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Contribution of mineral waters to dietary calcium and magnesium intake in a French adult population. (Research)

Journal of the American Dietetic Association, Nov, 2002, by P. Galan, M. J. Arnaud, S. Czernichow, A.-M. Delabroise, P. Preziosi, S. Bertrais, C. Franchisseur, M. Maurel, A. Favier, S. Hercberg


Osteoporosis is a bone disease characterized by a reduction in bone tissue relative to the volume of anatomical bone that increases susceptibility to fracture, particularly in menopausal women (1). With the increase in life expectancy and in the number of elderly people, osteoporotic fractures are becoming a major public health problem in industrialized countries (2). Among dietary factors implicated as risk factors for the development of osteoporosis, calcium intake is considered one of the major determinants of bone health (3). Calcium intakes influence acquisition and maintenance of peak bone mass as well as the subsequent rate of bone loss (4). Peak bone mass is established during childhood, adolescence, and young adulthood. Bone loss, which occurs throughout life after the peak bone mass has been reached, is increased in women in the postmenopausal years. Inadequate calcium and vitamin D intake contributes to the problem of bone loss and the risk for osteoporosis. Numerous studies performed in France and other industrialized countries, however, revealed that calcium intakes in most of age groups are low in comparison with recommended levels (5-7).

The same problem has been observed for other nutrients such as magnesium. Most dietary surveys show that usual diets may no longer meet the recommended dietary magnesium allowances. However, magnesium plays an essential role in a wide variety of fundamental cellular reactions (8-12). It is involved in numerous enzymatic and other critical biologic mechanisms such as the synthesis of deoxyribonucleic acid (DNA) and ribonucleic acid (RNA), phosphoryl transfer, glycolysis, lipid metabolism, the action of peptidic hormones, and so forth. Hence, it is not surprising that magnesium deficiency in the organism may lead to severe biochemical changes (9,10).

Maintaining adequate calcium and magnesium status is thus considered beneficial for health. Consumption of certain mineral waters with high natural concentrations of calcium and magnesium may be an efficient means of improving calcium and magnesium status in countries where such waters are available. This may be of particular interest in light of recently published works that found that calcium, magnesium, or both in drinking water is associated with a protective effect against the risk of colorectal cancer (13,14), gastric cancer (15), and cerebrovascular diseases (16).

Using data issued from the Supplementation en Vitamines et Mineraux Antioxydants (SU.VI.MAX) cohort undertaken in France in 1994, a matched case control study was carried out to assess the contribution of mineral water containing different amounts of calcium and magnesium to the total dietary intakes of these minerals.



This study was carried out on a sample of adult subjects living in France and participating in the SU.VI.MAX cohort. The SU.VI.MAX study is a randomized double-blind, placebo-controlled, primary-prevention trial designed to test the efficacy of daily supplementation with antioxidant vitamins and minerals at nutritional doses in reducing the major health problems in industrialized countries and especially the main causes of premature death. The cohort is composed of 12,735 eligible subjects (women aged 35 to 60 years and men aged 45 to 60 years) included in 1994 and followed up for 8 years. Age range is different by sex in order to be able to detect early breast cancer among women. The background and rationale behind the SU.VI.MAX study have been published previously (17). Data on baseline characteristics of the participants suggest that the present sample is, for the selected age groups, close to the national population of France in terms of geographic density and socioeconomic status (18).

The SU.VI.MAX study has been approved by the ethical committee for studies with human subjects of Paris-Cochin and the Comite National Informatique et Liberte for keeping all medical information confidential and anonymous.

We selected 4 groups of water consumers: regular drinkers of Contrex (Nestle, Vittel, France), a calcium- and magnesium-rich mineral water (calcium, 486 mg/L; magnesium, 84 mg/L); drinkers of Vittel (Nestle, Vittel, France), a water classified as having a moderately mineralized content (calcium, 202 mg/L; magnesium, 36 mg/L); drinkers of either Volvic (Danone, France) or Valvert (Nestle, Vittel, France), 2 low-mineralized waters (calcium, 9.9 to 67.6 mg/L and magnesium, 1.6 to 2 mg/L, respectively), and drinkers of tap water. Regular drinkers were defined as exclusive consumers of tap water or specific brand of mineral water. Groups were matched according to age, sex, socioprofessional category, level of education, family situation, tobacco habits, and geographic area of residence. Finally, the analysis was performed on 664 subjects (240 men and 424 women). Each of the 4 groups was composed of 166 subjects: 60 men and 106 women.

Assessment of Food and Nutrient Intakes

Dietary intake and particularly mineral water consumption were assessed using 24-hour dietary records performed every 2 months during a 1-year period, resulting in 6 dietary records for each subject. Records included food and water consumption.

For the intake record, subjects received a free, tiny central processing unit specifically developed for the study and loaded with ad hoc software. This material enabled subjects to fill out computerized questionnaires offline and to transmit data during a brief telephone connection. They were connected to the main SU.VI.MAX computer server via a network (Minitel Telematic). A small terminal widely used in France as an adjunct to the telephone has been used to gain access to the network. Subjects were helped in this task by conversational facilities through our telephone center.

Moreover, subjects were given an instruction manual for food codification, including photographs of food portions, allowing 7 possible estimations of portion size. Pictures of these portion sizes had been previously validated on 780 subjects in a pilot study (19). Data were collected on cooking methods, seasonings, type of foods (fresh, frozen, canned, etc), place and time of dietary intake, and so forth. Precise information on the brand and volume of the intakes of mineral water were also recorded.

The calcium and magnesium content of the diet was estimated using the computerized French food composition database (CIQUAL, 2nd ed., Tec Doc, Paris, France). For a few numbers of foods with missing data in the French table, we extrapolated values according to Mac Cance and Widowson table (20).


Data were analyzed on an Alpha-VMS system using SAS and a specific database developed for handling the data by SAS. In univariate analysis, quantitative data were compared using Student's t test. Multiple mean comparisons were performed in multivariate analysis by analysis of variance. P values <.05 were considered to indicate significant differences.


Table 1 presents daily energy and nutrients intake in the different groups of consumers of mineral water. No differences were observed for alcohol and iron intakes in sex or in lipid intakes in men and in protein intakes in women. Significant (P < [10.sup.-3]) differences were observed for calcium and magnesium intakes, which were markedly higher in the groups consuming mineral-rich and moderately mineralized water.

Dietary calcium intake provided by the various food groups did not differ between the 4 consumer groups, except for calcium provided by mineral water (Table 2). According to its calcium concentration, mineral water may contribute to one fourth of the total daily calcium intake. Subjects who regularly drink mineral-rich water have a calcium intake that is significantly higher (P < [10.sup.-3]) than those drinking low-mineral-content water or tap water.

Calcium intake provided by dairy products in the 4 groups of consumers of various types of water is presented in Table 2. Dairy products were the main source of calcium in this study population. The contribution of calcium provided by dairy products was not different in the 4 groups of water drinkers.

Dietary magnesium intake provided by the various food groups did not differ between the 4 consumer groups, except for magnesium provided by mineral water (Table 3). Depending on the magnesium concentration of the mineral water, it contributed 6% to 17% of total daily magnesium intake of subjects. Drinkers of magnesium-rich mineral waters and waters with a moderate mineral content had magnesium intakes significantly higher (P < [10.sup.-3] than those drinkers on low-mineralized or tap water.


Numerous studies performed during the last years in industrialized countries have reported that subjects consuming usual diets did not meet the recommended dietary calcium and magnesium allowances. For instance, in the SU.VI.MAX cohort in France (from where the sample for this study was selected) 45% of men and 62% of women had daily calcium intake lower than 1,200 mg/day (which is the French and US Recommended Dietary Allowance [RDA]) (21). Among women, 77% had dietary magnesium intakes lower than the 330 mg/day French RDA (US RDA: 320 mg/day); among men, 72% had dietary magnesium intakes lower than 420 mg/day (French and US RDA). These data are consistent with other studies performed in the French population as well as in other European countries (22-26). This may be explained by the fact that during the last few decades, the typical lifestyle has been substantially modified: the energy output necessary for manual labor and ther-moregulation has been considerably reduced, and a global decrease in energy inp ut has been observed (27-28). Moreover there has been an increase in consumption of refined foods or foods characterized by a high energy content from simple carbohydrates without other nutrients. Thus, the mineral and vitamin density of our diet has decreased. The consequence of these 2 phenomena is a reduction in mineral (notably, calcium and magnesium) and vitamin intake. From a public health viewpoint, it is not possible to recommend a substantial increase in energy intake in populations living in industrialized countries. If energy output does not increase, then increasing the calcium and magnesium intake through dietary intake would lead to an adverse effect (ie, overnutrition with consequences such as obesity). Thus, it is particularly important to recommend a choice of foods particularly rich in calcium and magnesium and in sufficient quantities to attain RDA goals. This point is particularly relevant considering the necessity for humans to obtain adequate dietary calcium and magnesium intakes require d by the many functions in which they are involved in human organisms.

Although calcium and magnesium from water is present in a soluble form that is expected to be better absorbed than those from food, absorption and bioavailability of these minerals have been assessed in various studies performed in animal model or in humans. In 1991, a study compared the absorption of calcium between water and milk in lactase-deficient subjects (29). It was shown that higher calcium plasma levels were observed in most of the subjects when water classified as a moderately mineralized content (Vittel) was ingested. Others studies were then published using stable isotopes or loading test with calcium balance or calcium and parathormone (PTH) blood kinetics. The bioavailability of calcium from a calciumrich water (Contrex) (30) or sparkling mineral water (31,32) appeared to be similar to calcium present in milk and dairy products as well as pharmaceutical supplements (33). An acute administration of 0.5 L water containing 370 mg/L calcium decreased significantly (P<.002) plasma PTH levels as well as plasma and urine CrossLaps bone marker in the 4 hours following the oral ingestion, compared with a water containing less than 10 mg/b calcium (34).

In addition to these short-term clinical studies, long-term effects of the consumption of calcium-rich mineral waters have been reported recently. A 1-year study was performed on 45 early postmenopausal women receiving 1 L mineral water--containing either 80 or 408mg/L calcium--per day (35). Although the 2 groups were not homogenous, the results showed that the decrease in bone mineral density at distal radius was only significant after 1 year in the group with the lowest calcium intake (mean [+ or -] standard deviation [SD]): 1,510[+ or -]202 vs 949[+ or -]181 mg/day. The specific effect of calcium from mineral water, however, is not compared in this study with that from diet (35). Results of the bioavailabllity studies seem sufficient to consider that the calcium absorption in mineral water is not different than in other foods.

In a prospective study on the identification of risk factors for bone fractures, 7,575 women aged 80.5[+ or -]3.8 years have been studied in France for 2 years (EPIDOS). The specific effect of calcium provided through mineral water was evaluated using a dietary questionnaire where the brands and the volume of mineral water consumed were recorded as well as total calcium intake from food. Bone mineral density was positively correlated with the time spent doing housework as well as body weight, calcium from water, height of the subject, and calcium from food. An increased intake of 100 mg calcium from mineral water increased bone density by 0.51% whereas 100 mg from food increased it only by 0.18% (36). The higher effect of calcium from water is not explained but could be related to the highest absorption efficiency observed when the dose ingested is divided and taken throughout the day. Further research work is needed to confirm and explain this difference between food and water. Calcium-rich mineral waters are an alternative to reach adequate calcium intake in subjects who are lactose-intolerant but more generally who dislike dairy products and milk, which remains the primary source of calcium (37).

Magnesium absorption and bloavailability from Vittel have been shown in animal models (38) as well as in another mineral water containing 110 mg/L magnesium (39). In this study, the bioavailability of magnesium from water was similar to magnesium pidolate salt commonly used in therapy. More recently, it has been shown that in human patients with migraine characterized by low intracellular magnesium concentrations, these concentrations in lymphocytes and erythrocytes were shown to increase back to values of healthy subjects when 1 L Vittel mineral water was drunk daily for 2 weeks (40).



Table 1.  Daily energy, macronutrient, and mineral intake in 4 groups of consumers of water (mean [+ or -] standard deviation) (a)
Drinkers of Highly Mineralized Water
  Men Women
Energy (kcal/d) 217 [+ or -]70 160 [+ or -] 44
Lipids (g/d)  97 [+ or -] 30  72 [+ or -] 20
Proteins (g/d)  93 [+ or -] 24  74 [+ or -] 19
Alcohol (g/d)  29 [+ or -] 28  11 [+ or -] 13
Iron (mg/d) 14.5 [+ or -] 6.9  10.4 [+ or -] 3.9
Calcium (mg/d) 1,206 [+ or -] 342 1,111 [+ or -] 363
Magnesium(mg/d)  413 [+ or -] 121  331 [+ or -] 96
Drinkers of Moderately Mineralized Water
  Men Women
Energy (kcal/d) 2,463 [+ or -] 592 1.810 [+ or -] 508
Carbohydrates (g/d) 232 [+ or -] 73 179 [+ or -] 60
Lipids (g/d) 102 [+ or -] 30  78 [+ or -] 27
Proteins (g/d) 100 [+ or -] 22  75 [+ or -] 22
Alcohol (g/d)  31 [+ or -] 33  13 [+ or -]17
Iron (mg/d) 14.4 [+ or -] 3.7  10.2 [+ or -] 3.2
Calcium (mg/d) 1,087 [+ or -] 408  948 [+ or -] 329
Magnesium(mg/d)  369 [+ or -] 100 300 [+ or -] 97
Drinkers of Poorly Mineralized Water
  Men Women
Energy (kcal/d) 2,208 [+ or -] 509 1,789 [+ or -] 470
Carbohydrates (g/d) 205 [+ or -] 63 180 [+ or -] 53
Lipids (g/d)  97 [+ or -] 30  78 [+ or -] 25
Proteins (g/d)  88 [+ or -] 21  76 [+ or -] 20
Alcohol (g/d)  23 [+ or -] 26  10 [+ or -] 13
Iron (mg/d) 12.6 [+ or -] 3.5 10.3 [+ or -] 3.6
Calcium (mg/d) 944 [+ or -] 320  854 [+ or -] 279
Magnesium(mg/d) 360 [+ or -] 97 288 [+ or -] 84
Tap Water Drinkers
  Men Women
Energy (kcal/d) 2,581 [+ or -] 685 1,834 [+ or -]559
Carbohydrates (g/d) 263 [+ or -] 89  182 [+ or -] 62
Lipids (g/d) 104 [+ or -] 29   82 [+ or -] 27
Proteins (g/d) 103 [+ or -] 26   77 [+ or -] 24
Alcohol (g/d)  25 [+ or -] 25    9 [+ or -] 11
Iron (mg/d) 15.7 [+ or -] 5.1 11.0 [+ or -] 4.2
Calcium (mg/d) 1,003 [+ or -] 411  881 [+ or -] 395
Magnesium(mg/d  377 [+ or -] 114 284 [+ or -] 99

Energy (kcal/d) P=.005 (men), P=.04 (women)
Carbohydrates (g/d) P<[10.sup.-3] (men), P=.01 (women)
Lipids (g/d) NS (men, P=.03 (women)
Proteins (g/d) P=.001 (men). NS (b) (women)
Alcohol (g/d) NS (men and women)
Iron (mg/d) NS (men and women)
Calcium (mg/d) P<[10.sup.-3] (men and women)
Magnesium(mg/d) P<[10.sup.-3] (men and women)

(a)Each group is composed of 60 men and 106 women.
(b)NS = not significant.



Table 2.  Sources of calcium in the 4 groups of consumers of water: mean [+ or -] standard deviation (percentage of total intake) (a)
Drinkers of Highly Mineralized Water
  Men Women
Calcium provided by water (mg/d) 298 [+ or -] 170 (18) 308 [+ or -] 171 (20)
Calcium provided by dairy products (mg/d) 484 [+ or -] 258 (28) 423 [+ or -] 224 (28)
Other sources of calcium (mg/d) 908 [+ or -] 335 (54) 803 [+ or -] 309 (52)
Drinkers of Moderately Mineralized Water
  Men Women
Calcium provided by water (mg/d) 117 [+ or -] 76 (7) 120 [+ or -] 74 (9)
Calcium provided by dairy products (mg/d) 518 [+ or -] 320 (32) 446 [+ or -] 249 (32)
Other sources of calcium (mg/d) 971 [+ or -] 385 (61) 828 [+ or -] 313 (59
Drinkers of Poorly Mineralized Water
  Men Women
Calcium provided by water (mg/d) 9 [+ or -] 12 (1) 8 [+ or -] 9 (1)
Calcium provided by dairy products (mg/d) 511 [+ or -] 291 (35) 463 [+ or -] 231 (35)
Other sources of calcium (mg/d 935 [+ or -] 319 (64) 846 [+ or -] 278 (64)
Tap Water Drinkers
  Men Women
Calcium provided by water (mg/d)  0.6 [+ or -] 0.3 (0.1) 0.5 [+ or -] 0.4 (0.1)
Calcium provided by dairy products (mg/d) 547 [+ or -] 316 (35) 475 [+ or -] 290 (35)
Other sources of calcium (mg/d 1.002 [+ or -] 411 (64.9)    880 [+ or -] 395 (64.9)

Calcium provided by water (mg/d) P<[10.sup.-4] (men and women)
Calcium provided by dairy products (mg/d) NS (b) (men and women)
Other sources of calcium (mg/d) NS (men and women)

(a)Each group is composed of 60 men and 106 women.
(b)NS = not significant.



Table 3.  Total daily intake and sources of magnesium in the 4 groups of consumers of water: mean [+ or -] standard deviation (percentage of total intake)(a)
Drinkers of Highly Mineralized Water
  Men Women
Magnesium provided by water (mg/d 52 [+ or -] 31 (14)  55 [+ or -] 31 (17)
Other sources of magnesium (mg/d) 359 [+ or -] 126 (86) 276 [+ or -] 88 (83)
Drinkers of Moderately Mineralized Water
  Men Women
Magnesium provided by water (mg/d) 21 [+ or -] 13 (6) 21 [+ or -] 13 (7)
Other sources of magnesium (mg/d) 349 [+ or -] 100 (94 279 [+ or -] 93 (93)
Drinkers of Poorly Mineralized Water
  Men Women
Magnesium provided by water (mg/d) 2 [+ or -] 1 (1) 3 [+ or -] 2 (1)
Other sources of magnesium (mg/d 357 [+ or -] 97 (99) 285 [+ or -] 84 (99)
Tap Water Drinkers
  Men Women
Magnesium provided by water (mg/d)    
Other sources of magnesium (mg/d) 377 [+ or -] 114 (100) 284 [+ or -] 99 (100)

Magnesium provided by water (mg/d/td> P<[10.sup.-4] (men and women)
Other sources of magnesium (mg/d NS (b) (men and women)

(a)Each group is composed of 60 men and 106 women.
(b)NS = not significant.



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Mineral-rich water may constitute an important supplementary contribution to total calcium and magnesium intake. This is of particular interest, because calcium and magnesium that are provided by these mineral waters are well absorbed.

Moreover, our study shows that consumption of mineral-rich water does not interfere with consumption of other sources of calcium, particularly dairy products, and contributes significantly to fulfill the recommended daily intake.

For dietetics professionals, use of mineral-rich water may provide for dietitians--in place of the usual recommendations concerning the consumption of dairy products--a good way to improve calcium and magnesium intakes, particularly in subjects who don't like dairy products.

P. Galan, S. Czernichow, P Preziosi, S. Bertrais, C. Franchisseur, M. Maurel, and S. Hercberg are with the Institut Scientifique et Technique de la Nutrition et l'Alimentation, Conservatoire National des Arts et Metiers, Paris, France. M. J. Arnaud and A.-M. Delabroise are with the Water Institute, Vittel, France. A. Favier is with the Laboratoire de Biochimie, CHR de Grenoble, France

Address correspondence to: Serge Herc berg, ISTNA/CNAM - INSERM U. 557, 5 rue Vertbois, F-75003, Paris, France. E-mail: