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Abstract

Water is essential for life, participating in the metabolism of all the living organisms. In recent years, the consumption of tap water has decreased and the consumption of bottled water has increased worldwide. The mineral quality and composition of natural mineral water is known and constantly over the year, and their potential effects on health must be determined. Only magnesium, calcium and sodium are present in water in sufficient quantities to complement the diet. Given that the bioavailability of calcium and magnesium in water is comparable to that of other foods, the consumption of water can contribute to the daily intake of these minerals. Therefore, including natural mineral water in the diet may be a valid way of complementing calcium and magnesium intake, and complying with the daily dietetic recommendations of these nutrients.
1136-4815/23/4-18
Alimentacion, Nutricion y Salud Alim . N u t ri . S Al u d
Copyright © 2016 Instituto Danone Vol. 23, N.º 1, pp. 4-18, 2016
4
INTRODUCTION, DEFINITIONS
AND TYPES OF WATER
In the last two decades, the consumption of tap water has
decreased and, at the same time, the consumption of bottled
natural mineral water has increased significantly all over the
world because of the growing concern that certain water com-
ponents or contaminants can affect health (1,2). For this rea-
son, the scientific community is taking more interest in study-
ing how the consumption of bottled water can affect health.
It is recognized that the main source of minerals is food,
however some types of water can be an important source
of them contributing to cover recommendations. Water can
be regarded both as an essential nutrient for hydration, and
also as a food, because it contains several nutrients (calcium,
magnesium, sodium, etc.). It cannot accumulate in the body
so it must be ingested several times during the day. And
depending on its chemical composition and the amount
consumed, it can also be a significant source of minerals (3).
The quality and composition of tap and bottled waters vary
enormously around the world (2-4).
Water mineralization and its importance for health
C. Ferreira-Pêgo1,2, N. Babio1,2, F. Maraver Eyzaguirre3, I. Vitoria Miñana4,
J. Salas-Salvadó1,2
1HUMAN NUTRITION UNIT. HOSPITAL UNIVERSITARI DE SANT JOAN DE REUS. FACULTY
OF MEDICINE AND HEALTH SCIENCES. IISPV (INSTITUT D’INVESTIGACIÓ SANITÀRIA PERE
VIRGILI). BIOCHEMISTRY BIOTECHNOLOGY DEPARTMENT. UNIVERSITAT ROVIRA I VIRGILI.
REUS, BARCELONA. SPAIN. 2CIBEROBN (CENTRO DE INVESTIGACIÓN BIOMÉDICA EN RED
FISIOPATOLOGÍA DE LA OBESIDAD Y NUTRICIÓN). INSTITUTE OF HEALTH CARLOS III.
MADRID, SPAIN. 3PROFESSIONAL SCHOOL OF MEDICAL HYDROLOGY. FACULTY OF MEDICINE.
COMPLUTENSE UNIVERSITY. MADRID, SPAIN. 4NUTRITION AND METABOLOPATHIES UNIT.
HOSPITAL LA FE. VALENCIA, SPAIN.
RESUMEN ABSTRACT
E
l agua es esencial para la vida, ya que participa en el
metabolismo de todos los seres vivos. En los últimos años
el consumo de agua del grifo ha disminuido y el consumo
de agua embotellada ha aumentado a escala mundial. La
composición mineral del agua mineral natural es conocida
y constante durante el año, y sus efectos potenciales sobre
la salud deben ser determinados. Solamente el magnesio,
calcio y sodio están presentes en el agua en cantidades
sucientes para complementar la dieta. Dado que la biodis-
ponibilidad de calcio y magnesio en el agua es comparable a
la de otros alimentos, el consumo de agua puede contribuir
a la ingesta diaria de estos minerales. Por lo tanto, incluir
el agua mineral en la dieta puede ser una forma válida de
complementar la ingesta de calcio y magnesio, y de esta
manera cubrir las recomendaciones dietéticas diarias de
estos nutrientes.
Palabras clave: Agua. Mineralización. Calcio. Magnesio.
Salud.
W
ater is essential for life, participating in the
metabolism of all the living organisms. In recent years,
the consumption of tap water has decreased and the
consumption of bottled water has increased worldwide.
The mineral quality and composition of natural mineral
water is known and constantly over the year, and their
potential effects on health must be determined. Only
magnesium, calcium and sodium are present in water in
sufcient quantities to complement the diet. Given that
the bioavailability of calcium and magnesium in water is
comparable to that of other foods, the consumption of
water can contribute to the daily intake of these minerals.
Therefore, including natural mineral water in the diet may
be a valid way of complementing calcium and magnesium
intake, and complying with the daily dietetic recommen-
dations of these nutrients.
Key words: Water. Mineralization. Calcium. Magnesium.
Health.
Vol. 23, N.º 1, 2016 WATER MINERALIZATION AND ITS IMPORTANCE FOR HEALTH
5
Of the minerals present in water, only one small group
deserves special attention because of their possible effect
as a complement to dietary intake. These minerals are es-
sential for health and are mainly magnesium, calcium and
sodium (4).
Bottled drinking waters have different chemical compos-
itions and can therefore be classified in a variety of ways.
Table I shows the classification of bottled natural mineral
waters in Spain according to Royal Decree 1798/2010,
BOE n.º 16, of 19 January 2011 (5).
According to the definition of the World Health Organiz-
ation (WHO), very weakly mineralized water is practically or
completely free of dissolved minerals, sometimes as a result
of distillation, deionization, membrane filtration, electrodi-
alysis or some other technology (4). At the other extreme,
highly mineralized water is generally defined as water that
contains a high concentration of calcium and magnesium
ions and bicarbonates. The most common sources of
hardness in water are the minerals found in the aquifer:
limestone, which is the source of calcium, and dolomite,
which is the source of magnesium. Nevertheless, hardness
can be caused by such other dissolved metals as aluminum,
barium, strontium, iron, zinc and manganese. Normally,
monovalent ions such as sodium and potassium do not
determine the hardness of water (6). However, these def-
initions cannot be applied to natural mineral waters, since
Royal Decree 1798/2010 states that the mineralization
of this type of water cannot be modified artificially. In this
regard, natural mineral waters can be subject only to the
following operations:
Separation of unstable natural elements, such as sul-
fur and iron compounds, by filtration or decantation,
preceded in each case by oxygenation, as long as the
composition of those constituents of the water that
provide it with its essential properties is not modified.
Separation of iron, manganese and sulfur compounds,
and arsenic, in some natural and spring mineral waters
by ozone-enriched air, as long as the composition of
those constituents of the water that provide it with its
essential properties is not modified and the handler
adopts all the measures necessary to guarantee the
effectiveness and innocuity of the process, and notifies
the health authorities so that appropriate control can
be exercised.
Separation of fluoride by activated alumina in natural
mineral waters and spring waters (5,7).
At present, there are considerable variations in the min-
eral content of the bottled waters available in Spain, so it
is essential to understand the potential effects that these
minerals can have on an individual’s health (1). This in-
formation is absolutely necessary if the benefits or risks of
certain bottled waters are to be determined.
Drinking water is often subdivided into bottled drinking
water and water for human consumption or tap water. Ac-
cording to Royal Decree 140/2003, of 7 February, which
establishes the health criteria for the quality of water for
human consumption (8), drinking water is regarded as:
All water, whether in its original state or after treatment,
used for drinking, cooking, preparing food, personal
hygiene and other household purposes, whatever its
origin and independently of whether it is supplied to
the consumer by public or private distribution networks,
cisterns and/or public or private deposits.
All water used in the food industry for purposes of
making, treating, conserving or commercializing prod-
ucts or substances for human consumption, as well as
that used for cleaning surfaces, objects and materi-
als that may come into contact with foodstuffs.
All water supplied for human consumption as part of
a commercial or public activity, regardless of the mean
daily volume supplied.
Water for human consumption can come from any
source, as long as it does not involve a risk to the health of
the people it is supplied to (8). Normally this sort of water
comes from rivers, reservoirs, desalination plants or even
wells. Its chemical and mineral composition varies over time
and can depend on its source and any potabilization treat-
ments it is subject to.
Bottled water, on the other hand, can be divided into
three types: natural mineral water, spring water and pre-
pared water.
Natural mineral water is microbiologically healthy water
which comes from an underground stratum or deposit. It
comes to the surface in the form of a spring or can be col-
lected artificially by means of a probe, a well, a pit or gallery
or any combination of these. It can be clearly distinguished
from other ordinary drinking water because of (5):
Its content of minerals, dietary elements and other
components and, on occasions, particular effects it
may have.
TABLE I
SPANISH NATURAL MINERAL WATER CLASSIFICATION
Reference Criteria for making the references based on content
Very low mineralized water Up to 50 mg/L of dry residue
Low mineralized water Up to 500 mg/L of dry residue
Medium mineralized water Between 500 mg/L and 1,500 mg/L of dry residue
Highly mineralized water More than 1,500 mg/L of dry residue
C. FERREIRA-PÊGO, ET AL. ALIM. NUTRI. SALUD
6
Its chemical constancy and,
Its original purity, given the fact that it is from an
underground source that has provided natural protec-
tion against all risk of contamination.
As has been mentioned in the introduction to this review,
natural mineral waters are classified according to their min-
eral composition: very low mineralization, low mineraliza-
tion, medium mineralization and high mineralization. This
classification is specific to natural mineral waters and must
not be used to define or classify other types of water, like tap
water. It is important to highlight that in Spain, the majority
of the Natural Mineral Waters consumed and sold presents
a low mineralization.
Spring waters flow spontaneously from underground
sources to the surface or are collected. They are natur-
ally pure and can therefore be consumed. They remain
pure because, being from an underground source, they
are naturally protected by the aquifer from any risk of
contamination (5). What is more, constancy of the chem-
ical and mineral composition of these waters cannot be
guaranteed.
Prepared drinking water is that which comes from a
fountain or is collected, and is then subject to treatment so
that it can be drunk. It is this treatment that means it can
no longer be classified – if it ever was – as spring water or
natural mineral water, and can never again opt to be classi-
fied as such (9). Just like tap water, its chemical and mineral
composition is not always constant, which means that it is
not always known and well described.
Finally, water can be bottled and distributed to house-
holds for public consumption in special circumstances, with
the sole purpose of compensating for temporary deficien-
cies in the general public water supply (9). The mineral
composition of drinking water can depend heavily on local
geological conditions.
WATER RECOMMENDATIONS
Water plays a crucial role for life and health, and is also
fundamental if human tissues are to function properly (10).
According to the European Food Safety Agency
(EFSA), the recommended daily intake of water is the
minimum amount required to balance the loss of fluids
in the human body (11). The water ingested daily comes
from both different types of drink and food. At present it
is thought that food provides approximately 20% of the
daily water needs and drinks the remaining 80%. The
EFSA set the daily recommendations for water intake for
Europeans at 2.5 liters for men and 2.0 liters for women
over 14 years of age, from both food and drink. If only
drinks are to be considered, the recommended amount of
water would be 2.0 liters/day for men and 1.6 liters/day
for women (10). These recommendations need to be in-
creased by 300 mL/day and 700 mL/day for pregnant
and lactating women, respectively.
These amounts of water would cover the needs related to
exercise, sweating and solute overload, all of which increase
the need for liquid. Exposure to cold does not modify the
need for water, but exposure to heat and stress increases
it (12).
MINERAL CONTENT IN WATER:
CONTRIBUTION TO WATER
RECOMMENDATIONS
DIFFERENCES IN THE MINERAL
COMPOSITION OF WATER
Several authors have described considerable differ-
ences in the mineral composition of bottled water and tap
water (2,4). There are also considerable differences in the
mineral content of tap water between countries and even
within the same country (2).
Table II shows the results (expressed as median [P25,
P75] and mean) of an analysis of 75 different types of
natural mineral waters on sale in Spain (data obtained from
labels, the website of the respective brands or the website
www.aguainfant.com).
Francisco Maraver, a lecturer at the Complutense Uni-
versity in Madrid, and Isidro Vitoria Miñana, from the Hos-
pital La Fe (Valencia), analyzed 109 natural mineral waters
on sale in Spain (14 of which are carbonated). Samples
were analyzed at environment temperature. The results of
this analysis expressed as median [25th and 75th percentiles]
and (mean) can be seen in table III.
As can be seen from the data in tables II and III for waters
in Spain, there are considerable variations in the chem-
ical composition of natural mineral waters within the same
country. The mean content of magnesium in still natural
mineral waters varies from 1.8 to 107.3 mg/L, the content
of sodium from 3.6 to 1,740.5 mg/L, and the content of
calcium from 3.8 to 399.6 mg/L.
Substantial variations in the concentrations of the three
most common minerals in natural mineral waters have also
been published (1). In their study, these authors reported
that the content of magnesium in bottled waters could
vary from 0 to 126 mg/L, the content of sodium from
0 to 1,200 mg/L and the content of calcium from 0 to
546 mg/L. These variations may be due to the particular
features of each spring (geological profile, residence time
and temperature) which determine the specific composition
of the water. It should also be remembered that the min-
eral composition of a spring is constant over time, so the
mineral composition of natural mineral water is also always
constant. The same cannot be said of tap water since its
composition generally varies throughout the year.
Vol. 23, N.º 1, 2016 WATER MINERALIZATION AND ITS IMPORTANCE FOR HEALTH
7
RECOMMENDATIONS ON THE INTAKE
OF KEY MINERALS: MAGNESIUM, CALCIUM
AND SODIUM
Table IV shows the daily intakes of magnesium, cal-
cium and sodium recommended by the Institute of Medi-
cine (IOM) (13) adapted to the world population.
Also with reference to the Spanish population, table V
shows the latest dietary intakes of magnesium, calcium and
sodium recommended by FESNAD (Spanish Federation of
Societies of Nutrition, Diet and Dietetics) (14).
CONTRIBUTION OF DRINKING WATER
TO MINERAL RECOMMENDATIONS
All over the world it is becoming increasingly common
for the daily intake of calcium and magnesium to be inad-
equate. In Spain, according to data from the National Sur-
vey on Dietary Intake (ENIDE) carried out in 2011, about
20-30% of the population (a percentage that can reach as
high as 82% in women between 45 and 64 years of age)
have an inadequate intake of calcium. And the percentage
of the population with inadequate intakes magnesium is
about 30%. Nevertheless, intakes of sodium have been ob-
TABLE II
CONTENT OF SODIUM, CALCIUM AND MAGNESIUM IN 75 DIFFERENT TYPES OF NATURAL MINERAL WATER
ON SALE IN SPAIN
Na (mg/L) Ca (mg/L) Mg (mg/L)
Still bottled waters (n=70)
Very low mineralized water (n = 6) 3.1 [1, 5.6] (3.3) 2.4 [0.8, 4.2] (2.5) 1.7 [0.7, 2.3] (1.6)
Low mineralized water (n = 55) 11.7 [5.2, 30] (20.2) 50 [27, 73.7] (51.3) 10.9 [5, 18] (12.3)
Medium mineralized water (n = 5)* 39.5 [7.1, 170] (57.8) 92 [70.5, 161.9] (101.9) 36.5 [11.7, 39.9] (29.1)
Highly mineralized water (n = 4)* 892 [568, 1138] (872.5) 67.4 [47, 219] (100.2) 27.8 [0.0, 77.0] (33.2)
Carbonated natural mineral waters (n=5)
Low mineralized water (n=4)* 15.5 [1, 38.5] (17.6) 39.5 [27.7, 86.6] (48.3) 10.5 [2.5, 23.3] (11.7)
Highly mineralized water (n=1)* 1115 [1115, 1115] (1115) 53.7 [53.7, 53.7] (53.7) 9.2 [9.2, 9.2] (9.2)
Median [P25, P75], except *Median [min, max] and (mean).
TABLE III
CONTENT OF SODIUM, CALCIUM AND MAGNESIUM IN 109DIFFERENT TYPES OF NATURAL MINERAL
WATERS ON SALE IN SPAIN (UNPUBLISHED DATA SUPPLIED BY THE COMPLUTENSE UNIVERSITY
IN MADRID AND HOSPITAL LA FE IN VALENCIA)
Na (mg/L) Ca (mg/L) Mg (mg/L)
Still bottled water (n = 95)
Very low mineralized water (n = 7) 3 [1.5, 6] (3.6) 3.3 [1.9, 6.6] (3.8) 1.4 [0.9, 2.3] (1.8)
Low mineralized water (n = 75) 10 [3.4, 21.4] (18.7) 39.6 [24.3, 65.2] (43.3) 9.3 [3.9, 18.1] (12.2)
Medium mineralized water (n = 11) 37.5 [32.2, 81.8] (59.5) 90.1 [74.1, 154.1] (108.16) 38.6 [19.5, 51.9] (39)
Highly mineralized water (n = 2)* 1740.5 [717, 2764] (1740.5) 399.6 [189.1, 610.2] (399, 6) 107.3 [73.4, 141.2] (107.3)
Carbonated bottled waters (n = 14)
Low mineralized water (n = 3)* 42.4 [19.7, 114.9] (59) 57.8 [11.7, 80.3] (49.9) 27.6 [6.2, 34.7] (22.8)
Medium mineralized water (n = 2)* 187.1 [156.9, 217.2] (187.1) 111.6 [82.8, 140.4] (111.6) 71 [60.4, 81.6] (71)
Highly mineralized water (n = 9) 706 [558.8, 1092.1] (820.3) 56.9 [15, 96.9] (59) 12.9 [7.9, 36.6] (22.1)
Median [P25, P75], except *Median [min, max] and (mean).
C. FERREIRA-PÊGO, ET AL. ALIM. NUTRI. SALUD
8
served to be above the daily recommended amounts (15).
The consumption of weakly, medium or strongly mineral-
ized water, which contain considerable amounts of cal-
cium and magnesium can increase the total intake of min-
erals, and bring it closer to the recommendations (4).
It is certainly true that the contribution of magnesium in
water to total intake is small in comparison to the amount
consumed through food. Even so, two liters of water with
35 mg/L of magnesium can provide 20% of the recom-
mended 350 mg/day. In comparison, two liters of water
with less than 10 mg/L of magnesium can provide less
than 10% of daily needs. The same can be said of calcium
since a liter of strongly mineralized water can provide ap-
proximately 15% of daily needs. The situation for sodium
is different since strongly mineralized water contains a very
high amount of this mineral. Thus, a liter of water that
provides 890 mg of sodium would provide about 60% of
daily intake. However, most of the weakly mineralized bot-
tled waters analyzed in this study contain no more than
20 mg/L of sodium. Therefore, the regular consumption
of natural mineral waters rich in magnesium could make a
significant contribution to the nutritional recommendations
of magnesium and sodium (16). It should be pointed out
that the Spanish population was observed to consume an
excessive amount of sodium only from food (15).
Using the mean content of sodium, calcium and
magnesium of 109 bottled natural mineral waters listed
above (Table III), we calculated the extent to which they
matched the recommendations of calcium, magnesium and
sodium. We created four examples (boy and girl between 10
and 13 years of age, and adults of both sexes), for which we
used the EFSA’s recommendations for daily liquid consump-
tion (1,680 mL for boys, 1,520 mL for girls, 1,600 mL
for women and 2,000 mL for men) and the FESNAD’s
recommendations for the daily intake of these minerals.
The results are displayed in table VI.
This analysis reveals that different types of water pro-
vide different amounts of minerals. For example, depending
on the mineralization and the sex and age of the person,
still bottled waters can provide between 0.5 and 88.8% of
calcium and between 0.9 and 65.3% of the daily recom-
mendation of magnesium. And carbonated bottled waters
can provide between 6.9 and 24.8% of the recommended
daily intake of calcium, and between 12.2 and 43.2% of
magnesium, depending on the mineralization of the water.
Several factors influence the nutritional contribution of
mineral intake through water, either at the individual or the
TABLE IV
DAILY INTAKES OF SODIUM, CALCIUM
AND MAGNESIUM RECOMMENDED BY IOM
Age Na
(mg/day)
Ca
(mg/day)
Mg
(mg/day)
6 months 120 200 30
6-12 months 370 260 75
1-3 years 1,000 700 80
4-8 years 1,200 1,000 130
9-13 years 1,500 1,300 240
Males
14-18 years 1,500 1,300 410
19-30 years 1,500 1,000 400
31-70 years 1,500 1,000 420
> 70 years 1,500 1,200 420
Females
14-18 years 1,500 1,300 360
19-30 years 1,500 1,000 310
31-50 years 1,500 1,000 320
51 years 1,500 1200 320
Pregnancy 1,500 1,000-1,300 350-400
Breastfeeding 1,500 1,000-1,300 310-360
TABLE V
DAILY INTAKES OF MAGNESIUM, CALCIUM AND
SODIUM RECOMMENDED BY FESNAD FOR THE
SPANISH POPULATION
Age Na
(mg/day)
Ca
(mg/day)
Mg
(mg/day)
6 months 120 400 40
7-12 months 370 525 75
1-3 years 1,000 600 85
4-5 years 1,200 700 120
6-9 years 1,200 800 170
Males
10-13 years 1,500 1,100 280
14-19 years 1,500 1,100 350
20-49 years 1,500 900 350
50-59 years 1,300 900 350
60-69 years 1,300 1,000 350
70 years 1,200 1,000 350
Females
10-13 years 1,500 1,100 250
14-19 years 1,500 1,100 300
20-49 years 1,500 900 300
50-59 years 1,300 1,000 300
60-69 years 1,300 1,000 320
70 years 1,200 1,000 320
Pregnancy 1,500 1,000 360
Breastfeeding 1,500 1,200 360
Vol. 23, N.º 1, 2016 WATER MINERALIZATION AND ITS IMPORTANCE FOR HEALTH
9
population level, because it depends not only on the indi-
vidual but also on the source, the amount and the frequency
of the consumption. So the general benefits on health will
depend on the total intake of liquids and other factors, as
well as the mineral composition of the water (2,3).
A control case study carried out in France on 240 men
and 424 women, using data from the SU.VI.MAX cohort,
determined the contribution made by the consumption
of natural mineral waters to the daily intake of calcium
and magnesium. The population was divided into four
groups (n = 166/group): regular drinkers of natural mineral
water rich in magnesium and calcium, drinkers of medium
mineralized water, drinkers of weakly mineralized water,
and drinkers of tap water. The results showed that, de-
pending on the concentration of calcium, natural mineral
water can contribute a quarter of the total daily intake and,
depending on the concentration of magnesium, can con-
tribute between 6 and 17% of the total daily intake. The
authors argue that natural mineral water can contribute
significantly to the total intake of magnesium and calcium.
They also point out that it can be a useful strategy for
nutrition and dietary professionals to increase the calcium
intake of patients who do not consume dairy products (17).
The people who can benefit from the minerals present in
drinking water are those who have diets that are lack-
ing in the minerals in question: for example, in areas of the
world where food is in short supply or where there are no
programs of public health for nutrient supplementation. In
those cases in which the mean intake of nutrients is below
the dietary reference intake (DRI), the minerals provided by
natural mineral water could be a supplement. Therefore,
water with lower concentrations of these elements may be
sufficient to benefit general health in some areas of the
world, but higher concentrations are required if any effect
is to be observed in other areas with greater needs (4).
Nevertheless, drinking water can be an extra source of min-
erals not only in developing countries but also in developed
countries. In Spain, for example, part of the population has
been observed to have an inadequate intake of calcium and
magnesium (15).
TABLE VI
EXTENT TO WHICH WATER INTAKE MATCHES RECOMMENDATIONS FOR MINERAL INTAKE
Boys (%) Girls (%) Women (%) Men (%)
Still natural mineral waters
Na
Very low mineralized water 0.41 0.37 0.39 0.48
Low mineralized water 2.10 1.90 2.00 2.50
Medium mineralized water 6.67 6.03 6.35 7.94
Highly mineralized water 194.93 176.37 185.65 232.06
Ca
Very low mineralized water 0.57 0.52 0.67 0.84
Low mineralized water 6.62 5.99 7.70 6.93
Medium mineralized water 16.52 14.94 19.23 24.03
Highly mineralized water 61.03 55.22 71.04 88.80
Mg
Very low mineralized water 1.06 1.07 0.94 1.00
Low mineralized water 7.32 7.42 6.51 6.97
Medium mineralized water 23.42 23.74 20.82 22.31
Highly mineralized water 64.40 65.26 57.25 61.34
Carbonated natural mineral waters
Na
Low mineralized water 6.61 5.98 6.30 7.87
Medium mineralized water 20.95 18.95 19.95 24.94
Highly mineralized water 91.87 83.12 87.49 109.37
Ca
Low mineralized water 7.62 6.90 8.87 11.09
Medium mineralized water 17.05 11.31 19.84 24.80
Highly mineralized water 8.59 8.16 10.50 13.12
Mg
Low mineralized water 13.70 13.89 12.18 13.05
Medium mineralized water 42.61 43.17 37.87 40.58
Highly mineralized water 13.26 13.44 11.79 12.63
C. FERREIRA-PÊGO, ET AL. ALIM. NUTRI. SALUD
10
Nevertheless, is important to emphasise that the first
priority in developing countries is to have potable water
availability and not the quality of the mineral content.
However the mineral content in drinking water must be
considered important in designing public health programs
in these countries.
Although research has been limited, the studies reviewed
highlight that water that is rich in minerals functions as a
supplement but never as a substitute for the calcium and
magnesium provided by food, and contributes to gener-
al balance and nutrition (2-4,6,16). More accurate data is
required and studies of greater scientific relevance need to
be carried out on the impact of the consumption of natural
mineral water and its composition under a wider range of
physiological and climatic conditions for the most vulnerable
sectors of the population. This would enable us to assess
more accurately the influence that the minerals in water
have on health and sickness.
BIOAVAILABILITY OF WATER
MINERALS
CALCIUM BIOAVAILABILITY
Only about 0.1% of total body calcium is found in the
extracellular liquid, about 1% of total body calcium is
found inside the cells and the rest is stored in bones and
teeth (18). This store can be as much as 99% of total body
calcium, which functions as a key structural element (3).
In this regard, bones act as great calcium reserves: they
store it when there is an excess but also release it when
the concentration in the extracellular liquid decreases.
The body’s calcium reserve is special in comparison with
other minerals because it is also functional: the increase
in bone mass is linearly related to a reduction in the risk
of fracture (19,20). Likewise, a clear relationship has been
reported between an insufficient intake of calcium and a
greater risk of osteoporosis (21,22). However, it should be
pointed out that bone health is related not only to calcium
but also to vitamin D (23).
Inverse relationships have also been observed between
the consumption of calcium and the risk of suffering from
other diseases (3). The calcium that is not stored in the
bone tissue has metabolic functions in many physiological
processes: for example, the contraction of skeletal, cardiac
and smooth muscle, blood clotting and the transmission of
nerve signals, among others (18). It can also have benefi-
cial effects on several non-skeletal systems of the human
metabolism (24): for example, it can act as a transduction
messenger (25).
Excitable cells such as neurons are very sensitive to
modifications in the concentration of calcium ions, so
any increase in this concentration above its normal value
(hypercalcemia) can cause excitation of the nervous
system.
Some studies suggest that when calcium comes from min-
eralized waters, just like the calcium that comes from food, it
is absorbed through the human intestine (26,27).
In a crossover experimental study, Couzy et al. (1995)
analyzed the bioavailability of calcium in drinking water
and compared it with the same amount of calcium from
milk (1,000 mg) in 9 healthy women between 21 and
36 years of age. The study was divided into two stages,
each of which lasted for five days. In each stage, for the
first three days the volunteers consumed milk containing a
specific amount of calcium (12.5 mmol/day) and for the last
two days they consumed either milk or water depending on
the study group they had been assigned to. The absorption
of calcium was determined in a fasting state using stable
isotope techniques. It was found that the calcium from water
was absorbed and retained in the same way as the calcium
from milk (28).
Heaney et al. (1994) also used a crossover study design
to study the bioavailability of calcium in calcium-rich natural
mineral water in 18 healthy women. This was then com-
pared with the bioavailability of the same amount of calcium
in milk (2.5 mmol) using the isotope 45Ca. They observed
that the calcium present in the water was highly bioavailable
(an absorption fraction of 0.475), and as bioavailable as the
calcium from milk (29).
Another crossover trial analyzed the bioavailability of
calcium from six different types of food (fresh cheese,
calcium-rich fresh cheese, fresh cheese enriched with iron,
enteral nutrition supplements, natural mineral water and
natural mineral water consumed with a meal of spaghetti).
This analysis was carried out in 12 health women between
20 and 29 years of age. Each stage of the intervention
lasted for two days and there was a wash out period of two
weeks between interventions. The absorption of calcium
was analyzed using stable isotopes (44Ca and 48Ca). The
absorption of calcium from drinking water was not signifi-
cantly different from the absorption of calcium from dairy
products. However, the absorption of calcium from natur-
al mineral water consumed with a meal of spaghetti was
significantly greater than the absorption of calcium from
the other food assessed (46.1% vs. 37%; P < 0.05) (30).
The authors believe that these results may be related to the
stimulation of the secretion of gastric acid, the formation
of soluble calcium complexes and a lower rate of gastric
emptying, which leads to a better solution. Likewise, it
should be pointed out that the consumption of calcium from
natural mineral waters did not interfere in the consumption
of calcium from other sources (largely dairy products).
Bacciottini et al. (2004) studied the bioavailability of the
calcium contained in calcium-rich natural mineral water in
27 participants (9 men, 9 pre-menopausal women and
9 post-menopausal women). Also, in eight of them the
bioavailability of calcium from water was compared with
the bioavailability of calcium from milk. The natural mineral
water and milk were marked with 30 mg of isotope 44Ca. To
ingest the same amount of calcium (100 mg), the subjects
consumed 490 mL of natural mineral water and 83 mL of
milk. It was observed that the calcium from the water was
Vol. 23, N.º 1, 2016 WATER MINERALIZATION AND ITS IMPORTANCE FOR HEALTH
11
highly bioavailable in the three groups of individuals, and
that this bioavailability was equivalent to the calcium from
the milk. Therefore, the authors suggest that calcium-rich
natural mineral water be consumed in the context of a
balanced diet that includes calcium-rich food (non-dairy
products such as almonds, nuts, cabbage, etc.) so that the
requirements of this mineral can be fulfilled in individuals
who are intolerant to lactose or overweight (since the water
is a non-caloric source of calcium) (31). However, it should
be pointed out that to consume the same amount of calcium
contained in milk, a greater volume of natural mineral water
must be consumed (the exact amount obviously depends on
its composition).
A review carried out in 2006 confirmed the results dis-
cussed above that the capacity to absorb the calcium from
all the mineral waters assessed seems to be similar to the
absorption of calcium provided by milk when they are stud-
ied in the same conditions (32).
Finally, a meta-analysis carried out in the year 2000 con-
cludes that, despite the lack of studies in small populations,
calcium from drinking water can be an interesting, effective
and supplementary alternative to calcium consumed in milk
or derivatives because of its comparable or even greater
bioavailability (25).
MAGNESIUM BIOAVAILABILITY
Magnesium is the fourth most abundant cation in the hu-
man body and the second most abundant in the intracellular
fluid. It is a cofactor in about 350 cellular enzymes, most
of which are related to energy metabolism (for example,
glycolysis and ATP metabolism) but it also modulates signal
transduction and cell proliferation. It also acts as a cofac-
tor in the transport of ions and nutrients, such as sodium,
potassium and calcium, through membranes. It is also in-
volved in protein and nucleic acid synthesis, and it is es-
sential if normal sensitivity to insulin and proper vascular
tone are to be maintained since it has been observed to be
involved in neuromuscular excitability and muscle contrac-
tion (4,33,34). Neuromuscular hyperexcitability is the first
problem perceived by individuals who present magnesium
deficiency (35). The total body reserves of this mineral are
about 25 g, and it is stored above all in bone tissue (33).
Magnesium is generally absorbed into the human body in
the intestine (principally in the ileum and the jejunum) in
the form of ions (34). The intestinal bioavailability of mag-
nesium depends on such factors as the type of salt it is
contained in, the type of dose, the amount of active in-
gredient and the deposits of body magnesium (36). After
absorption, the magnesium is transported to the tissues
where it is taken up only if required (37). Magnesium fre-
quently modulates ion transport by pumps, carriers and
channels. The second part of the transcellular transport of
magnesium is urinary excretion, which eliminates the excess
in plasma. Approximately 75% of total plasma magnesium
is filtered through the glomerular membrane. Anorexia,
nausea, vomiting, apathy and weakness are the primary
symptoms of magnesium deficiency. Severe deficiency can
cause paresthesia, muscle cramp, irritability, and attention
deficit and mental confusion (34).
In a crossover study carried out on 10 healthy men be-
tween 25 and 42 years of age, Verhas et al. (2002) analyzed
the bioavailability of magnesium from natural mineral wat-
ers. Each individual took 300 mL of natural mineral water
with 1.2 mmol of 28Mg or was given 1.2 mmol of 28Mg
intravenously in two different sessions (with a washout per-
iod of at least a week). They observed that the bioavailability
of magnesium from natural mineral water was 59% (38).
Another crossover study carried out in 10 healthy
women between 25 and 45 years of age used stable iso-
tope techniques to study the bioavailability of magnesium
from water associated with the consumption of a meal.
The population was divided into two groups of similar
ages and BMIs. For 4 days, the two groups consumed
magne sium-rich natural mineral water by itself on two alter-
nate days or accompanied by a light meal (56 g of toast,
10 g of butter and 30 g of marmalade) on the other two
days. The authors showed that the absorption and retention
of magnesium from natural mineral water was greater when
it was consumed with a light meal. The results were the
same for both groups independently of the order in which
they started the study (16). It should be pointed out that this
study was short, the sample was small and there was no
wash out period between the stages.
Another crossover study analyzed the effect on the bio-
availability of magnesium consumed in natural mineral water
in 12 healthy Caucasian males between 18 and 40 years
of age. Each subject was randomly assigned to one of the
two existing groups. All the participants consumed 1.5 liters
of natural mineral water containing a total of 84 mg. One of
the groups took seven servings of water on the first day
and two on the second, while the other group took two on
the first day and seven on the second. The results indicat-
ed that the absorption of magnesium from natural mineral
water was 32.4% when it was consumed in two servings
and 50.5% when it was consumed in seven. The authors
recommend consuming magnesium-rich water throughout
the day to cover the needs of this mineral given the greater
absorption of magnesium when water is consumed in seven
different serving (39).
For health professionals, and particularly dieticians and
nutritionists, including natural mineral water in the diet may
be a valid option to supplement the intake of calcium and
magnesium, and cover the daily dietary recommendations
for these nutrients.
POSSIBLE BENEFITS OF CONSUMING
MINERALS IN WATER
In its Geneva congress, the WHO announced that
the consumption of strongly mineralized water has no
C. FERREIRA-PÊGO, ET AL. ALIM. NUTRI. SALUD
12
known effects on health (6). What is more, as has been
mentioned above, strongly mineralized water, and par-
ticularly if it is very strongly mineralized, can provide a
considerable calcium and magnesium intake for some
individuals alongside that provided by the consumption
of source foods (17).
Some authors have suggested that the consumption of
water with medium-high concentrations of magnesium and
calcium and low concentrations of sodium (Table II) may
help to cover the daily recommendations of minerals, and
consequently improve some aspects of health (1).
CARDIOVASCULAR DISEASE
Magnesium uses cardiomyocytes to regulate the flow of
cations through the calcium and potassium channels. It is
also required to maintain normal cardiac electrophysiol-
ogy (40). Abnormally low levels of circulating magnesium
is a well-known risk factor for cardiac arrest (41).
It is currently thought that the effect of magnesium in
the prevention of cardiovascular diseases may be partly
mediated through inflammation. An increase in extracellu-
lar magnesium concentrations can reduce inflammatory
response, while a decrease can activate phagocytes and
endothelial cells. It is also thought that the inflammation
caused by magnesium deficiency may be the mechanism
that induces hypertriglyceridemia and pro-atherogenic
changes in the lipoprotein profile (42-44). The consumption
of magnesium has been inversely associated with markers of
systemic inflammation and endothelial dysfunction in the
general population (45) and post-menopausal women (46).
Likewise, endothelial cells make an active contribution to
inflammation in states of magnesium deficiency.
At the physiological level, magnesium is regarded as a
calcium blocker, so it reduces the release of calcium from
and to the sarcoplasmic reticulum, and protects the cells
against calcium overload during ischaemia (47-49). Magne-
sium reduces systemic and pulmonary vascular resistance,
with the resulting decrease in arterial pressure and a slight
increase in the cardiac index (50-52). Any increase in the
levels of extracellular magnesium reduces arterial tone, and
increases the endogenous dilation (adenosine, potassium
and some prostaglandins) and exogenous dilation (isoproter-
enol and nitroprusside) of some vasodilators (47,49,53,54).
As a result, magnesium slightly reduces systolic and diastolic
arterial pressure (55).
In a recent prospective study carried out in a population
at high cardiovascular risk by our group of research, an
inverse relationship was observed between the consump-
tion of magnesium from the diet (without taking the con-
sumption of natural mineral water into account) and the
incidence of cardiovascular disease, cancer and all-cause
disease (56). A recent meta-analysis has assessed the as-
sociation between magnesium and the risk of suffering a
cardiovascular event, and demonstrated that both serum
magnesium and magnesium from the diet are inversely re-
lated to the total risk of cardiovascular events (57). In two
other recent meta-analyses, similar effects were observed
between the high consumption of magnesium and a re-
duced risk of suffering a cerebral vascular accident or heart
ischemic disease (43,58).
The relationship between the intake of both magnesium
and calcium from strongly mineralized waters and the ef-
fects of these minerals on various aspects of health is con-
troversial. Previous studies suggest an inverse relationship
between the intake of magnesium and calcium from drink-
ing water and levels of arterial pressure (59-61). According
to a recent review by Sengupta, most large-scale studies
have observed an inverse relation between the consump-
tion of strongly mineralized water and cardiovascular dis-
ease (6,62,63). However, other studies have not observed
this relation (64-65).
Leoni et al. (1985) studied the relation between the
hardness of water and the pattern of mortality as a result
of cardiovascular diseases, ischemic disease and cerebro-
vascular diseases in the region of Abruzzio (Italy) in a town
of 594,323 inhabitants. They observed an inverse relation
between the prevalence of cardiovascular mortality and the
hardness of the water, but only in the population between
45 and 64 years of age (66).
Case-control studies carried out in Sweden on
1,746 women (67) and 1,843 men (68) between 50 and
69 years of age compared the consumption of calcium
and magnesium from water among those who had died
of myocardial infarction (cases) and those who had died of
cancer (controls). Both studies revealed an inverse rela-
tion between the consumption of magnesium from natural
mineral water and mortality by myocardial infarction. In
women, but not in men, this inverse relation was also
observed with the consumption of calcium from natural
mineral water (67).
In Finland and South Africa an inverse relation was also
observed between the concentrations of magnesium in
drinking water and the risk of death attributed to ischemic
heart disease (69).
Since then, several studies have reported an inverse re-
lation between the hardness of water and cardiovascular
disease, particularly in relation to the content of magnesium
and calcium in drinking water. Nevertheless, it also points
out that more large-scale and longer-lasting epidemiological
studies are required to determine how the consumption of
natural mineral water and its components (mainly calcium
and magnesium) affects health.
CEREBROVASCULAR MORTALITY
The lack of magnesium leads to a decrease in the intra-
cellular concentration of potassium and an increase in cal-
cium levels. It can also increase the contractility of blood
vessels. Magnesium causes vasodilation by stimulating the
Vol. 23, N.º 1, 2016 WATER MINERALIZATION AND ITS IMPORTANCE FOR HEALTH
13
release of endothelial prostacyclin and, in vivo, it prevents
the vasoconstriction of intracranial vessels after experiment-
al subarachnoid haemorrhage (6).
Some epidemiological studies have shown that calcium
from the diet (not taking into account the calcium from
natural mineral water) is inversely associated with levels of
arterial tension. These results suggest that it is reasonable
to expect that the intake of calcium in the diet may reduce
the risk of cerebrovascular events (70). Nevertheless, so
far there have been no solid epidemiological studies, or
intervention studies, to confirm this.
CANCER
Some studies suggest an inverse relation between the
intake of calcium from the diet and the risk of colorectal
cancer (71). However, very few studies have examined the
relation between the consumption of certain minerals from
water and the risk of cancer.
Some case-control studies suggest an inverse associ-
ation between the intake of calcium and magnesium from
drinking water and the risk of mortality as the result of co-
lon cancer (72) or gastric cancer (73,74). In these studies,
the population was divided into tertiles according to the
content of calcium and magnesium in the water supply of
their area of residence. Gastric or colon cancer mortality
(cases) was compared with all-cause mortality (controls in
the area between 1987 and 1993). The authors revealed
a negative relation between higher contents of calcium in
the water supplied and the risk of mortality as a result of
gastric or colon cancer (72,73). In the case of magnesium,
an inverse relation was only observed in those individuals
whose water had higher contents of magnesium and gastric
cancer (73). More recent studies also support the inverse
relation between the intake of calcium and the lower risk
of gastric cancer (74).
Recently, another case-control study examined the in-
take of calcium and magnesium from drinking water and
lung-cancer mortality in women. No significant relationship
was observed (75).
Therefore, to date, the scientific evidence available is not
sufficient to demonstrate a relationship between the intake
of calcium and magnesium from natural mineral water and
the risk of suffering from several types of cancer.
DIABETES MELLITUS
Magnesium plays an important role in the physiopathol-
ogy of diabetes mellitus. Magnesium deficiency in cells can
decrease the insulin secretion through interaction with cell
calcium homeostasis (76). Hypomagnesemia is common to
individuals diagnosed with type 2 diabetes mellitus (77–79).
In this regard, important prospective epidemiological stud-
ies (44,80,81) have assessed the intake of magnesium from
the diet and the risk of developing type 2 diabetes. In a
study of 85,060 women and 42,872 men, followed for
18 and 12 years, respectively, it was observed that those
subjects in the highest quintile of magnesium intake from
the diet had a protection against developing type 2 dia-
betes of 34% in women and 33% in men (80). More recent
studies also confirm this association in Japanese (81) and
American populations (44). It has been suggested that the
inverse association between magnesium consumption and
the incidence of diabetes is mediated by an improvement
in sensitivity to insulin and a reduction in inflammatory pro-
cesses, as has been observed in intervention studies with
magnesium supplements (82). Hruby et al. (2014) showed
that a higher intake of magnesium was associated with a
37% lower risk of undergoing alterations in levels of plasma
glucose and a 32% lower risk of developing diabetes in
those who already presented altered basal glucose at the
beginning of the study (44).
A 20-year prospective study on 83,779 women ana-
lyzed the relationship between the consumption of calcium
and the risk of type 2 diabetes. The authors observed that
women with a total daily calcium intake (diet + supple-
ments) that was equal to or above 1,200 mg presented
a 21% lower risk of developing diabetes than those who
consumed less than 600 mg/day (83). Similar results with
respect to protection against type 2 diabetes were observed
in other prospective studies (84,85), reviews (86) and me-
ta-analyses (87) which assessed the consumption of cal-
cium from the daily intake of dairy products. One important
meta-analysis reported a relationship between intake or cal-
cium serum levels and the prevalence or incidence of type 2
diabetes. However, the authors conclude that the available
scientific evidence is limited since most of the studies are
cross-sectional and in many cases were not adjusted for
important confounding factors (88).
Although the relationship between magnesium consump-
tion and diabetes seems to be quite clear, a sufficient num-
ber of studies have not proved that there is a relationship
between magnesium from natural mineral waters and the
prevalence or incidence of type 2 diabetes. Likewise, to
date no studies have related the consumption of calcium
from natural mineral waters with glucose metabolism.
NEPHROLITHIASIS
At present, there is general consensus consuming large
amounts of liquid can help prevent urinary lithiasis because
it decreases the concentrations of elements that can crys-
talise (89). However, there is some controversy about the
possible impact of the different qualities of natural min-
eral water, including the hardness, on the risk of renal
calculi (90).
A cross-sectional study carried out in 4,833 patients with
a history of nephrolithiasis examined the hardness of the
C. FERREIRA-PÊGO, ET AL. ALIM. NUTRI. SALUD
14
water habitually consumed in the geographical area they
lived in and the number of episodes of renal calculi that
they presented. No significant differences were observed.
However, the concentrations of calcium, magnesium and
citrate present in urine over 24 hours correlated directly
with the content of these minerals in drinking water (91).
A study carried out in 29 men with a history of renal
calculi (n = 14) and patients without the pathology (n = 15)
examined the effect of consuming three different types of
water (minimal hardness, moderate hardness [tap water]
and maximum hardness) on urinary parameters. The au-
thors observed that in the group that had experienced
nephrolithiasis, the calcium-creatine ratio increased with
the hardness of the water consumed, which lead to a great-
er risk of renal calculi. These results were not observed in
the group with no history of the pathology. The patients
with a history of nephrolithiasis also presented a ratio of
magnesium/creatine excretion that was significantly lower
than that of the patients without the pathology. The auth-
ors regard that this parameter may be one of the reasons
why patients with a history of nephrolithiasis tend to form
renal calculi (90).
A random, double-blind, crossover study carried out
on 18 patients with idiopathic nephrolithiasis analyzed
whether the hardness of the water consumed modified
the risk of renal calculi if it was consumed apart from the
main meals. The consumption of strongly mineralized
water was associated with a 50% increase in the urinary
concentration of calcium with no changes in the excre-
tion of oxalates, and tripled the calcium citrate index in
comparison with the consumption of weakly mineralized
water. The authors suggest that the recurrence of renal
calculi can be reduced if weakly mineralized water is con-
sumed apart from main meals because it is associated with
the lowest risk (92).
Siener et al. (2004) carried out an intervention study on
12 healthy men. They analyzed the effect of calcium-rich
natural mineral water (232 mg/L), magnesium (337 mg/L)
and bicarbonate (3,388 mg/L) on the composition of urine.
The authors observed that the content of magnesium and
bicarbonate in natural mineral water led to favorable chan-
ges in urinary pH, the excretion of magnesium and citrate,
and inhibitors of the formation of calcium oxalate calculi.
Nevertheless, the urinary excretion of oxalate did not dimin-
ish. Therefore, further studies are required if we are to be
able to affirm that the intake of calcium-rich natural mineral
water can limit intestinal absorption and the urinary excre-
tion of calcium and oxalate (93).
To date no association has been demonstrated between
the hardness of water, its composition and calcium content,
and the formation of urinary calculi. Some studies suggest
that the consumption of weakly or very weakly mineral-
ized water may be more beneficial for the prevention of
renal lithiasis than the consumption of strongly mineralized
water, since it is associated with a lower risk of recurrence
of calcium calculi (92,94). However, to reduce the risk of
the recurring formation of calcium calculi, the European
Association of Urology recommends an adequate con-
sumption of calcium and only recommends restriction for
important individual health reasons and always following
specialist medical advice (89). The formation of renal calculi
is a complex process that has not been fully clarified, and
factors such as diet, physical activity, environmental condi-
tions, medicines, supplements and underlying diseases can
be important factors (90).
MINERAL BONE DENSITY
As has been pointed out previously, although dairy prod-
ucts are the main source of calcium from the diet, the cal-
cium from natural mineral water can make a valuable extra
contribution of calcium (95).
A cross-sectional study was made of the relationship
between the consumption of calcium from natural mineral
water and the femoral bone density in 4,434 women of
more than 75 years of age from the EPIDOS cohort. It was
observed that an increase of 100 mg/day of calcium from
natural mineral water was associated with an increase of
0.5% in femoral bone density, while a similar increase in
the consumption of calcium from other sources of the diet
was only associated with a greater bone density of 0.2%,
although the difference was not significant. The authors
suggested that the consumption of calcium-rich water may
make an extra contribution, particularly in adult and elderly
women who consume little calcium from food such as dairy
products (95). Likewise, in a study carried out in Norway on
5,472 men and 13,604 women between 50 and 85 years
of age followed for between 3 and 14 years an inverse rela-
tionship was observed between the consumption of calcium
and magnesium from water and the risk of hip fracture. The
authors concluded that the magnesium present in drinking
water may protect against hip fractures. Further research
is required to provide more scientific evidence and clarify
this possible relationship (96).
In a cohort study of 255 women, Costi et al. (1999)
analyzed the importance of calcium from water for main-
taining the bone mass. They divided the participants into
two groups: those who regularly drank strongly mineral-
ized water (group A) and those who consumed different
types of water with a lower content of calcium (group B).
The mean values of bone density were slightly (but signifi-
cantly) higher in the participants from group A, even after
adjusting for confounding variables such as age, BMI and
menopause (97).
Nevertheless, the influence of calcium and magnesium
on bone health may be affected not only by their concentra-
tion in natural mineral water, but also by the concentrations
of other minerals. For example, in a crossover study carried
out on 39 post-menopausal women (mean age 64 years
old), it was observed that, with the same concentration of
calcium, a bicarbonate-rich water had a more positive effect
on the metabolism than a sulfate-rich water. In the group
that consumed water rich in calcium and bicarbonate, the
Vol. 23, N.º 1, 2016 WATER MINERALIZATION AND ITS IMPORTANCE FOR HEALTH
15
ionized calcium in the urine and its pH increased, while the
parathyroid hormone (PTH) and bone resorption markers
decreased (98).
In a double-blind, randomized trial controlled with pla-
cebo for six months, Meunier et al. (2005) observed similar
results. Their objective was to assess the effects of the daily
consumption of calcium-rich natural mineral water on the
levels of PTH in serum and several biochemical markers
of bone remodeling. It was carried out on 176 post-meno-
pausal women (mean age 70 years old) who presented a
low calcium intake (< 700 mg/day). The placebo group
consumed 1 liter of natural mineral water with low cal-
cium content (10 mg/L), and the test group consumed
1 liter of natural mineral water with high calcium content
(596 mg/L). The authors observed that after an interven-
tion of six months with calcium-rich water, the PTH levels
decreased by 14.1%. These decreases were in the order
of 8.6% for osteocalcine, 11.5% for bone alkaline phos-
phatase, and 16.3% and 13% for type 1 collagen in serum
and urine, respectively. The authors concluded that a daily
calcium supplement of 596 mg through the consumption
of 1 liter of calcium-rich natural mineral water can help to
reduce age-related bone loss (99).
IN SUMMARY
In accordance with the existing literature on the con-
sumption of calcium or magnesium, or both, from drinking
water, it is suggested that there is an inverse relationship
with the risk of colorectal cancer, gastric cancer, cerebro-
vascular and cardiovascular diseases, cardiovascular-cause
mortality, diabetes mellitus, nephrolithiasis and even bone
diseases. However, the relation between the consumption
of drinking water rich in minerals and their effect on various
aspects of human health have not been sufficiently elucidat-
ed, so it is clear that more epidemiological studies need to
be carried out on larger populations and for longer periods
before any recommendations can be made to the general
population (95,96,99).
RISK OF VERY-LOW MINERALIZED WATER
CONSUMPTION
A WHO report has evaluated some years ago the pos-
sible harmful effects of drinking this type of water, however
the lack of research on this issue was evident, conducting a
series of recommendations for minimum, maximum and/or
optimal mineral content of water (Table VII). The potential
adverse effects of demineralized water have not sufficiently
been studied to date since this type of water is not normally
found freely in nature, except in the form of rain water and
naturally formed ice. Unfortunately, during the last two dec-
ades, little research has been carried out into the beneficial
or harmful effects of some minerals from drinking water.
CONCLUSION
Different types of water make widely varying dietary con-
tributions of calcium, magnesium and sodium. For example,
in Spain depending on the type of mineralization of still
bottled waters, they can provide between 0.5 and 88.8% of
calcium recommendations, between 0.9 and 65.3% of mag-
nesium and between 0.4 and 232.1% of sodium. Also de-
pending on mineralization, carbonated waters can provide
between 6.9 and 24.8% of the recommended intake of cal-
cium, between 12.2 and 43.2% of magnesium and between
6.6 and 109.4% of sodium. However, in this review most of
the waters analyzed are weakly mineralized natural mineral
waters that can provide between 6 and 7.7% of calcium,
TABLE VII
WHO RECOMMENDATIONS ON MINIMUM, MAXIMUM AND/OR OPTIMUM MINERAL CONTENT OF VERY WEAKLY
MINERALIZED WATERS (TDS<50 mg/L)
Minimum levels Optimum levels Maximum levels
Total dissolved salts 100 mg/L 250-500 mg/L ND
Alkalinity ND ND 6.5 mEq/L
Bicarbonate 30 mg/L ND ND
Calcium 30 mg/L ND ND
Magnesium 10 mg/L 20-30 mg/L ND
Sodium ND ND 200 mg/L
Boron ND ND 0.5 mg/L
Bromine ND ND 0.01 mg/L
ND: No data.
C. FERREIRA-PÊGO, ET AL. ALIM. NUTRI. SALUD
16
between 6.5 and 7.4% of magnesium and between 1.8 and
2.5% of sodium. These results indicate that drinking water
can be a source of extra minerals not only in developing
countries but also in such developed countries as Spain, the
population of which presents an inadequate consumption
of calcium and magnesium. Moreover, despite the limited
amount of scientific evidence available to date, the calcium
and magnesium from drinking water may be an interesting,
effective and complementary alternative to consuming these
minerals through food because their bioavailability is similar
or even greater. Although food are the principal source
of this minerals, for health professionals, particularly diet-
itians-nutritionists, the inclusion of natural mineral waters
in the diet may be a valid option to complement the intake
of calcium and magnesium, and therefore cover the daily
dietary recommendations of these nutrients. The existent
scientific literature suggests that the consumption of calcium
and/or magnesium from drinking waters are inversely relat-
ed to the risk of some chronic diseases. If these relations are
to be firmly established, however, further epidemiological
studies on large population samples are required
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... According to classification in [7,23,26], the water of the examined lakes by the averaged values of TDS in the period of summer stratification, were classified into the following categories: ultra-fresh (<100 mg/L)-Biosadskoe (19) < Srednii Pert (28) = Pit'evoe (28) < Svyatoe (33) < Bolshoe Kumozh'e (36) < Nizhnii Pert (38) < Bannoe (39); fresh (100-500 mg/L)-Lesnoe (102) < Varvarinskoe (115). In this case, the variations of water electric conductance and TDS for the lakes were not large, except for the Varvarinskoe and Lesnoe lakes. ...
... Mineral water comes from natural groundwater reservoirs and mineral springs, giving it a much higher 'mineral' content than tap water -minerals such as salts of magnesium, calcium, bicarbonate, sodium, sulphate, chloride and fluoride, as well as other naturally occurring chemical constituents are present in varying amounts (Ferreira-Pêgo et al., 2016;Quattrini et al., 2017). The types and amounts of minerals and other chemical constituents in 'highly mineralised waters', so also their health benefits, vary greatly and depend on the location from which the water comes. ...
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... Despite the extensive database of experimental and theoretical research findings on droplet collisions, the collision behavior of liquids with different mineralization levels remains understudied. These liquids are often used in industrial processes such as oil recovery (Chaturvedi et al. 2021), emulsification (Jiang et al. 2020), mineral flotation, oil flooding (Khajepour et al. 2020), etc. Mineralization, often referred to as salinity, is understood as the concentration of mineral and organic substances dissolved in water, with the exception of gases (Ferreira-Pêgo et al. 2016 Page 3 of 15 _####_ minerals, soluble additives or pollutants in water changes its properties and, hence, affects the characteristics of droplet evaporation and surface transformation as they travel in a gaseous medium as well as their collision behavior. Nowrouzi et al. (2019a) established that increasing the salinity of water by adding chemical additives (soluble ions) increased the efficiency of oil recovery by reducing interfacial tension. ...
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Increasingly bottled Natural Mineral Water (NMW) is proposed as a healthy and safe alternative to supply water. However, tap supply water often comes from aquifers (TGW), even from the same aquifers as NMW, sharing the exact formation mechanisms and mineralization processes. Therefore, it is hypothesized that NMW and TGW cannot be distinguished. The chemical composition of TGW and NMW samples in Spain has been compared using five criteria: expert judgment, hydrochemistry, legal regulations, statistical analysis, and machine learning (ML). Hydrochemical criteria included all the NMW samples in the TGW group, as did the legal criterion, whereas classical statistical analysis could not find significant differences between the two groups. Although experts could correctly differentiate a small subsample of both types of water with an accuracy of 0.67, ML-based classification with Extreme Gradient Boosting yielded a balanced accuracy of 0.92 on an extremely imbalanced data set. Shapley Additive Explanations (SHAP) analysis identified pH, SiO2, E, K+, Ca2+, K+/Na+ and NO3- as the most relevant variables for water type discrimination. The overall consistency and generalization ability of the ML classifier has been proven by the spatial distribution of hits and misses, where the few cases of indistinguishable waters seem to be related to proximity to nature reserves (i.e., land use) more than to geological characteristics. Therefore, it can be concluded that NMW and TGW are indeed different and that only ML could find the hidden structure in the chemical data that determines the differences. This structure originates in how the market and consumers decide which water is ultimately bottled. The results can help on future choices of TGW and NMW in a context of water scarcity.
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