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Nutrición Hospitalaria

versión On-line ISSN 1699-5198versión impresa ISSN 0212-1611

Nutr. Hosp. vol.30 no.1 Madrid jul. 2014 



The calcium concentration of public drinking waters and bottled mineral waters in Spain and its contribution to satisfying nutritional needs

Calcio en el agua de consumo publico y aguas minerales naturales en España y su contribución en cubrir las necesidades nutricionales



Isidro Vitoria1, Francisco Maraver2, Cíntia Ferreira-Pêgo3,4, Francisco Armijo2, Luis Moreno Aznar5 and Jordi Salas-Salvadó3,4

1 Nutrition and Metabolopathies Unit. Hospital La Fe. Valencia. Spain.
2 Professional School of Medical Hydrology. Faculty of Medicine. Complutense University. Madrid. Spain.
3 Human Nutrition Unit. Sant Joan University Hospital. Reus. Faculty of Medicine and Health Sciences. IISPV (Pere Virgili Health Research Institute). Department of Biochemistry and Biotechnology. Rovira i Virgili University. Reus. Spain.
4 CIBERobn (Biomedical Research Centre in Physiopathology of Obesity and Nutrition). Carlos III Institute of Health. Madrid. Spain.
5 GENUD (Growth, Exercise, Nutrition and Development) Research Group. Faculty of Health Sciences. University of Zaragoza. Spain.





Introduction: A sufficient intake of calcium enables correct bone mineralization. The bioavailability of calcium in water is similar to that in milk.
Objective: To determine the concentration of calcium in public drinking water and bottled mineral water.
Methods: We used ion chromatography to analyse the calcium concentrations of public drinking waters in a representative sample of 108 Spanish municipalities (21,290,707 people) and of 109 natural mineral waters sold in Spain, 97 of which were produced in Spain and 12 of which were imported.
Results: The average calcium concentration of public drinking waters was 38.96 ± 32.44 mg/L (range: 0.40159.68 mg/L). In 27 municipalities, the water contained 50-100 mg/L of calcium and in six municipalities it contained over 100 mg/L. The average calcium concentration of the 97 Spanish natural mineral water brands was 39.6 mg/L (range: 0.6-610.1 mg/L). Of these, 34 contained 50-100 mg/L of calcium and six contained over 100 mg/L. Of the 12 imported brands, 10 contained over 50 mg/L. Assuming water consumption is as recommended, water containing 50-100 mg/L of calcium provides 5.4-12.8% of the recommended intake of calcium for children aged one to thirteen, up to 13.6% for adolescents, 5.8-17.6% for adults, and up to 20.8% for lactating mothers. Water with 100-150 mg/L of calcium provides 10-31% of the recommended dietary allowance, depending on the age of the individual.
Discussion: Public drinking water and natural mineral water consumption in a third of Spanish cities can be considered an important complementary source of calcium.

Key words: Calcium. Public drinking water. Natural mineral water. Water softening. Nutritional requirements.


Introducción: Una adecuada ingesta de calcio condiciona una buena mineralización ósea.
Objetivo: Determinar el contenido en calcio en aguas de bebida.
Métodos: En 2012 se analizaron las concentraciones de calcio, por cromatografía iónica, de aguas de consumo público de una muestra representativa de 108 poblaciones españolas que abastecen a 21.290.707 personas, así como de 109 aguas minerales naturales comercializadas en España (97 españolas y 12 importadas).
Resultados: La concentración media de calcio en aguas de consumo público fue de 38,96 ± 32,44 mg/L (rango: 0,40-159,68 mg/L). En 27 poblaciones el agua contiene entre 50-100 mg/L de calcio y en 6 fue superior a 100 mg/L. La concentración media de calcio de las 97 marcas españolas de aguas fue de 39,6 mg/L (rango: 0,6-610,1 mg/L), 34 de ellas contenían entre 50-100 mg/L de calcio, mientras que en 6 de ellas más de 100 mg/L. De las 12 marcas importadas, 10 contenían más de 50 mg/L. Asumiendo una ingesta de agua recomendada, si el agua contiene entre 50-100 mg/L de calcio, ésta aportaría entre 5,4-12,8% de la ingesta de calcio recomendada para los niños de 1-13 años, hasta el 13,6% en adolescentes, entre 5,8-17,6% en adultos, y hasta el 20,8% en madres lactantes. El agua conteniendo 100-150 mg/L de calcio aportaría entre 1031% de las recomendaciones según la edad.
Discusión: El agua de consumo público de un tercio de ciudades españolas y de aguas minerales naturales puede ser considerada como una fuente complementaria importante de calcio ingerido.

Palabras clave: Calcio. Agua de bebida. Agua mineral natural. Ablandamiento del agua. Necesidades nutricionales.

PDW: Public drinking waters.
NMW: Natural mineral waters.
EU: European Union.
EFSA: European Food Safety Agency.
IOM: Institute of Medicine.
RDA: Recommended Dietary Allowances.
PTH: Parathyroid hormone.



Sufficient calcium consumption is important for maintaining correct bone health and preventing osteoporosis1,2. It may also help to prevent obesity3, insulin resistance4 and other chronic illnesses associated with the immune and neuromuscular system5.

The United States Institute of Medicine (IOM) recently set the recommended dietary allowances (RDA) for calcium. These ranges from 700 to 1,000 mg/day for children aged between one and nine and from 1,000 to 1,300 mg/day for adolescents and adults6 (table I). These daily allowances are not met by the entire Spanish population7, especially at two key stages of bone metabolism: infancy and menopause. Representative studies of the Spanish population found that the calcium consumptions of 76.7% of children of school age8 and 79.6% of menopausal women9 were insufficient.



Where recommended daily intake is not satisfied via food consumption, medical calcium supplements may be taken10. However, administering these supplements involves practical difficulties11 as well as cardiovascular risks12 that have not yet been fully determined.

For this reason, in recent years much interest has been generated in calcium-enriched foods (milk, yoghurt, cereals, fruit juices, etc.) and other sources of calcium. The calcium present in drinking water should therefore also be considered since its bioavailability from drinking water is similar to that from dairy products13. When recommendations regarding types of drinking water are reviewed, however, their calcium concentrations are rarely considered important14. For example, neither Spanish15 nor European16 regulations on public drinking water (PDW) refer to the concentration of this mineral. The Codex rule17 for natural mineral waters (NMW) also does not mention calcium concentration and Spanish and European regulations on bottled water only indicate that these beverages can be described as calcic if they contain over 150 mg/L of calcium-Few studies have determined the calcium concentration of Spanish PDW and NMW18,19. Even fewer studies have analysed how frequent and continuous consumption of calcium may prevent osteoporosis or other chronic illnesses20. In this study, therefore, we analyse the calcium concentration of the PDW and NMW consumed in Spain and evaluate their contribution to the recommended dietary intake of this mineral.


Material and methods

During 2012 we selected PDW samples from 108 of the 144 Spanish cities with a population of over 50,000 inhabitants (total population of 21,290,707, or 45.3% of the total Spanish population). These cities were selected at random so that they would represent all Spanish geographical regions. The number of inhabitants in each city was taken from the de jure population figures by municipalities recorded for 2012 by the Spanish Statistical Office21. In each of the cities studied, we collected three two-litre samples of PDW in opaque plastic bottles after allowing the water to flow from the tap for at least three minutes. These samples were taken from private homes or public establishments that were without domestic filters or reverse osmosis systems. Similarly, three bottles (with different bottling dates) of 97 Spanish brands of NMW and 12 brands of imported NMW were acquired from supermarkets or grocery stores in various Spanish cities. From the full list of 151 Spanish NMW recognized by the EU22, we selected 97 samples of the most consumed Spanish brands that also represented the geographical regions with the most springs. The locations of the springs of the NMW are shown in Figure 1. For both types of sample (PDW and NMW), the bottles were stored in the dark and at ambient temperature until they were analysed.

Calcium concentrations were determined by ion chromatography (EPA method 300.7) using the Dionex DX-120 ion chromatograph with Fluka 39865 standard calibration solution. Sample calibrations and concentrations were obtained using PeakNet 5.10d-SE and the 4110-B method recommended by the American Public Health Association, the American Water Works Association, and the Water Environment Federation23.



Table II shows the average calcium concentration in the PDW of the 108 Spanish cities studied. The average calcium concentration for all cities was 38.96 ± 32.44 mg/L, ranging from 0.40 mg/L in San Vicente del Raspeig to 159.68 mg/L in Girona.



In 48 of the 108 cities, the calcium concentration was below 25 mg/L. In 27 cities, it was between 25 and 50 mg/L and in another 27 cities, which supply 3,726,377 people it was between 50 and 100 mg/L. Finally, in 6 other cities, home to almost one million people, the calcium concentration was over 100 mg/L (table III).

Figure 2 shows the Spanish cities where the calcium concentrations in the PDW were determined.

Tables IV and V show the calcium concentrations in mg/L of the 109 NMW brands studied (97 Spanish brands and 12 imported brands, respectively). The average calcium concentration of the Spanish NMW brands was 39.6 mg/L and the concentration ranged from 0.6 mg/L (Aquasana®) to 610.1 mg/L (Agua de Manzanera®). Of the Spanish brands, 57 (58.76%) contained less than 50 mg/L, 34 (35.05%) contained between 50 and 100 mg/L, and 6 (6.19%) contained over 100 mg/L. The average calcium concentration of the imported NMW was 93.52 ± 47.11 mg/L, with a maximum of 158.4 mg/L and a minimum of 14 mg/L. Of the 12 brands studied, 10 had a calcium concentration of over 50 mg/L and four had a calcium concentration of over 140 mg/L.



Consuming the recommended dietary allowances for calcium is important for achieving better bone mineral density. Because of their high calcium content and high bioavailability of around 30%, the main dietary sources of calcium are milk and dairy products. The high calcium content in milk and its derivatives is similar to that of water. In an experimental study, Couzy et al.13 compared the bioavailability of calcium from cow's milk and calcium-rich waters (467 mg/L) in 10 young women aged between 21 and 36. The rates of absorption were 25.0 ± 6.7% for milk and 23.8 ± 4.8% for water. In another experimental study, Bacciottini et al.25 observed that the absorption of a calcium content of 3.18 mmol from water was 23.15 ± 4.06%, but this percentage does not appear to be constant. The authors of a systematic review and meta-analysis also observed that in waters with a lower calcium concentration (< 100 mg/L), the percentage absorbed was greater (47.5%)26. In summary, the absorption coefficient of calcium in water with respect to the absorption coefficient of calcium in milk ranges from 1.129 ± 0.056 to 0.985 ± 0.070. According to the bibliography, therefore, calcium in water is absorbed at least as easily as the calcium in dairy products27. Also, according to a review conducted in 2006, as occurs with other food sources of calcium, the calcium in water is absorbed almost 20% more if it is consumed along with other foods than if it is consumed on its own28.

People who do not consume sufficient calcium may be given supplements usually to be taken once a day. However, as supplements with large quantities of calcium may inhibit parathyroid hormone (PTH) and bone resorption29 more intensely but for less time, it is recommended that the doses be broken up in order to achieve a more sustained inhibition of bone resorption30,31. Water consumed throughout the day can therefore be a significant food alternative to satisfy requirements for this mineral32. In a six-month randomized double-blind test conducted on postmenopausal women, calcium-rich drinking water was found to have a positive effect on the biochemical parameters associated with bone metabolism33. In the EPIDOS cohort, a 100 mg per day increase in calcium consumption from drinking water in women aged over 75 was associated with a 0.5% increase in bone mineral density34. However, we should also mention that people with osteoporosis treated with bisphosphonates should take these drugs with water that is low in calcium since a tendency to form complexes with divalent cations (calcium, magnesium, iron, etc.) and a reduction in the absorption of the bisphosphonates have been reported35.

The calcium concentrations of the PDW vary greatly and basically depend on the type of bedrock on which the aquifer lies (if the water is from a subterranean source) or on the origin of the water (if the water is from an above-ground source).

In a review of the mineral content of the PDW of 44 cities in the United States36, the average calcium concentration in 36 cities whose PDW source was above ground was 34 ± 21 mg/L and in the eight cities whose source was subterranean it was 52 ± 24 mg/L. Calcium concentration ranged from 2 to 85 mg/L. In a descriptive transversal study of PDW in Canada, the average calcium concentration was 48.8 mg/L and the calcium concentration ranged from 1 to 135 mg/L. When the authors of that study also analysed the calcium concentration of PDW in the United States, they found that the average concentration was 50.6 mg/L and that the concentration ranged from 8.3 to 131 mg/L35.

According to information provided by Spanish health authorities, the average calcium concentration of most of the 333 PDW analysed was below 100 mg/L and above 200 mg/L in only four PDW19.

With regard to NMW, a review of the mineral contents of water commercialized in North America37 found that calcium concentrations were above 100 mg/L in only four of the 28 brands analysed. However, when the same authors analysed the calcium concentrations of 20 waters sold in Europe, they found that the calcium concentration exceeded 100 mg/L in 11 of them. In a descriptive study conducted in Silesia (Poland), the average calcium concentration of 35 NMW analysed was 178.7 ± 107.3 mg/L38. In a study that analysed the chemical composition of 21 types of NMW sold in Saudi Arabia, the authors found that the calcium concentrations analysed in the laboratory ranged from 12 to 90 ppm, although the labels on the bottles indicated that it ranged from 6 to 40 ppm39. Finally, a review of calcium concentration in European NMW found that almost half of them contained over 100 mg/L. Swiss NMW had the highest calcium concentrations, which ranged from 436 to 663 mg/L20.

In the present study we also found that the European NMW consumed in Spain, which are mainly bottled in France and Italy, also generally contain higher calcium concentrations than waters obtained from Spanish sources.

The European Food Safety Agency (EFSA), in establishing the recommended dietary allowances of water, assumes that consuming water is fundamental to maintaining good hydration at all stages of life. The Agency also states that roughly 20% of our daily water requirements are provided by foods40 (table VI).

Based on this recommended intake of water and on the recommended intake of calcium by age and gender, the percentage of recommended calcium intake provided by water according to its calcium concentration (from 25 to 150 mg/L) has been calculated (tables VIIa and VIIb). These tables show that water containing a calcium concentration of between 50 and 100 mg/L provides 5.4-12.8% of the RDA for children aged between one and 13, up to 13.6% for adolescents, 5.8-17.6% for adults, 8-16% for expectant mothers, and up to 20.8% for lactating mothers. These data should be taken into account because, according to the bibliography, calcium intake among the Spanish population is insufficient7. In 27 of the 108 cities analysed in this study (with a total population of 3,726,377), the calcium concentration of the water was precisely within this 50-100 mg/L range. Moreover, the calcium concentration also ranged from 50 to 100 mg/L in 34 of the 97 Spanish NMW and in six of the 12 imported NMW analysed.

According to our information, waters with a calcium concentration of between 100 and 150 mg/L provide 10-20.4% of RDA in children and adolescents and 17.6-26.4% of RDA in menopausal women. These are stages in which calcium intake is found to be lower8-9.

Moreover, sufficient intake of calcium during pregnancy has also been found to help prevent eclampsia41. Consuming water with a calcium concentration of between 100 and 150 mg/L during pregnancy can provide 12-24% of the RDA of calcium. In adults, consuming water with this same calcium concentration (between 100 and 150 mg/L) can provide 11.6-26.4% of the RDA. In women over 51 years of age, whose RDA of calcium is higher (1200 mg/day), consuming water with this calcium concentration can provide 11.6-17.4% of the RDA. These figures are similar for women aged 70. This could be especially important for adults with lactose intolerance or minor digestive problems that require a lower consumption of dairy products-foods which in the west are fundamental to providing calcium, especially for people at risk of osteoporosis42.

In the present study, the water of only 6 of the 108 cities had a calcium concentration of over 100 mg/L. The city with the highest concentration was Girona, with an average concentration of 159.7 mg/L. Of the 109 NMW analysed, only 10 had a concentration of over 100 mg/L. The calcium concentrations of five of these ten NMW were between 100 and 150 mg/L. According to the bibliography currently available, waters excessively rich in calcium are not recommended for children still on a milk diet because of the risk of their developing calcium lithiasis. For example, the use of French NMW (Hepar®) containing 550 mg/L of calcium to make up starting formulas for babies' bottles was associated with the development of coraliform renal calculus. In this case, the daily calcium intake via water was 1,750 mg/day rather than the recommended daily amount of 210 mg43.

Another aspect that must be taken into account with calcium-rich or hard PDW waters is the softening of the water aimed at preventing the annoying encrustation associated with taps and domestic electrical appliances. Two basic methods of softening water exist: one uses ion exchange resins and the other is reverse osmosis. With ion exchange resins, the calcium is adsorbed and replaced by other ions (especially sodium). The exchange of ions continues as long as there are sufficient ions in the resin to be replaced. Most domestic water softeners use this principle. The Brita® filter, for example, removes 89.4% of the calcium contained in the water35. Reverse osmosis is based on the use of a semipermeable membrane that removes 94-98% of the calcium and magnesium. In countries that use desalinated water, the calcium concentration of PDW is therefore below 6 mg/L. In short, domestic filters or reverse osmosis applied to PDW in people's homes almost completely eliminate the calcium content of the water even though the benefits or detriments to the individual of doing so are unknown44.

Finally, we should always remember that, from the nutritional point of view, water and milk should continue to be our fundamental beverages and that soda drinks, because of their low nutritional value, should be consumed only occasionally45. Consuming water rather than sugary drinks also helps to prevent overweight and its complications46.

In conclusion, a third of the PDW of 108 Spanish cities and 50 of the 109 NMW sold in Spain contain over 50 mg/L of calcium. Given its bioavailability and its use as a healthy means of hydration, drinking water should be taken into account as a complementary dietary source of calcium.



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Isidro Vitoria.
Nutrition and Metabolipathies Unit.
Hospital La Fe.
Bulevar sur, s/n.
46021 Valencia. Spain.

Recibido: 5-IV-2014.
Aceptado: 5-V-2014.

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