¼ 18–24.9, overweight as BMI
¼ 25–29.9, and obese as BMI $ 30.31
Chronic health conditions module.
Ten questions from the 2011 Behav-
ioral Risk Factor Surveillance System
diabetes, hypertension awareness, car-
diovascular disease prevalence, and
tobacco use modules were included29
to assess health conditions of partic-
ular interest in the region. Variables
were dichotomous as yes/no for each
chronic disease indicator. Respon-
dents were categorized as having at
least 1 chronic condition if they re-
ported yes to $ 1 obesity-related
chronic disease diagnosis. Respon-
dents with $ 2 obesity-related condi-
tions were also categorized if they
responded yes to $ 2 chronic condi-
tions (ie, smoking, myocardial infarc-
tion, cardiovascular disease, stroke,
diabetes, hypertension).
Beverage consumption module.
Items from a valid and reliable
beverage questionnaire (BEVQ-15)
were used to assess an individual’s
consumption of water and SSB intake
(in fluid ounces and energy in
kilocalories).32 Participants responded
with frequency of consumption and
portion size for each type of beverage
(ie, plain water included tap or bottled,
sugar-sweetened beverages [non-diet])
and survey administrators used the
following beverage portion descrip-
tors as prompts for portion size re-
sponses: < 6 fluid oz (0.75 cup): for
example, the size of a small juice box
or juice glass; 8 fluid oz (1 cup): for
example, the size of a school milk
carton; 12 fluid oz (1.5 cups): for
example, the size of a regular can of
soda; 16 fluid oz (2 cups); and > 20
fluid oz (2.5 cups).
Statistical Methods
Descriptive statistics including fre-
quencies, means, and SD were
computed for covariates, as well as in-
dependent and dependent variables
(Statistical Package for Social Science,
version 20.0, International Business
Machines Corporation, Armonk, NY,
2012). Chi-square and 1-way ANOVA
self- using Bonferroni-corrected alpha levels
tested for differences between dependent
variables by sociodemographics and resi-
dency. To predict both SSB intake (kilo-
calories) and water intake (fluid
ounces), 3 multiple linear regression
models were tested, including: (1) demo-
graphics only, (2) demographics plus
food security and participation in food
assistance programs, and (3) demo-
graphics plus chronic disease status.
These models were then tested using lo-
gistic regression. Meeting recommenda-
tions for water intake was defined as >
20 fluid oz/d33; meeting recommenda-
tions for SSB intake was computed using
gender-specific general recommenda-
tions (ie, females # 100 kcal/d; males
# 150 kcal/d).2 No government-
supported quantitative drinking water
intake recommendations existed;
guidelines published by the Beverage
Guidance Panel33 represented the
only quantitative drinking water rec-
ommendations (20–50 fluid oz/d).
Therefore, 20 fluid oz was selected so
as to be conservative in terms of hav-
ing met minimum water intake recom-
mendations.
The researchers used purposeful se-
lection methods for logistic regression
to enter and test potential covariates
for the final regression models.34 In
this approach, potential covariates
are retained in the model if univariate
tests are significant at P < .25.34 These
variables were then tested in multivar-
iate models including a check for
confounding among covariates. Co-
variates that remained in the multiple
linear and logistic models included
age, gender, race, income, and
employment status. Education status
and residency were not significant co-
variates; therefore, they were not
included. All models presented in the
tables included coefficients adjusted
for covariates and significance level
set at P < .05.
RESULTS
A total of 930 participants completed
the telephone survey. One hundred
forty-six respondents were from pub-
lic housing; of the public housing res-
idents contacted, 97% completed the
survey. The remaining 784 partici-
pants were from the random-digit
dial sample (77% response rate).
Table 1 lists descriptive characteristics
of the study sample. Mean age was
Journal of Nutrition Education and Behavior  Volume 47, Number 3, 2015 Davy et al 199

Table 1. Sociodemographic Characteristics for Overall Sample of Residents of a Medically Underserved, Rural Area by Sugar-
Sweetened Beverage and Water Consumption

Sugar-Sweetened Beverage, kcala,b Water, fluid ozc

Meeting Meeting
Total Recommendations, Recommendations,
N (%) Mean ± SDa n (%)b Mean ± SDa n (%)b
Age, y
18–35 133 (15) 352.4
365 45 (34) 32.8
19 96 (73)
36–54 250 (27) 311.6
343 84 (33) 31.9
19 179 (72)
$ 55 532 (58) 191.1
237† 256 (48)† 31.0
18 379 (71)
Gender
Male 228 (25) 303.0
310 69 (38) 29.6
19 153 (67)
Female 702 (75) 227.0
290‡ 325 (45)* 32.0
19 510 (73)
Race/ethnicity
White 582 (64) 242.3
293 245 (42) 29.3
19 394 (68)
Black/other 329 (36) 253.3
302 126 (41) 34.9
19‡ 253 (77)†
Education
Less than high school 152 (16) 252.9
313 62 (41) 32.4
19 114 (75)
High school or graduate 339 (37) 256.4
303 139 (41) 30.6
19 234 (69)
equivalency diploma
Some college 287 (31) 232.3
282 127 (44) 32.3
18 213 (74)
College graduate 152 (16) 241.2
296 65 (42) 30.7
20 102 (67)
Income
< $20,000 348 (44) 277.9
323 138 (40) 31.3
20 245 (70)
$20,000–$49,999 269 (34) 248.0
268 105 (39) 31.3
19 189 (71)
> $50,000 178 (22) 233.2
320 80 (45) 32.8
19 131 (74)
Employment
Employed for wages 321 (35) 278.4
329 117 (36) 31.4
18 229 (71)
Unemployed 101 (11) 328.8
343 36 (36) 30.6
21 68 (67)
Student/homemaker 87 (9) 287.5
322 38 (44) 33.5
19 65 (75)
Retired 311 (34) 158.4
196‡ 163 (52)† 30.6
18 227 (73)
Disabled 103 (11) 299.3
319 36 (35) 33.0
20 69 (67)
Marital status
Married/living with someone 448 (49) 239.6
295 187 (42) 31.5
19 323 (72)
Divorced/separated 173 (19) 250.6
257 69 (40) 29.1
19 111 (64)
Widowed 130 (14) 172.0
243† 70 (54) 31.6
18 98 (75)
Never married 172 (18) 319.5
358 63 (37) 33.2
19 126 (73)
Residency
Public housing 146 (15) 308.2
360 57 (39) 31.9
20 103 (71)
Rural 574 (62) 237.4
287 244 (43) 31.5
19 414 (72)
Urban 210 (23) 224.6
269 93 (44) 30.7
19 146 (70)
Household food security
Food-insecure 332 (36) 298.2
333 128 (39) 32.0
19 234 (71)
Food-secure 598 (64) 216.5
271‡ 266 (45)* 31.1
19 429 (72)
SNAP
Participants 271 (29) 294.1
334 101 (37) 31.7
20 190 (71)
Not participants 659 (71) 225.7
278‡ 293 (45) 31.3
18 473 (72)
WIC
Benefits 76 (8) 381.7
44 26 (34) 30.1
19 50 (66)
No benefits 854 (92) 287.0
10† 368 (43) 31.6
19 613 (72)
Weight status
Normal 255 (29) 245.7
286 114 (45) 29.5
18 178 (70)
Overweight 308 (34) 235.3
292 138 (45) 31.3
18 214 (70)
Obese 334 (37) 260.3
315 134 (40) 33.2
19 245 (73)
(continued)

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200 Davy et al Journal of Nutrition Education and Behavior  Volume 47, Number 3, 2015

Table 1. Continued

Sugar-Sweetened Beverage, kcala,b Water, fluid ozc

Meeting Meeting
Total Recommendations, Recommendations,
N (%) Mean ± SDa n (%)b Mean ± SDa n (%)b
Chronic disease
No chronic conditions 450 (48) 277.3
318 172 (38) 30.5
19 312 (69)
$ 1 chronic condition 228 (25) 206.4
255* 108 (47)* 32.3
19 165 (72)
$ 2 chronic conditions 252 (27) 224.6
286 122 (48) 32.4
19 186 (74)
Diabetes 174 (19) 190.0
255* 93 (53)* 32.3
19 129 (74)
No diabetes 753 (81) 259.2
304 307 (41) 31.3
19 532 (71)
Hypertension 419 (45) 217.2
273* 197 (47) 32.8
19 307 (73)
No hypertension 510 (55) 269.5
313 204 (40) 30.2
19 355 (70)
Myocardial infarction/ 85 (9) 262.2
275 38 (45) 28.0
17 58 (68)
coronary artery disease
No myocardial infarction/ 845 (91) 244.0
299 384 (45) 31.7
19 605 (72)
coronary artery disease
Stroke 49 (5) 203.8
316 27 (55) 34.1
18 40 (82)
No stroke 876 (95) 248.3
296 373 (43) 31.4
19 620 (71)
Smoking status
Smoker 196 (21) 348.2
338 62 (32) 26.2
19 123 (63)
Nonsmoker 733 (79) 217.8
279‡ 340 (46)* 32.2
19† 539 (74)†
SNAP indicates Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, In-
fants, and Children.
a
Significant differences using ANOVA test for kilocalories of SSB consumed and fluid ounces of water consumed; bSignificant
differences using chi-square test for meeting SSB recommendations and meeting water recommendations; cConversion to mil-
liliters: 1 fluid oz ¼ 29.6 ml; Bonferroni-corrected significant values are reported to account for multiple tests across sociodemo-
graphics: *P < .05; †P < .01; ‡P < .001.

56
17 years (median, 58 years),
approximately one-third were black
or of another race, and most were fe-
male. More than one-third reported
income < $20,000, most were not col-
lege graduates, and about half of the
sample was married or part of a long-
term couple. Compared with US
Census data,35 the current sample
was older than the regional median
age of 43.9 years and females were
more heavily represented. The sample
was representative in terms of marital
status and income. The outlying rural
counties have a higher proportion of
white residents compared with urban
areas, which is reflected in the current
rural sample. The housing sample was
younger, predominately black fe-
males, which aligns with the demo-
graphics captured by the regional
housing authority. More than one-
third of households reported food
insecurity and approximately 29%
and 8% participated in SNAP and
WIC, respectively. The majority of
the sample was overweight or obese,
with diabetes, hypertension, and
smoking status commonly reported
(Table 1).
Sugar-Sweetened Beverage
Intake
Mean intake of SSB was 246
297 kcal;
41% of the sample met SSB intake rec-
ommendations. Differences by socio-
demographic characteristics were
detected for both SSB intake and
meeting recommendations for SSB ki-
localories (Table 1). Males consumed
more SSB than did females; those
over age 55 years and those who were
retired and widowed consumed less
SSB. These differences were consistent
with respect to meeting SSB intake rec-
ommendations in all cases except for
marital status.
For the outcomes of interest, food-
insecure households and SNAP or
WIC participants reported higher SSB
intake. Fewer food-insecure partici-
pants met recommendations for SSB
intake. However, food assistance pro-
gram participation was not related to
having met SSB intake recommenda-
tions. Participants who reported no
chronic conditions consumed more
SSB kilocalories than those with $ 1
or $ 2 chronic conditions; individuals
with diabetes and hypertension
consumed fewer SSB kilocalories and
smokers consumed more SSB than
did nonsmokers.
Table 2 lists linear and logistic
regression results for SSB kilocalories
and recommendations. Race (P < .01)
and age (P < .01) predicted whether
the SSB recommendation was met
(Model 1a). Those aged >55 years
were twice as likely to meet SSB recom-
mendations compared with younger
adults (models 2a [P < .01] and 3a [P
< .05]). Individuals aged $ 55 years
who were retired and female reported
lower SSB intake (models 2b [P < .001]
and 3b [P < .01]). After controlling for
covariates, food security and participa-
tion in food assistance programs were
not related to meeting SSB recommen-
dations. However, a significant inverse
relationship existed between food secu-
rity and SSB kilocalories (P < .05).

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Table 2. Demographic, Food Security Status, Federal Nutrition Program Participation, and Self-Reported Chronic Disease Status Associations With Meeting
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Recommendations for Sugar-Sweetened Beverage and Sugar-Sweetened Beverage Intake (n ¼ 930)

Model 1a, Model 1b, Model 2a, Model 2b, Model 3a, Model 3b,
OR (95% CI) b (SE) OR (95% CI) b (SE) OR (95% CI) b (SE)
Age, y (reference: 18–35 y) – – –
36–54 1.35 (0.81–2.25) 41.01 (35.22) 1.44 (0.84–2.48) 51.91 (37.45) 1.31 (0.77–2.21) 30.71 (35.85)
$ 55 y 2.09 (1.23–3.56)† 128.5 (37.19)‡ 2.21 (1.24–3.93)† 134.12 (40.2)‡ 1.88 (1.07–3.33)* 107.48 (39.35)†
Gender (reference: female) 1.38 (0.97–1.97) 76.49 (25.15)† 1.4 (0.98–1.99) 77.04 (25.23)† 1.48 (1.02–2.13)* 79.47 (25.47)†
Race (reference white) †
1.6 (1.13–2.25) 60.91 (24.64)* 1.46 (1.02–2.08) 50.95 (25.38) 1.41 (0.98–2.01) 33.96 (25.34)
Income (reference: < $20,000) –* – – – –* –
$20,000–$49,999 1 (0.70–1.45) 22.09 (26.05) 1.11 (0.75–1.64) 11.46 (27.89) 0.99 (0.69–1.45) 5.87 (26.52)
> $50,000 1.37 (0.88–2.12) 69.8 (31.66) 1.74 (1.08–2.81)* 48.97 (34.67) 1.58 (0.99–2.49) 44.36 (32.64)
Employment (reference: – – – – – –
employed)
Unemployed 0.88 (0.51–1.50) 29.27 (37.39) 0.84 (0.48–1.45) 28.99 (38.35) 0.97 (0.56–1.68) 9.67 (37.6)
Student/homemaker 1.53 (0.89–2.46) 17.09 (39.94) 1.34 (0.77–2.33) 8.04 (40.39) 1.4 (0.81–2.46) 11.16 (40.1)
Retired 1.26 (0.83–1.93) 44.1 (34.33) 1.43 (0.93–2.19) 66.71 (31.35)* 1.29 (0.94–2.00) 54.83 (31.6)*
Disabled 0.83 (0.48–1.44) 29.99 (38.71) 0.76 (0.43–1.34) 20.5 (39.85) 0.67 (0.37–1.20) 32.59 (40.05)
Food security – – 1.1 (0.78–1.56) 52.63 (24.56)* – –
SNAP – – 0.77 (0.50–1.19) 14.82 (31.2) – –
WIC – – 0.94 (0.52–1.72) 6.85 (42.5) – –
Chronic disease
$ 1 condition – – – – 2.42 (1.15–5.09)* 88.72 (52.96)*
$ 2 conditions – – – – 1.33 (0.67–2.63) 45.32 (47.9)
Diabetes – – – – 0.84 (0.46–1.54) 3.31 (42.53)
Hypertension – – – – 2.2 (1.03–4.68) 72.6 (53.83)
Myocardial infarction/coronary – – – – 1.41 (0.76–2.64) 69.06 (44.43)
artery disease
Stroke – – – – 1.09 (0.51–5.09) 36.92 (54.82)
Smoking status – – – – 0.61 (0.39–0.97)* 108.08 (30.97)†
SNAP indicates Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children; OR, odds ratio; CI, confi-
dence interval.
*P < .05, †P < .01, ‡P < .001.

Davy et al 201
Notes: Model 1: sample sociodemographic characteristics only; model 2: sociodemographic characteristics and food security and food assistance; model 3: sociodemo-
graphic and chronic disease indicators; models 1a, 2a, and 3a are associations by logistic regression and models 1b, 2b, and 3b are associations by linear regression.
202 Davy et al
Individuals who reported at least 1
chronic condition consumed fewer
SSB kilocalories (P < .05) and were
twice as likely to have met SSB recom-
mendations (P < .05). For individual
conditions, only current smoking status
related to SSB intake, in that smokers
consumed more SSB (P < .001) and
nonsmokers were more likely to meet
SSB recommendations (P < .05).
Water Intake
Mean water intake in the sample was
31
19 fluid oz; 72% of the sample re-
ported meeting water intake recom-
mendations. Total intake and
meeting water intake recommenda-
tions differed by socioeconomic char-
acteristics; black and mixed-race
participants drank more water and a
higher percentage met recommenda-
tions for water intake compared with
white participants (Table 1). Smokers
reported less water consumption
than did nonsmokers and 63% met
recommendations for water intake
compared with 74% of nonsmokers.
Table 3 lists linear and logistic
regression results for total water intake
and meeting recommendations for wa-
ter. Non-white participants reported
consuming more water (P < .001)
and were twice as likely to report
meeting water intake recommenda-
tions (P < .01). After controlling for co-
variates, water intake was not different
according to food security status or
food assistance program participation.
Individuals with a myocardial infarc-
tion or coronary artery disease re-
ported higher water intake (P < .05).
DISCUSSION
In this sample of adults living in a pri-
marily rural, health-disparate region,
the authors found that SSB consump-
tion was about 60% higher than that
reported in nationally representative
samples.25 Consistent with national
data and those for Australians, lower
SSB intake was noted among females
and older adults.14,25 Although recent
data indicate that SSB consumption
may be declining in general,25 the cur-
rent findings suggest that the trend
may not be evident among all popula-
tion segments, particularly among
health-disparate populations.
The DGA consumer message to
‘‘drink water instead of sugary drinks’’
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Journal of Nutrition Education and Behavior  Volume 47, Number 3, 2015
may represent an achievable recom-
mendation for low-SES populations.
The mission of the Food and Nutri-
tion Service of the US Department of
Agriculture,36 which administers
federal nutrition assistance programs
including SNAP and WIC, is to ‘‘in-
crease food security and reduce
hunger by providing children and
low-income people access to food, a
healthful diet and nutrition education
programs’’; both SNAP Education
Guidance37 and WIC38 use the DGA
as a primary source of their nutrition
education messages. Yet the finding
that SNAP and WIC participants are
not more likely to achieve SSB intake
recommendations suggests that these
participants may not be receiving the
DGA message to ‘‘drink water instead
of sugary drinks’’ or may not have
enough guidance about how to
change health behaviors. There has
also been considerable controversy
surrounding whether nutrient-poor
food and beverage purchases should
be permissible with SNAP funds.39
Yet the higher cost of consuming a
healthier diet6 may represent a barrier
to healthy food consumption among
low-SES groups. In this health-
disparate sample, those with a major
chronic disease indicator were more
likely to achieve SSB intake recom-
mendations. Related to this, Healthy
People 2020 goals include increasing
lifestyle counseling by primary care
providers40 and reducing added sugar
consumption from 16% to 10.8% of
total energy. Although consumers
consider family and friends to be
important and trustworthy sources
of information, health professionals
and government agencies are
perceived by consumers as the most
trustworthy sources of health infor-
mation.41 Thus, the current findings
could be used to promote greater
communication of this health mes-
sage by health care providers and pub-
lic health counselors to at-risk groups
such as rural, low-SES populations
and those with chronic diseases.
Daily drinking water intake in this
sample was slightly below that re-
ported in nationally representative
samples (36 fluid oz).23 Non-white par-
ticipants in the current rural, health-
disparate sample were more likely to
meet water intake recommendations
whereas smokers were less likely to
meet recommendations; this differs
from National Health and Nutrition
Examination Survey analyses that did
not find racial or ethnic differences in
water consumption or differences ac-
cording to smoking status.23 Although
others have examined associations be-
tween sociodemographic characteris-
tics and water consumption,15-17 it is
not known whether certain chronic
disease diagnoses or SNAP and WIC
participation are associated with
water intake and achieving intake
recommendations. Water intake is
inversely associated with risk of
hyperglycemia,42 insulin resistance,43
fatal heart disease,44 and other chronic
conditions,19 which suggests potential
benefits for those at risk for diabetes or
heart disease. The authors’ findings
suggest that only a diagnosis of
myocardial infarction or coronary ar-
tery disease is associated with greater
water consumption; therefore, physi-
cians, health care professionals, and
public health nutritionists could pro-
mote increasing water consumption
as a simple, specific, and economically
sensitive dietary recommendation.41
Strengths of this investigation
include recently collected data that
address timely public health issues—
SSB and water consumption, federal
nutrition program assistance, and
eating behaviors—within a hard-to-
reach population segment. The sam-
ple size, high response rate, and
significant proportion of food-
insecure participants (36%) are addi-
tional strengths. Limitations include
the reliance on self-reported data; the
cross-sectional nature of the study,
which precludes causal interpretation
of the findings; and the mean age of
respondents, which was slightly older
than the regional median age, and
which could affect the generalizability
of findings. Nevertheless, the findings
add important information to the
body of literature addressing associa-
tions of beverage intake patterns
with sociodemographic characteris-
tics in a rural, health-disparate popu-
lation.
IMPLICATIONS FOR
RESEARCH AND
PRACTICE
Individuals living in a health-disparate
region who may be accessing the
health care system (ie, those with a
 Journal of Nutrition Education and Behavior  Volume 47, Number 3, 2015
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Table 3. Demographic, Food Security Status, Federal Nutrition Program Participation, and Self-Reported Chronic Disease Status Associations With Meeting
Recommendations for Water and for Water Intake

Model 1a, Model 1b, Model 2a, Model 2b, Model 3a, Model 3b,
OR (95% CI) b (SE) OR (95% CI) b (SE) OR (95% CI) b (SE)
Gender (reference: female) 1.21 (0.86–1.70) 1.779 (1.462) 1.269 (0.90–1.78) 2.125 (1.469) 1.195 (0.85–1.69) 1.449 (1.48)
† ‡ ‡ ‡ †
Race (reference: white) 1.82 (1.27–2.61) 6.447 (1.464) 2.02 (1.38–2.90) 7.111 (1.517) 1.782 (1.23–2.58) 5.953 (1.488)‡
Education (reference: less than high – – – – – –
school)
High school/graduate equivalency 0.731 (0.47–1.15) 2.145 (1.849) 0.699 (0.44–1.10) 2.266 (1.865) 0.722 (0.46–1.14) 2.227 (1.862)
diploma
Some college 0.957 (0.60–1.53) 0.112 (1.912) 0.907 (0.56–1.46) 0.028 (1.948) 0.946 (0.58–1.54) 0.315 (1.948)
College graduate 0.667 (0.40–1.13) 1.657 (2.232) 0.608 (0.35–1.05) 1.948 (2.283) 0.671 (0.39–1.16) 1.439 (2.28)
Marital status (reference: married) –* – – – – –
Divorced/separated 0.594 (0.40–0.88)† 4.061 (1.716)* 0.633 (0.43–0.95)* 3.646 (1.772)† 0.663 (0.44–0.99)* 2.854 (1.754)
Widowed 1.118 (0.70–1.79) 0.249 (1.924) 1.116 (0.70–1.79) 0.200 (1.927) 1.112 (0.69–1.79) 0.636 (1.936)
Never married 0.756 (0.47–1.17) 2.295 (1.874) 0.929 (0.57–1.53) 0.623 (2.04) 0.839 (0.53–1.34) 1.266 (1.911)
Food security – – 1.058 (0.76–1.47) 1.017 (1.391) – –
SNAP – – 1.295 (0.86–1.95) 2.456 (1.715) – –
WIC – – 1.693 (0.96–2.98) 3.445 (2.448) – –
Chronic disease – – – – –
$ 1 condition – – – – 1.243 (0.59–2.60) 1.343 (3.094)
$ 2 conditions – – – – 1.644 (0.84–3.22) 4.525 (2.827)
Diabetes – – – – 1.253 (0.69–2.28) 3.407 (2.506)
Hypertension – – – – 1.251 (0.59–2.66) 0.521 (3.164)
Myocardial infarction/coronary – – – – 1.586 (0.86–2.90) 5.789 (2.614)*
artery disease
Stroke – – – – 0.639 (0.28–1.46) 1.587 (3.12)
Smoking status – – – – 0.560 (0.37–0.84)† 5.07 (1.781)†
SNAP indicates Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children; OR, odds ratio; CI, confi-
dence interval.
*P < .05, †P < .01, ‡P < .001.
Notes: Model 1: sample sociodemographic characteristics only; model 2: sociodemographic characteristics and food security and food assistance; model 3: sociodemo-

Davy et al 203
graphic and chronic disease indicators; models 1a, 2a, and 3b are associations by logistic regression and models 1b, 2b, and 3b are associations by linear regression.
204 Davy et al
major chronic disease) were more
likely to achieve SSB but not water
intake recommendations. In line with
the authors’ community-based partici-
patory approach and their guiding
ecological perspective, these findings
will be shared with local stakeholders,
with the goal of shaping local strate-
gies to address beverage consumption
behaviors at multiple levels (ie, intra-
personal or individual, interpersonal
factors, institutional, community, and
public policy). For example, re-
searchers affiliated with the DRPHC
are actively engaged in working with
local families, physicians, primary
care health care systems, public health
care systems (eg, public health depart-
ments with WIC affiliates), and other
community-based organizations (eg,
boys and girls clubs, parks and recrea-
tion departments, cooperative exten-
sion offices with SNAP affiliates) to
identify, implement, and evaluate
obesity reduction programs.45 The
findings from this report provide
powerful data to guide decision mak-
ing among local stakeholders and
establish a baseline metric on beverage
intake for the ongoing work of the
DRPHC.
Although SSB consumption may be
declining in the general US popula-
tion,25 that trend was not evident in
this health-disparate sample. Eco-
nomics and accessibility are barriers
to adopting healthier eating behaviors,
although the DGA consumer message
to ‘‘drink water instead of sugary
drinks’’ may represent a more achiev-
able and cost-saving recommendation
for low-SES populations. The authors’
finding that SNAP and WIC partici-
pants were not more likely to achieve
SSB intake recommendations suggests
that individuals who participate in
public food assistance programs may
not be receiving this message, or may
require additional guidance regarding
how to change their beverage con-
sumption behaviors. These findings
could be used to support efforts to in-
crease communication of this health
message to at-risk groups by health
care professionals and public health
nutritionists.
These findings may be used for
future studies designed to address
health behavior changes among
health-disparate populations. Although
SSB availability and access have
received much attention in this regard,
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Journal of Nutrition Education and Behavior  Volume 47, Number 3, 2015
water availability and safety have
received relatively little attention. How-
ever, perceptions of water safety in rural
areas could represent a barrier to pro-
moting water as an alternative to SSB.
The perception that local tap water is
unsafe varies by region and is more
common among young adults, those
with lower income levels, and racial/
ethnic minorities.46 Greater odds of
plain water low intake (# 1 glass/d)
were noted among Hispanic, black,
and other non-Hispanic adults who
did not believe their local tap water
was safe. Low consumers of plain water
were more likely to drink # 1 SSB/d.46
Efforts to build trust in public water
utilities to overcome tap water avoid-
ance and reliance on bottled water are
needed.18 This is a particular problem
for children in rural areas owing to
less exposure to fluoride. Future surveys
of water intake should include ques-
tions addressing beliefs about the safety
of the local water supply, reasons for
these beliefs (eg, contamination inci-
dents, boil water notices), and the
perceived cost of bottled water in areas
where local water is not believed to be
safe.
ACKNOWLEDGMENTS
Sources of financial support were the
Virginia Tech College of Agriculture
and Life Sciences (PI: Hill) and the Vir-
ginia Foundation for Healthy Youth
(MPI: Hill, Zoellner).
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205.e1 Davy et al Journal of Nutrition Education and Behavior  Volume 47, Number 3, 2015

CONFLICT OF INTEREST
The authors have not stated any con-
flicts of interest.

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