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BioFact Environmental Health Research Center, Bjorkasvagen 21, 44391 Lerum, Sweden
* To whom correspondence should be addressed. E-mail: envhealth{at}biofact.se.
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ABSTRACT |
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 TOP ABSTRACT IntroductionLITERATURE CITED |
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Introduction |
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TOPABSTRACTIntroductionLITERATURE CITED |
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A lack of magnesium and calcium may cause severe disease. These cations regulate muscular contractility, and a lack of magnesium leads to an increase in vascular tension and a lower muscular contraction threshold. This results in an increased risk of cardiovascular disease in terms of arrhythmia, muscular contraction, and a decreased fibrillation threshold, which may cause sudden death. Lack of calcium induces a deficiency in the bone reservoirs with consequent brittleness of the bones and an increased risk of fractures (osteoporosis).
Drinking water and disease
Some data suggest that the supply of minerals from drinking water is of importance for the mineral homeostasis. The first study demonstrating a relation between water quality, other than microbial contamination, and health risks came from Japan (1). The study related the death rate in apoplexy (sudden death) in different parts of Japan to the acidity of river waters. This was followed by a number of studies in different countries where water hardness and later the content of magnesium and calcium was used as the criterion for water quality. Critical evaluations of these data have been presented (2,3). Ecological studies in which groups of populations in different geographical areas are compared have been made in many different countries, and 10 of 23 such studies demonstrate an inverse relation between hardness and cardiovascular death.
Only 3 case-control studies with a control of other sources of magnesium intake and with a relevant range in the content of magnesium in the drinking waters have been reported (4–6). The risk of death by heart infarction was inversely related to the amount of magnesium in the drinking water, but significant differences were only found at 7.8 mg/L and above. At 17 mg/L Mg, the odds ratio was 0.65 (4). Similar results were found in the other studies (5,6). Another case-control study in which no relation was found compared only very low levels of magnesium and thus did not have the power to evaluate the relation (7).
Epidemiological studies can never prove causality, and intervention studies are required to assess this. Regarding diseases with a long-term induction such as cardiovascular disease, such intervention studies are not feasible. One must thus rely on studies that measure the homeostasis of the minerals or the effects on risk indicators for cardiovascular disease such as blood pressure.
Intervention studies
A number of intervention studies have been performed to assess the effect of minerals on risk indicators of cardiovascular disease. A meta-analysis of 33 studies on potassium intervention concluded that there might be a beneficial effect on blood pressure (8). Several of the studies reviewed were, however, dietary intervention studies, and thus, the intervention in reality comprised several minerals and other agents.
Regarding single minerals, several studies have been reported in which hypertensive persons were treated orally with nutritional doses of magnesium, and a review has been published (9). It was concluded that there was a suggestion of a dose-dependent reduction in blood pressure from the magnesium intervention but that the relation must be confirmed in larger studies, using higher doses of magnesium. The information was not considered sufficient for clinical application. Patki et al. (10) found no effect of magnesium supplementation but a decrease in blood pressure after treatment with potassium. Two studies reported a very small effect of calcium supplementation (11,12).
In summary, the results from these and other intervention experiments with the single elements calcium and magnesium are ambiguous and do not allow a clear-cut conclusion regarding causality.
An alternative hypothesis
There is considerable evidence that acid-base conditions in the body influence the mineral homeostasis. Each nutrient has an influence on the renal acid load (13). This is determined by the sum of major anions less the sum of major cations. Protein is a major inducer of acid load because of the formation of sulfur ions during the metabolism of amino acids.
The importance of acid-base conditions for mineral homeostasis has been demonstrated in a number of intervention studies (14,15). There is also evidence on health outcomes. In an investigation on 1413 women and 1125 men, a relation was found between osteoporosis and consumption of cola beverages but not other carbonated soft drinks (16). The likely explanation is that the phosphoric acid present in cola beverages leads to an increased acid load with a higher secretion of minerals (17). In an intervention study on 181 postmenopausal women, the administration of potassium citrate, which shifts the balance to the basic side, led to an increased bone mineral density and a reduction in urinary calcium excretion (18). A study on a population sample demonstrated a close association between the net excretion of acids and the amounts of magnesium and calcium in the urine (19). In comparison to a younger age group, the effects were more pronounced, suggesting that the elderly are a risk group for mineral deficiency caused by acid conditions in the body (20).
There is also support for the concept that drinking-water-related acid-base conditions play an important role for mineral homeostasis. Natural mineral waters represent a substantial alkaline load and may influence the calcium homeostasis and bone remodeling (21,22). In an intervention study, drinking water containing 403 mg/L hydrogen carbonate was found to reduce the blood pressure in a group of 20 subjects with mild hypertension (23).
Regarding the previously discussed studies on the relation between death in heart infarction and the content of magnesium in drinking water (4–6), it is of interest that there is a close relation between the concentrations of magnesium and hydrogen carbonate in drinking water sources in Sweden. Figure 1 illustrates the relation between death from heart infarction and the drinking water concentration of magnesium (4) as well as the corresponding values for hydrogen carbonate.
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From evaluations of the literature, it has been concluded that there is some evidence for a relation between the drinking water content of magnesium and calcium and the risk for cardiovascular disease. New data suggest that acid/base conditions in the body are of importance for the homeostasis of the minerals calcium and magnesium. Because drinking water contains hydrogen carbonate and thus influences mineral homeostasis, health criteria for a good drinking water should include a sufficient content of hydrogen carbonate.
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FOOTNOTES |
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2 The population study was supported by an independent research grant from Protina to Gothenburg University, Gothenburg, Sweden.
3 Author disclosures: R. Rylander, no conflicts of interest.
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LITERATURE CITED |
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TOPABSTRACTIntroductionLITERATURE CITED |
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1. Kobayashi J. On geographical relations between the chemical nature of river water and death rate from apoplexy. Ber Ohara Inst. 1957;11:12–21.
2. Rylander R. Environmental magnesium deficiency as a cardiovascular risk factor. J Cardiovasc Risk. 1996;3:4–10.[Medline]
3. WHO. Nutrients in drinking water. Geneva: WHO; 2005.
4. Rubenowitz E, Axelsson G, Rylander R. Magnesium in drinking water and death from acute myocardial infarction. Am J Epidemiol. 1996;143:456–62.
5. Rubenowitz E, Axelsson G, Rylander R. Magnesium and calcium in drinking water and death from acute myocardial infarction in women. Epidemiology. 1999;10:31–6.[Medline]
6. Rubenowitz E, Molin I, Axelsson G, Rylander R. Magnesium in drinking water in relation to morbidity and mortality from acute myocardial infarction. Epidemiology. 2000;11:416–21.[CrossRef][Medline]
7. Rosenlund M, Berglind N, Hallqvist J, Bellander T, Bluhm G. Daily intake of magnesium and calcium from drinking water in relation to myocardial infarction. Epidemiology. 2005;16:570–6.[CrossRef][Medline]
8. Whelton PK, He J, Cutler JA, Brancati LJ, Appel LJ, Follman D, Klag MJ. Effects of oral potassium on blood pressure. Meta-analysis of randomized controlled clinical trials. JAMA. 1997;277:1624–32.
9. Jee SH, Miller ER, Guallar E, Singh VK, Appel LJ, Klag MJ. The effect of magnesium supplementation on blood pressure: A meta-analysis of randomized clinical trials. Am J Hypertens. 2002;15:691–6.[CrossRef][Medline]
10. Patki PS, Singh J, Gokhale PM, Shroti DS, Patwardhan B. Efficacy of potassium and magnesium in essential hypertension: A double blind, placebo controlled, crossover study. BMJ. 1990;301:521–3.
11. Bucher HC, Cook RJ, Guyatt GH, Lang JD, Cook DJ, Hatala R, Hunt DL. Effects of dietary calcium supplementation on blood pressure. A meta-analysis of randomized controlled trials. JAMA. 1996;275:1016–22.
12. Cappuccio FP, Siani A, Strazzullo P. Oral calcium supplementation and blood pressure: an overview of randomized trials. J Hypertens. 1989;7:941–6.[CrossRef][Medline]
13. Remer T, Mantz F. Potential renal acid load of foods and its influence on urine pH. J Am Diet Assoc. 1995;95:791–7.[CrossRef][Medline]
14. Lutz J. Calcium balance and acid-base status of women as affected by increased protein intake and by sodium bicarbonate ingestion. Am J Clin Nutr. 1984;39:281–8.
15. Böhmer H, Müller H, Resch K-L. Calcium supplementation with calcium-rich mineral waters: a systematic review and meta-analysis of its bioavailability. Osteoporos Int. 2000;11:938–43.[Medline]
16. Tucker KL, Morita K, Qiao N, Hannan MT, Cupples LA, Kiel DP. Colas, but not other carbonated beverages, are associated with low bone mineral density in older women: The Framingham osteoporosis study. Am J Clin Nutr. 2006;84:936–42.
17. Heaney RP, Rafferty K. Carbonated beverages and urinary calcium excretion. Am J Clin Nutr. 2001;74:343–7.
18. Jehle S, Zanetti A, Muser J, Hulter HN, Krapf R. Partial neutralisation of the acidogenic western diet with potassium citrate increases bone mass in postmenopausal women with osteopenia. J Am Soc Nephrol. 2006;17:3213–22.
19. Rylander R, Remer T, Berkemeyer S, Vormann J. Relationship of magnesium and acid-base balance in an elderly population. J. Eur J Nutrition. 2006;136:2374–7.
20. Remer T, Berkemeyer S, Rylander R, Vormann J. Muscularity and adiposity in addition to net acid excretion as predictors of 24-h urinary pH in young adults and elderly. Eur J Clin Nutr. 2007;61:605–9.[Medline]
21. Roux S, Baudoin C, Boute D, Brazier M, del la Gueronnière V, de Vernejoul MC. Biological effects of drinking-water mineral composition on calcium balance and bone remodelling markers. J Nutr Health Aging. 2004;8:380–4.[Medline]
22. Meunier PJ, Jenvrin C, Munoz F, de la Guerrinière V, Garnero P, Menz M. Composition of a high calcium mineral water lowers biochemical indices of bone remodeling in postmenopausal women with low calcium intake. Osteoporos Int. 2005;16:1203–9.[Medline]
23. Rylander R, Arnaud MJ. Mineral water intake reduces blood pressure among subjects with low urinary magnesium and calcium levels. BMC Public Health. 2004;4:56–65.[CrossRef][Medline]
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