Perceived water safety and elevated liver enzymes in rural West Virginia: links between drinking water, beverage habits, and liver health

Early Abstract:

Introduction: In rural communities, aging infrastructure and environmental challenges can contribute to mistrust in tap water, potentially influencing hydration behaviors and health outcomes. The relationship between perceived water safety and liver health remains underexplored, particularly in low-resource Appalachian settings.
Methods: This cross-sectional study examined data from 240 adult patients in a rural West Virginia primary care clinic. Participants rated their home tap water safety on a 7-point scale and reported beverage consumption patterns via survey. Clinical indicators were abstracted from the electronic health record, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), hemoglobin A1c (HbA1c), body mass index (BMI), and diagnosis of metabolic dysfunction-associated steatotic liver disease (MASLD). Descriptive and inferential statistics were used to evaluate associations between perceived water quality and health indicators.
Results: One-third of participants rated their home water safety as low. While no significant association was found between water perception and a known diagnosis of MASLD, liver enzyme elevations were significantly more common among those with poor water perceptions. ALT >40 U/L was present in 58.82% of participants with low water safety perception, compared to 31.47% of those reporting higher water safety (χ²(1) = 5.24, p = 0.022; OR = 3.11, 95% CI: 1.13–8.55). A similar pattern was observed for AST >40 U/L (χ²(1) = 4.67, p = 0.031; OR = 3.73, 95% CI: 1.06–13.08). No statistically significant relationships were found with HbA1c or BMI. Despite concerns about tap water, most participants reported moderate or low sugar-sweetened beverage (SSB) consumption, and 68.5% drank unfiltered tap water at least occasionally.
Discussion: Findings suggest that lower perceived water quality was associated with elevated liver enzymes, even in the absence of diagnosed disease. These associations should be interpreted as exploratory but suggest that perceived or actual environmental stressors may coincide with hepatic changes. In regions with aging or unregulated municipal systems, individuals expressing lower water safety perceptions may also experience recurring water disruptions or exposure concerns, highlighting a complex intersection of infrastructure, perception, and health. Importantly, no substitution effect was observed between unsafe water perceptions and high SSB intake.
Conclusion: Understanding how local hydration behaviors intersect with environmental perceptions is essential to designing effective public health interventions. Community-centered efforts that improve transparency in water quality reporting, support affordable filtration access, and address environmental and psychosocial stressors may strengthen chronic disease prevention and health promotion in rural and underserved areas.