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.
SUBJECTS AND METHODS
Sample
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).
STATISTICAL ANALYSIS
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.
RESULTS
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.
DISCUSSION
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
|
P-value
|
|
|
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)
|
P-value
|
|
|
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)
|
P-value
|
|
|
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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RELATED ARTICLE: APPLICATIONS
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: hercberg@vcnam.cnam.fr.
http://www.mgwater.com/
Healthy Water
Association--USA