Structural and Systemic Drivers of Sugary Drink and Water Consumption in Puerto Rico: A Qualitative Participatory Systems Map

Authors

Uriyoán Colón-Ramos, Department of Global Health, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Avenue, Washington DC. 20052. Electronic address: uriyoan@gwu.edu.
Maribel Campos Rivera, Center for Community Outreach for Health Across the Lifespan, University of Puerto Rico Medical Sciences Campus, Office A144 Edificio Guillermo Arbona, P O Box 365067, San Juan, Puerto Rico 00936.
Alyssa Luisi, Center for Community Resilience and Department of Global Health, Milken Institute School of Public Health, George Washington University, 2175 K St. NW, Suite 200, Washington, DC 20037.
Kuan-Lung Daniel Chen, Center for Community Resilience and Department of Global Health, Milken Institute School of Public Health, George Washington University, 2175 K St. NW, Suite 200, Washington, DC 20037.
Wendy Ellis, Center for Community Resilience and Department of Global Health, Milken Institute School of Public Health, George Washington University, 2175 K St. NW, Suite 200, Washington, DC 20037.

Document Type

Journal Article

Publication Date

9-10-2025

Journal

Journal of the Academy of Nutrition and Dietetics

DOI

10.1016/j.jand.2025.09.004

Keywords

Hispanics; community-based system dynamics; diet disparities; sugary drinks; water

Abstract

BACKGROUND: Empirical evidence shows that communities experiencing water hardship tend to consume more sugar-sweetened beverages (SSBs); however, the underlying mechanisms are not well understood. OBJECTIVE: This study aimed to integrate the perspectives of multiple stakeholders across different sectors to develop a shared understanding of the drivers of water and SSB consumption in Puerto Rico (PR), where the majority of residents have experienced water hardship. DESIGN: A participatory system dynamics modeling approach (Group Model Building-GMB) was employed to engage stakeholders across multiple sectors in PR to develop a shared understanding of what are the underlying drivers of water and SSB consumption in PR; how these interconnect; and to identify potential leverage points. The GMB workshop was conducted in January 2023 and a parent group discussion in April 2023. PARTICIPANTS: /Setting: Stakeholders in San Juan PR were purposefully recruited from public service (n=7), commercial sector (n=3), civil groups (n=13) and parents (n=5). ANALYSIS: Multiple rounds of feedback and member checking sessions were conducted to synthesize the workshop outputs into an integrated systems map and a set of leverage points. RESULTS: Stakeholders conceptualized water and SSB consumption in PR as outcomes of two interconnected subsystems, both shaped by distrust in government. Fear of contaminants in tap and bottled water discouraged water consumption, and indirectly increased SSB intake. Aggressive marketing reinforced habitual SSB consumption across generations. Stakeholders identified the following leverage points in PR: a) leverage water infrastructure funding; b) provide water quality data in real time; c) coordinate counter-marketing campaigns targeting SSBs paired with drinking water promotion. CONCLUSIONS: This participatory approach brought together stakeholders from diverse sectors, encouraging them to look beyond individual behaviors of interest. Participants agreed that water would not become a viable alternative to SSBs if water insecurity was not addressed first.

APA Citation

Colón-Ramos, Uriyoán; Rivera, Maribel Campos; Luisi, Alyssa; Daniel Chen, Kuan-Lung; and Ellis, Wendy, "Structural and Systemic Drivers of Sugary Drink and Water Consumption in Puerto Rico: A Qualitative Participatory Systems Map" (2025). GW Authored Works. Paper 7966.
https://hsrc.himmelfarb.gwu.edu/gwhpubs/7966

Department

Global Health