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OCR for page 265
v
The Contribution of
Drinking Water to
Mineral Nutrition in
Humans
GENERAL CONSIDERATIONS OF MINERAL INTAKE FROM WATER
The initial undertaking of the first Safe Drinking Water Committee
(SDWC) was the identification of substances and their concentrations in
the national water supply that might pose risks to the public health and,
therefore, require the setting of limits. The committee's report, Drinking
Water and Health (National Academy of Sciences, 1977) contained gaps
for which data were not available or were just emerging at the time the
report was written. In other cases. the data were not reviewed in depth
because the specific substances were not considered pertinent to the
initial charge of the committee, i.e., identification of adverse conse-
quences of various substances in water.
One such area was that of nutrients, known to be essential or strongly
suspected as being necessary for optimal health of humans and animals.
While a few of the nutrients, notably the trace elements, were reviewed in
the first report, the coverage was generally toxicological. The committee
examined them as sources of potential risk to human populations.
In view of these considerations, the second Safe Drinking Water
Committee established a Subcommittee on Nutrition arid charged it with
the responsibility of reviewing this area by selecting elements of interest
and evaluating the effects of their presence in water. In this report, the
subcommittee has examined the concentrations of nutrients in dr eking
water and the contribution of these concentrations to the observed
265
OCR for page 266
266 DRINKING WATER AND H"LTH
intake and optimal nutrient requirements of human populations. It
studied the benefits of the presence of an element in water and, in cases
in which symptoms of both deficiency and toxicity are known to occur,
adverse effects. This is a departure from most of the studies of the
SDWC conducted previously or in progress, which were or are limited to
adverse effects. The subcommittee chose to title this review The
Contribution of Drinking Water to Mineral Nutrition in Humans, focusing
on the positive effects of suites of elements that are known or assumed to
interact in the environment or in biological systems.
In Drinking Water and Health (National Academy of Sciences, 1977),
the committee reviewed eight metals (chromium, cobalt, copper, magne-
si-am~ manganese, molybdenum, tin, and zinc) that are essential to
human nutrition. The nutritional aspects of others, such as nickel,
selenium, arsenic, and vanadium, were not considered. Rather, their
toxicity was reviewed. In this study the subcommittee has reviewed
potassium, chlorides iron' calcium, phosphorus, and silicon, and has
extended the original review only where there was a need for updating or
for examining ~ particular element as a nutrient as opposed to a
potentially toxic substance. In the section on fluoride, the subcommittee
decided against including an in-depth review because of its uncertainty
concerning fluoride's essentiality to nutrition. However, in view of the
contribution of fluoride to overall dental health and, through this, its
eject on total health, some discussion of fluoride has been included.
Chromium has not been dealt with at great length because it is not
certain that the nutritionally useful form of the element occurs in water.
It is generally thought that cobalt has nutritional value only as a
component of vitamin By. Although some preliminary studies suggest
that inorganic cobalt may have a physiological role independent of its
functon in vitamin BE (Roginski and Mertz, 1977), cobalt has not been
discussed in this chapter.
The subcommittee also examined the difference in water intake
between young and adult humans. Infants (7 kg) consume approximately
one-third as much water on the average as an adult, but their body
weight is only approximately one-tenth of adult weight and their food
intake is also obviously lower. For this reason, the water intake of an
infant may contribute a significant quantity of a given element (National
Academy of Sciences 19744.
When people consume unusual diets, e.g., the diets of vegans. who
consume no animal foods or dairy products, the intake of certain
elements may be significantly different from the average. Athletes or
people engaged in heavy labor and those living in a hot climate consume
larger than normal amounts of water. In these instances, the contribution
OCR for page 267
Contribution of Drinking Water to Mineral Nutrition 267
of water to the overall nutrient intake may be significantly different from
the average.
The contributions from air have been considered only when amounts
of possible significance were suspected. Where such contributions were
negligible, no comment has been made. Only in rare instances. such as
unusually high airborne levels, might air contribute to the nutrient needs
of individuals. It is not always known whether elements taken in from
such exposures are used for nutritional (metabolic) purposes.
Requirements for nutrients are generally discussed in terms of the
recommended dietary allowances (RDA's) (National Academy of
Sciences, 1974) or those intakes that have been judged adequate and safe
(National Academy of Sciences 1980) not minimal intakes necessary
for survival.
The subcommittee examined the new literature on water hardness
because it involves nutritionally essential elements. However, it found no
significant conclusive data concerning the relationship of water hardness
and the incidence of cardiovascular disease since Drinking Water and
Health (National Academy of Sciences, 1977) was published. An
extensive evaluation of the literature in this area has recently been
published (National Academy of Sciences, 19791. Therefore, this topic is
not covered in this report.
Clearly, some elements that have been reviewed are subject to changes
in concentration in water because of the activities of humans. Elements
in this category are zinc, copper, molybdenum, tin, manganese, nickel,
and vanadium. These may require somewhat closer surveillance than
elements such as magnesium whose concentrations in water appear to be
little affected by human activity.
The subcommittee believes that a study of the contribution of drinking
water to mineral nutrition in humans is essential in a balanced appraisal
of drinking water. It also believes that the data in this review are up-to-
date and accurate and that they should help those charged with
evaluating the nutritional value of drinking water in the United States.
Most information on the mineral composition of water has been
gathered from large v~ater-supply systems. In 1975, approximately 35.7
million water consumers ( 16.7% of the population) were served by
systems supplying less than 25 persons. The minerals in water from
smaller systems and individual supplies, e.g., wells, may exceed the
concentrations in large water supplies which form the basis for most
levels cited in this report. Therefore, the potential contributions of water
to nutrient intake that are given below must not be taken as the absolute
. . .
llamas.
The interplay between mineral elements and nutrition is exceedingly
OCR for page 268
268 DRINKING WATER AND H"LTH
complex. In this report, it has been considered in light of the best
available knowledge, but it should be remembered that this knowledge is
still incomplete.
CALCIUM
Presence in Food and Water
Dairy products provide the largest source of calcium in the American
diet. Table V-1 lists calcium concentrations for some of these products
and other foods (Davidson et al., 19751.
In a survey of U.S. surface waters from 1957 to 1969, calcium levels
ranged from 11.0 to 173.0 mg/liter (mean, 57.1 mg/liter) for 510
determinations (National Academy of Sciences, 1977~. Finished water
that was sampled ire public water supplies for the 100 largest cities in the
United States contained almost as much calcium (range, 1-145 mg/liter).
The calcium concentrations in 9337O of the city supplies were less than 50
mg/liter (Durfor and Becker, 1964~. Similar results were reported in a
Canadian study (Nerd et al., 1977~. Zoeteman and Brinkmann (1977)
reported that the public water supplies for 21 large European cities
contained between 7 and 140 mg/liter (mean, 85 mg/liter).
The daily intake of calcium for most western adult populations
averages between 500 and 1,000 mg (Walker, 19721. The U.S. Health and
Nutrition Examination Survey estimated calcium intakes for 20,749
people from 1 to 74 years old, and concluded that the only population
segment with an intake appreciably (Woo 4057O3 below the recommended
daily allowance was the adult black female. The allowance values used in
this survey were 450 mg for children aged 1 to 9 years, 650 mg for ages 10
to 16 years, 550 mg for ages 17 to 19 years, 400 mg for men 20 years and
older? 600 mg for women 20 years or older, 800 mg for pregnant women,
and 1,100 mg for lactating women (Abraham et al., 19771.
Requirements
The amount of calcium required by the body daily and the level of
dietary calcium needed to meet this requirement are controversial issues.
Healthy individuals accustomed to low-calcium diets appear to do as
well as similar individuals accustomed to high calcium intakes. To some
extent, the daily calcium allowances recommended by various interna-
tional agencies reflect the calcium levels of normal local diets. In the
United States, the Food and Nutrition Board of the National Research
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Contribution of Drinking Water to Mineral Nutrition 269
TABLE V- 1 Calcium Concentrations in Foods and
Foodstuffs a
Food Item
Calcium Concentration,
mg/100 g or rngllOO rot
Cheese, hard
Cheese, soft
Milk, cow
Milk, human
Nutmeats
Legumes, dried
Vegetables, leafy
Vegetables, roots
Grains, whole
Eggs
Fish
Sardines, whole
Meats
Fruits
SOO- 1 ,200
80-725
20
20-40
13-250
40-200
25-2s0
20-100
4-60
50-60
17-100
400
3-24
3-60
a Data from Da~dsone~al., 1975.
Council (National Academy of Sciences, 1974) has recommended daily
calcium intakes of 80{) mg/day for adults on the basis that the daily
excretion of calcium is 320 mg and that only 4037c of dietary calcium is
absorbed by the average American. However, the excretion rate and
absorption percentage can vary with age and physiological state. The
recommended dietary allowances (RDA) of calcium for Americans,
then, are 360 mg for infants less than 6 months old, 540 mg for 6- to 12-
month-old infants, 800 mg for children aged 1 to 10 years, 1,200 mg for
11- to 18-year-old children, and 800 mg for individuals 19 years and
older. During pregnancy and lactation the RDA is increased to 1,200
mg/day.
Toxicity Versus Essential Levels
DEFICIENCY
There is no clearly defined calcium deficiency, syndrome in humans. This
may be due, in part. to an adaptation in calcium absorption and
utilization which varies with calcium intake. In a study of 26 male
prisoners ranging in age from 20 to 69 years, Maim (1958) observed that
23 of them achieved calcium balance immediately or within several
OCR for page 270
270 DRINKING WATER AND H"LTH
months after restricting their calcium intakes from 650 or 930 mg/day to
approximately 450 mg/day.
The etiology of osteoporosis, a degenerative disease involving loss of
bone calcium, is not clear, but prolonged inadequate intakes of calcium
may play an integral role. Diets that were deficient in both calcium and
vitamin D caused rickets and osteoporosis to develop in rats 6 weeks
after they had been started on the diet at weaning. Osteoporosis was
reversed when the rats were given a high-calcium diet that still lacked
vitamin D (Gershon-Cohen and Jowsey, 1964~. When the animals were 2
months old before receiving the low calcium, vitamin-D-deficient diet,
osteoporosis resulted without rickets.
Osteoporosis affects a large portion of older people and is most
prevalent in older women. Calcium supplements that were given to
osteoporosis patients for 2 years did not appear to reverse the calcium
loss from bone (Shapiro et al., 1975~.
Hypocalcemia due to impaired alimentary adsorption of calcium in
newborn children can result in tetany, consisting of twitches and spasms
(Davidson et al., 1975, p. 645~.
TOXICITY
Calcium is relatively nontoxic when administered orally. There have
been no reports of acute toxicity from the consumption of calcium
contained in various foods. Peach (1975a) indicated that calcium intakes
in excess of 1,000 mg/day when coupled with high vitamin D intakes can
raise blood levels of calcium. An excess of 1,000 mg/day (2.5 times the
RDA) for long periods can depress serum magnesium levels. Diets that
are high in calcium have also produced symptoms of zinc deficiency in
rats, chickens, and pigs after prolonged feeding. Kidney stones in
humans have been associated with high calcium intakes (Hegsted, 1957~.
Interactions
Low calcium intakes increase the rat's susceptibility to lead poisoning
(Snowdon and Sanderson 1974), while high intakes of calcium decrease
lead absorption from the intestine (Kostial et al., 1971~. Recent studies in
young children have associated high blood levels of lead with low dietary
intakes of calcium. MahaFey and coworkers (1976) observed that 12- to
47-month-old children with normal concentrations of lead (~0.03
mg/100 ml) in their blood had higher levels of dietary calcium (and
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Contribution of Drinking Water to Mineral Nutrition 271
phosphorus) than did matched children with elevated (>0.04 mg/100
ml) lead levels in their blood. Dietary calcium intake was not reported.
Sorrel and coworkers (1977) found concentrations of lead and calcium in
blood inversely correlated in control and lead-burdened children aged 1
to 6 years. For children with high concentrations of lead ~ 20.06 mg/100
ml blood). average daily calcium intakes were 610 + 20 ma, while
children with blood lead concentrations <0.03 mg/100 ml had average
daily calcium intakes of 770 + 20 ma. Itokawa et al. (1974) suggested
that the bone pain in itai-itai disease in Japan was causally related to
diets low in calcium and protein coupled with cadmium poisoning. Low
calcium intakes increase the intestinal absorption of cadmium and the
deposition of cadmium in bone and soft tissue (Pond and Walter, 1975~.
Furthermore, cadmium inhibits the synthesis of 1,25-dihydroxycholecal-
ciferol by reread tubules (Suda et al., 19731. This hormone facilitates
intestinal absorption of calcium (Suda et al., 1974), an especially
important function when calcium intake is low. The same or highly
similar mechanisms may control the absorption of calcium and ma~e-
sium into the bloodstream and their deposition into tissues.
Contribution of Drinking Water to Calcium Nutrition
Using an average calcium concentration in public water supplies of 26
mg/liter and a maximum of 145 mg/liter (Durfor and Becker, 1964) and
assuming that the average adult drinks 2 liters of this water daily, then
the drinking water could contribute an average of 52 mg/day and a
maximum of 290 mg/day. On an average basis this would represent 5%
to 10% of the usual daily intake or approximately 6.5% of the adult
RDA. For hard waters with high calcium levels, the water would
contribute approximately 29% to 58% of the usual daily intake or
approximately 36% of the adult RDA. Thus. public drinking water
generally contributes a small amount to total calcium intake, but in some
instances it can be a major contributor.
Conclusions
Current levels of calcium in U.S. drinking water are well below levels
that pose known risks to human health. No upper limit for calcium need
be set to protect public health. In cases of dietary calcium deficiencies
the presence of this element in drinking water may provide nutritional
benefit.
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272 DRINKING WATER AND HEALTH
MAGNESIUM
Presence in Food and Water
Schroeder and coworkers (1969) measured the magnesium contents of a
variety of foods and foodstuffs using atomic absorption spectrophotome-
try. On a wet weight basis, spices, nuts, and whole grains had the highest
magnesium contents, and refined sugars, human milk, oils, and fats had
the lowest. The food data are summarized in Table V-2.
Magnesium and calcium are responsible for most of the hardness of
drinking water. In a nationwide study in Canada, the mean concentra-
tion of magnesium in finished water before it entered the distribution
systems was 10.99 mg/liter. This concentration changed little during
distribution (Nerd et al., 19771. In the United States, the mean
concentration of magnesium in public water supplies in 100 cities was
6.25 mg/liter (range, ~120 mg/liter). The concentration of magnesium
in 96% of the water supplies was <20 mg/liter (Durfor and Becker,
19644. From 1957 to 1969, the average magnesium concentration in U.S.
surface waters was 14.3 mg/liter (range, 8.5-137 mg/liter) for 1,143
determinations (National Academy of Sciences, 1977~.
In the United States, the average adult ingests between 240 and 480
mg of magnesium daily (Wacker et al., 19774. Approximately 60% to 7090
of this is excreted in the feces. The British diet is reported to provide 200
to 400 mg of magnesium daily (Davidson et al., 19751.
Requirements
The daily need for dietary magnesium is a function of the amounts of
calcium, potassium, phosphate, lactose, and protein consumed. For the
average healthy American on an average diet, the daily magnesium
intake recommended by the Food and Nutrition Board of the National
Research Council (National Academy of Sciences, 1974) is 60 mg for
infants less that 6 months old, 70 mg for 6- to 12-month-old infants, 150
mg for 1- to 3-year-old children, 200 mg for 4- to 6-year-old children, 250
mg for 7- to 10-year-old children, and 300 mg for females 11 years and
older. For adolescent and adult males the recommended dietary
allowances (RDA's) are 350 mg for ages 11 to 14, 400 mg for ages 15 to
18 years, and 350 mg for those 19 years of age and older. The RDA for
pregnant and lactating women is 450 ma.
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Contribution of Drinking Water to Mineral Nutrition 273
TABLE V-2 Magnesium Concentrations in Foods and
Foodstuffsa
Magnesium Concentration,
Bag
Single Values
Food Item or Range Mean
Condiments, spices 230-4,225 2,598
Nuts 1,078-3,175 1,970
Grains and cereal products 18-2,526 805
Fish and seafood 154-532 348
Meats 195-402 267
Vegetables, fresh legumes 185-297 241
Fresh roots 75-478 226
Fresh fleshy 66-487 174
Fresh leafy 85-321 170
Dory products, eggs 102-270 183
Fruits and juices 102-270 78
Sugars and syrups 0.1-108 59
Milk, human 28-29 29
Oils and fats 1-27 7
Beverages
Coffee 48 barb
Tea 3- 11 NR
Whisky, gin 0.3-4.5 NR
Wine,white 98 FIR
Beer 100 NR
Vermouth, Italian 135 NR
a Data from Schroeder et al., 1969.
b NR, not reported.
Toxicity Versus Essential Levels
DEFICIENCY
Despite several studies. magnesium deficiency in humans is still not well
defined, primarily because it has been studied in individuals also
suffering from other metabolic and physiological disorders. Electrolyte
imbalance, especially for calcium and potassium. is characteristic of
magnesium deficiency.
Magnesium deficiency is most often observed in patients with
gastrointestinal diseases that lead to malabsorption and in those with
hyperparathyroidism, bone cancer, aldosteronism, diabetes mellitus, and
OCR for page 274
274 DRINKING WATER AND H"LTH
thyrotoxicosis (Wacker and Parisi, 1968~. Alcohol can deplete magne-
sium levels in heavy drinkers by apparently increasing renal loss. These
heavy drinkers show extensive neuromuscular dysfunction such as
tetany, generalized tonic-colonic and focal seizures, ataxia, vertigo,
muscular weakness, tremors, depression, irritability, and psychotic
behavior. By giving them magnesium, these dysfunctions can be reversed
(Wacker and Parisi, 1968~.
In the rat, prolonged magnesium deficiency retards growth and results
in loss of hair? skin lesions, edema, and degeneration of the kidney
(Kruse et al., 1932~.
TOXICITY
Because magnesium is rapidly excreted by the kidney, it is unlikely that
magnesium in food and water is absorbed and accumulated in tissues in
sufficient quantities to induce toxicity. Magnesium salts are used
therapeutically as cathartics, e.g., magnesium sulfate (MgSO4), hydrox-
ide [Mg(OH)2], and citrate iMg33tOOCCH2COH(COO)CH2COO]; as
antacids, e.g., magnesium hydroxide, carbonate iMg(CO3~], and trisili-
cate (Mg20~3Si3~; and as anticonvulsants to control seizures associated
with acute nephritis and with eclampsia of pregnancy (magnesium
sulfate). In patients with renal disease and impaired magnesium
excretion, large excesses of magnesium can lead to severe toxicity
resulting in muscle weakness, hypotension' sedation, confusion, de-
creased deep tendon reflexes, respiratory paralysis, coma, and death. At
plasma concentrations exceeding 9.6 mg/100 ml (8 mEq/liter) central
nervous system depression is evident. Arlesthesia is reached near 12
ma/ 100 ml ( 10 mEq/liter), and paralysis of skeletal muscle can be
produced at plasma concentrations of approximately 18 mg/100 ml (15
mEq/liter) (Peach 1975a). Normal values are 1 to 3 mg/100 ml (0.8 to
2.5 mEq/liter). Calcium ameliorates magnesium toxicity.
Interactions
The interactions of trace elements in nutrition were reviewed in Drinking
Water and Health (National Academy of Sciences, 1977~. The metabo-
lism of magnesium is tied closely to that of calcium and potassium.
Magnesium deficiency results in potassium loss, probably due to the
interaction of magnesium and phosphate in the active transport of
potassium and sodium across cell membranes. The release of parathy-
roid hormones calcitonin? and 1,25-dihydroxycholecalciferol, which are
hormones that govern calcium and phosphorus metabolism, is reduced
OCR for page 275
Contribution of Drinking Water to Mineral Nutrition 275
by lowered magnesium intakes. The mechanism for this reduction is not
understood.
Contribution of Drinking Water to Magnesium Nutrition
Using the magnesium concentrations reported by Durfor and Becker
(1964) for U.S. drinking waters (median, 6.25 mg/liter; maximum, 120
mg/liter), a daily intake of 2 liters of drinking water would supply an
average of approximately 12 mg of magnesium and a maximum of up to
240 ma. For Canadian (Nerd et al.
1977) and Western European
(Zoeteman and Brinkmann, 1977) drinking waters the daily contribution
would be approximately 20 and 24 mg of magnesium, respectively.
Therefore, typical drinking water in the United States, Canada, or
Europe provides approximately 3% to 7?'o of the RDA for magnesium
intake by a healthy human. In areas where the magnesium concentration
is high, over 50% of the RDA could come from 2 liters of water (see
Table V-321. Thus, drinking water could provide a nutritionally
significant amount of magnesium for individuals consuming a diet that is
marginally deficient in magnesium, especially in areas where the
magnesium concentration in water is high.
Conclusions
Current levels of magnesium in U.S. drinking water supplies appear to
offer no threat to human health, and no upper limit for magnesium
concentrations needs to be set to protect public health. For individuals
consuming a magnesium-deficient diet, the presence of this element in
drinking water may provide nutritional benefit.
PHOSPHORUS
Presence in Food and Water
Phosphorus, in the form of phosphate, is common to most foods and
foodstuffs. In foods of plant origin, phosphorus concentrates in seeds.
Nuts, beans, and whole grains contain high levels of phosphorus,
whereas leafy vegetables contain low levels. Fruits contain little
phosphorus, but meat and fish are relatively rich in the mineral. Table
V-3 summarizes the phosphorus contents of some of the foods listed by
Sherman (19524.
Data collected on the average daily consumption of soft drinks in the
OCR for page 394
394 DRlNKlNG WATER AND H"LTH
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Representative terms from entire chapter:
trace elements