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Kooshki A, Rivandi M, Reza Behroozikhah M, Akbarzadeh R. The Effect of Consuming Mineral Water and Piped Water on Blood Pressure and Lipid Profiles of Hypertensive Men . JNFS. 2019; 4 (2) :101-106
URL: http://jnfs.ssu.ac.ir/article-1-258-en.html
Department of Nutrition &Biochemistry, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran
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The Effect of Consuming Mineral Water and Piped Water on Blood Pressure and Lipid Profiles of Hypertensive Men 
 
Akram Kooshki; PhD1, Mahmood Rivandi; MSc2, Mohammad Reza Behroozikhah; MSc1
& Roya Akbarzadeh; MSc*3

 
1 Department of Nutrition &Biochemistry, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran.
2 Department of Organic Biochemistry, Sabzevar University of Applied Science and Technology, Sabzevar, Iran.
3 Department of Operating Room & Anesthesia, School of Paramedicine, Sabzevar University of Medical Sciences, Sabzevar, Iran.
 
ARTICLE INFO   ABSTRACT
ORIGINAL ARTICLE Background: Hypertension is the third risk factor for the cardiovascular diseases. This study investigated the effects of mineral water from Damavand spring on the blood pressure and serum lipid profiles in men with hypertension. Methods: In this study 41 hypertensive men were randomly assigned to Damavand mineral water (DM) and Tehran water groups (TW). The DM and TW received 1.5-liter bottle of mineral water of Damavand spring and Tehran piped water bottled, respectively. The participants' blood pressure, serum triglyceride (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDLc), and high-density lipoprotein cholesterol (HDLc) were measured at the beginning and end of the study. Total hardness of water was measured by titration with EDTA. Results: The results showed that the mean systolic and diastolic blood pressures decreased in both groups at the end of the study compared to the baseline (P < 0.05), but the difference was not significant. Serum TC and LDLc significantly in the case group at the end of week 8 compared to the baseline (P < 0.05) and this reduction was significant (P < 0.05). Moreover, no significant differences were observed between the two groups with regard to the mean changes of TG and HDLc (P > 0.05). Conclusions: The findings showed that the daily consumption of 1.5 liters of premium mineral water of Damavand springs decreased the systolic and diastolic blood pressure, total cholesterol, and LDLc levels.
Keywords: Hypertension; Serum lipid profiles; Mineral water.
Article history:
Received: 17 Apr 2018
Revised: 18 Jun 2018
Accepted: 14 Aug 2018
 
*Corresponding author
roakbarzadeh53@gmail.com
Department of Operating Room & anesthesia, School
of Paramedicine, Sabzevar University of Medical Sciences, Sabzevar, Iran.
 
Postal code: 961793114
Tel: 051-44018328
 
Introduction
D
ifferent definitions have been provided for hypertension or high blood pressure. The model provided by the Joint National Committee on prevention, detection, assessment and treatment of hypertension in adults stated that if in two consecutive time intervals, the average systolic blood pressure is more than 130 mmHg and the average diastolic blood pressure is 85 mmHg or higher, the person is considered to have hypertension (Cleeman et al., 2001)
It seems that the prevalence of hypertension is increasing among the developing countries. In the Mediterranean and the Middle East countries, high blood pressure prevalence is reported as 26 and 21.7 percent, respectively (Motlagh et al., 2009, Musaiger and Al-Hazzaa, 2012). The prevalence of hypertension in the population studied in Tehran Lipid and Glucose Study after adjustment for age was determined as 19.4 percent in women and 23.3 percent in men (Azizi et al., 2002).
In the long run, hypertension causes irreparable damages to the cardiovascular system and increases the incidence of stroke (Azizi et al., 2002). Hypertension is the third risk factor in the triangle of death from cardiovascular disease following the low-density lipoprotein cholesterol (LDL-c) and cigarettes (Jairath, 1999). Studies showed that non-pharmacological methods can reduce blood pressure and act as an effective method to reducing hypertension and cardiovascular diseases (Ralapanawa et al., 2017).
In recent years, various studies examined the role of nutrient elements such as calcium, magnesium, and sodium on the blood pressure and serum lipids. They argued that increased intake of calcium and magnesium is associated with reduced serum triglyceride and cholesterol levels (Azoicăi et al., 1996, Bain et al., 2015, Bostick et al., 1999) and leads to 30-35 percent reduction in ischemic disease or heart failure (Bostick et al., 1999). However, epidemiologic studies demonstrated a strong correlation between water hardness and cardiovascular disease, so that cardiovascular diseases were 10-30 percent more frequent in areas with light drinking water than areas with hard drinking water (Crawford and Crawford, 1967).
Some studies showed that mineral water reduced systolic blood pressure about 5 mm Hg, total cholesterol, and LDL-c (Capurso et al., 1999, Nerbrand et al., 2003).
Due to the high prevalence and serious complications of hypertension and the effects of mineral water on blood pressure and serum profile lipids and the controversies in this field, this study was conducted. The aim was to investigate the effects of consuming mineral water of Damavand spring on blood pressure and serum lipid profiles in men with hypertension.
Materials and Methods
Type study & participants: This double blind clinical trial was conducted on men with hypertension, who referred to the cardiovascular clinics in Tehran. After conducting simulating the participants' age, body mass index (BMI), waist hip ratio (WHR), smoking, type, dose of drugs, and duration of disease, 41 hypertensive men were randomly assigned to Damavand mineral water (DM) and Tehran water groups (TW). The DM and TW received 1.5-liter bottle of mineral water of Damavand spring and Tehran piped water bottled, respectively. Participants were advised not to change their diet, physical activity, and drug regimen during the study. Sample size was determined using sample size in small groups by following equation that α = 0.05 and power test was considered as:
N = (z1 α/2 + z1 β) 2 (12 - 22)/(μ12 μ22 )
Measurements: After obtaining permission from the management of the cardiovascular clinics and collecting written consents from the patients, height, waist, and hip circumference were measured with a tape measure with an accuracy of 1 cm. Weight was also calculated by Seca scale with an accuracy of 100 g. At the beginning of the study, blood pressure was measured with a mercury sphygmomanometer and 5 mL blood was taken from both group members to measure serum lipids. At the end of the study, their blood pressure measurement was repeated and 5 mL blood was taken from all participants again. Furthermore, at the baseline as well as four, and eight weeks after the study, 24-hour food recalls were taken from the participants in two days. The food recalls were analyzed using optimized Nutritionist 4 software according to the Food Bank of Iran.
Total cholesterol (TC), triglycerides (TG), and high density lipoprotein cholesterol (HDL-c) of serum were measured enzymatically using commercial kits (Pars Azemoon Co., Tehran, Iran), with the aid of a Hitachi 717 auto-analyzer (Boehringer Mannheim Diagnostics, Mannheim, Germany). The coefficient of variation (CV) for serum lipids was less than 5 percent. Since the serum TG concentration was less than 400 mg/dL in all participating patients, serum LDL-c was estimated using the Friedewald equation (Friedewald WT, 1972).  
Calcium, magnesium, and total hardness of Damavand Mineral Water and Tehran Piped Water were measured in the Water Laboratory of School of Public Health affiliated to Tehran University by titration with EDTA. In addition, sodium and potassium of water were measured by flame photometer.
Ethical considerations: People freely participated in the study and did not pay any fee. They could also be excluded freely from the study. All participants signed an informed consent form.


 Data analysis: Data analysis was performed using SPSS version 11.5 and paired and independent t-tests. 
Results
In this study, a total of 41 male patients were investigated. The mean age of participants was 48 ± 8 years, their mean BMI was 27.1 ± 3.1 kg per square meter, the mean WHR was 0.95 ± 0.5, and the duration of hypertension was 7 ± 3 years. No significant difference was observed between the two groups with regard to the mentioned variables.
The mean systolic blood pressure of both groups was reduced at the end of the study; 21.43 percent in case group and 14.88 percent in control group, compared to the baseline. Although the difference between the measures calculated at the baseline and end of the study was significant, the difference between the DM and TW not significant (Table 1).
Diastolic blood pressure at the end of the study was reduced to 17.61 percent and 16.47 percent compared to the beginning of the study for the DM and TW, respectively, which was statistically significant. However, the difference between the DM and TW was not significant (Table 1).
The mean of serum TG concentration was not statistically significant at the end of the study compared to the baseline measure in each group and between the two groups (P > 0.05). At the end of the study, the mean serum TC showed 15.95 percent increase in TW and 11.78 percent decrease in the DM compared to the baseline. The difference were statistically significant in each group and between the two groups. The mean serum LDL-c at the end of study changed -6.84 and 22 percent compared to baseline for the DM and TW, respectively. The difference was statistically significant in each group and between the two groups. The mean serum HDL-c at the end of study increased by 26.05 and 18.64 percent for the DM and TW, respectively, which was statistically significant compared to the baseline but was not statistically significant between the two groups (Table 1).
The mean ± SD of mineral contents as well as the hardness of Damavand mineral water and Tehran water are represented in Table 2.
At the beginning of the study, energy intake was 1750 ± 420 and 1810 ± 360 Kcal for the DM and TW, respectively, which reached  1780 ± 512 and 1850 ± 470 as well as 1730 ± 450, and 1750 ± 350 at the 4th and 8th weeks, for the DM and TW, respectively. However, the difference was not statistically significant (P ≥ 0.05).  
Moreover, in the present study, intake of nutrients and minerals through diet did not show any statistically significant difference between the case and control groups at the beginning, the fourth and final weeks of the study (P > 0.05).

 
Table 1. Comparison of mean (± SD) of systolic pressure, diastolic pressure and lipid profiles in two groups
 
(n = 21)  Tehran water (n = 20) Damavand mineral water                 Groups
Vaiables
Week 8 Baseline Week 8 Baseline
122.62 ± 13.29a 144.0 ± 8.31 119.50 ± 12.24a 151.50 ± 14.24 Systolic blood pressure (mmHg)
79.76 ± 12.5 a 95.48 ± 4.71 76.50 ± 8.72a 96.50 ± 5.64 Diastolic blood pressure (mmHg)
190.14 ± 47.43 186.95 ± 86.80 191.60 ± 95.29 189.35 ± 97.49 Triglyceride (mg/dl)
157.81 ± 19.04 136.10 ± 24.62 133.75 ± 31.97ab* 149.50 ± 31.16 Cholesterol (mg/dl)
68.48 ± 25.53a 56.09 ± 33.35 50.73 ± 27.38b* 55.53 ± 27.11 Low density lipoprotein cholesterol (mg/dl)
55.30 ± 14.24a 46.61 ± 14.97 55.56 ± 11.99a 44.15 ± 12.23 High density lipoprotein cholesterol (mg/dl)
a: Changes reflect week 8 versus baseline values; b: Changes reflect week 8 versus Tehran water values; ∗ Denote p < 0.01 versus Tehran water
 
Table 2. Mean (± SD) of hardness and mineral contents of Damavand mineral water and Tehran water
 
Total Hardness
mg/l caco3)
Sodium (mg/L) Potassium (mg/L) Magnesium (mg/L) Calcium (mg/L)           Minerals
Type of Waters
225 ± 15 b 4.48 ± 0.17 b 0.60 ± 0.2 b 16.31± 0.84b 58.9 ± 2.84a Damavand mineral water
183 ± 13 30.00 ± 1.00 1.55 ± 0.5 12.83 ± 0.83 49.32 ± 0.94 Tehran water
a  and b denote p < 0.01 and p < 0.001 versus Tehran water, respectively.
 
Discussion
In this study, consumption of mineral water and municipal water of Tehran reduced the systolic and diastolic blood pressure, but the impact of mineral water was more significant. Moreover, in the study of Erceg-Rukavina, mineral water consumption by patients with stage 1 hypertension decreased the blood pressure (Erceg-Rukavina and Stefanovski, 2014). These findings were consistent with the results of Luft (Luft et al., 1990) and Rylander (Rylander and Arnaud, 2004).
It seems that the impact of mineral water on blood pressure reduction was higher than the municipal water of Tehran, which could be due to higher total hardness of this water. In addition, mineral water contains more ions of calcium, magnesium, and potassium, whereas, its level of sodium is less than Tehran municipal water.
The results of this study showed that the serum TG concentration after eight weeks of consuming mineral water and municipal water did not change significantly compared to the baseline in the case and control groups. The results of this study are consistent with the study of Capurso, in which drinking mineral water for three weeks did not have any effects on the serum TG (Capurso et al., 1999).
In our study, TC and serum LDL-c levels reduced significantly after eight weeks of drinking mineral water. However, serum HDL-c levels increased significantly after eight weeks of consuming water compared to the beginning of study. The results of this study were consistent with the results of Bostick (Bostick et al., 1999). In the study of Bostick, prescription of calcium supplements reduced serum LDL-c by 4.5-11 percent, while serum HDL-c showed a slight decrease.
The findings of this study were consistent with the results of Bain (Bain et al., 2015). He stated that mineral water was rich in calcium and magnesium; so, it could be considered as an important source of calcium and magnesium supplement. Due to alkaline nature and osmotic effect, mineral water can have effect on fat and cholesterol absorption or bile acids excretion increase. It is demonstrated that absorption of fatty acids and cholesterol in the small intestine decreased throughout the water consumption period and the functions of pancreatic enzymes and bile salts enhanced with increased PH. Thus, increased luminal PH, caused by mineral water reduces intestinal uptake of cholesterol and fat (Chijiiwa and Linscheer, 1984, 1987, Shils et al., 1994).
Other researchers also indicated the reduced size of gallbladder with consuming mineral water rich in calcium sulfate (Coiro et al., 1997, Cuomo et al., 2002), bicarbonate and calcium (Potischman, 2003), as well as sulfate and bicarbonate (Grossi et al., 1996). A variety of mineral waters are able to increase the excretion of bile. So, it seems that mineral water with different ionic compounds affect stimulation of the bile flow into the duodenum due to high osmolarity (Capurso et al., 1999).
The mechanisms by which mineral water reduces serum TC and LDL-c are similar to those on which soluble fiber acts through. Soluble fibers reduce cholesterol absorption mainly due to the intestinal viscosity and interference with enterohepatic cycle (Rylander and Arnaud, 2004).
Our results were consistent with the results of Aslanabadi et al. In their study, consuming a liter of mineral water for a month, decreased total cholesterol and LDL-c, but had no effect on serum triglyceride and HDL-c (Aslanabadi et al., 2014).
Conclusions
The results of this study showed that daily consumption of 1.5 liters of premium mineral water of Damavand springs decreased systolic and diastolic blood pressure, TC, and LDL-c levels. Therefore, more research is required to verify the involved mechanisms as well as the effect of mineral water on the above-mentioned factors in longer periods.  
Acknowledgement
We appreciate National Nutrition and Food Technology Research Institute of Iran for financial support. We also thank the Managing Director of Damavand Mineral Water Company, Dr. Aminpoor, and Dr. Azar for their valuable assistance.
Authors' contribution
All authors equally contributed in this study. All authors read and approved the final manuscript.
Conflict of Interest
The authors declared no conflict of interest.
 
References
Aslanabadi N, Asl BH, Bakhshalizadeh B, Ghaderi F & Nemati M 2014. Hypolipidemic activity of a natural mineral water rich
in calcium, magnesium, and bicarbonate
in hyperlipidemic adults. Advanced pharmaceutical bulletin. 4 (3): 303.
Azizi F, Ghanbarian A, Madjid M & Rahmani M 2002. Distribution of blood pressure and prevalence of hypertension in Tehran adult population: Tehran Lipid and Glucose Study (TLGS), 1999–2000. Journal of human hypertension. 16 (5): 305.
Azoicăi D, et al. 1996. Multidisciplinary epidemiological observations on the role of mineral elements and other environmental factors in inducing essential arterial hypertension. Revista medico-chirurgicala a Societatii de Medici si Naturalisti din Iasi. 100 (1-2): 88-93.
Bain LK, et al. 2015. The relationship between dietary magnesium intake, stroke and its major risk factors, blood pressure and cholesterol, in the EPIC-Norfolk cohort. International journal of cardiology. 196: 108-114.
Bostick RM, et al. 1999. Relation of calcium, vitamin D, and dairy food intake to ischemic heart disease mortality among postmenopausal women. American journal of epidemiology. 149 (2): 151-161.
Capurso A, et al. 1999. Increased bile acid excretion and reduction of serum cholesterol after crenotherapy with salt-rich mineral water. Aging clinical and experimental research. 11 (4): 273-276.
Chijiiwa K & Linscheer WG 1984. Effect of intraluminal pH on cholesterol and oleic acid absorption from micellar solutions in the rat. American journal of physiology-gastrointestinal and liver physiology. 246 (5): G492-G499.
Chijiiwa K & Linscheer WG 1987. Mechanism of pH effect on oleic acid and cholesterol absorption in the rat. American journal of physiology-gastrointestinal and liver physiology. 252 (4): G506-G510.
Cleeman J, Grundy S, Becker D & Clark L 2001. Expert panel on detection, evaluation and treatment of high blood cholesterol in adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP III). Journal of the American medical association. 285 (19): 2486-2497.
Coiro V, Volpi R & Vescovi P 1997. Choleretic and cholagogic effect of sulphuric sulfate water from the springs of Tobiano in cholestasis in alcohol related liver diseases. La Clinica terapeutica. 148 (1-2): 15-22.
Crawford T & Crawford M 1967. Prevalence and pathological changes of ischaemic heart-disease in a hard-water and in a soft-water area. The Lancet. 289 (7484): 229-232.
Cuomo R, et al. 2002. Effects of carbonated water on functional dyspepsia and constipation. European journal of gastroenterology & hepatology. 14 (9): 991-999.
Erceg-Rukavina T & Stefanovski M 2014. Effects of Sulphate-Sulphide Mineral Water “Mlječanica” in Patients with Hypertension. Materia socio-medica. 26 (6): 364.
Friedewald WT LR, Fredrickson DS. 1972. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. . Clinical chemistry. 18 (6): 499-502.
Grossi F, et al. 1996. Motility of the gastric antrum and the gallbladder following oral administration of sulfate-bicarbonate. La Clinica terapeutica. 147 (6): 321-326.
Jairath N 1999. Coronary heart disease & risk factor management: A nursing perspective. Saunders.
Luft FC, Zemel MB, Sowers JA, Fineberg NS & Weinberger MH 1990. Sodium bicarbonate and sodium chloride: effects on blood pressure and electrolyte homeostasis in normal and hypertensive man. Journal of hypertension. 8 (7): 663-670.
Motlagh B, O'donnell M & Yusuf S 2009. Prevalence of cardiovascular risk factors in the Middle East: a systematic review. European journal of cardiovascular prevention & rehabilitation. 16 (3): 268-280.
Musaiger AO & Al-Hazzaa HM 2012. Prevalence and risk factors associated with nutrition-related noncommunicable diseases in the Eastern Mediterranean region. International journal of general medicine. 5: 199.
Nerbrand C, Agréus L, Lenner RA, Nyberg P & Svärdsudd K 2003. The influence of calcium and magnesium in drinking water and diet on cardiovascular risk factors in individuals living in hard and soft water areas with differences in cardiovascular mortality. BMC public health. 3 (1): 21.
Potischman N 2003. Biologic and methodologic issues for nutritional biomarkers. Journal of nutrition. 133 (3): 875S-880S.
Ralapanawa U, Dharmaratne SD, Jayawickreme K & Ekanayake M 2017. Epidemiology of newly diagnosed hypertensives in a tertiary care hospital in a developing country. Clinical and experimental hypertension. 39 (3): 251-256.
Rylander R & Arnaud MJ 2004. Mineral water intake reduces blood pressure among subjects with low urinary magnesium and calcium levels. BMC public health. 4 (1): 56.
Shils ME, Olson JA & Shike M 1994. Modern nutrition in health and disease.

 
Type of article: orginal article | Subject: public specific
Received: 2018/04/17 | Accepted: 2018/08/14 | Published: 2019/05/1

References
1. Aslanabadi N, Asl BH, Bakhshalizadeh B, Ghaderi F & Nemati M 2014. Hypolipidemic activity of a natural mineral water rich in calcium, magnesium, and bicarbonate in hyperlipidemic adults. Advanced pharmaceutical bulletin. 4 (3): 303.
2. Azizi F, Ghanbarian A, Madjid M & Rahmani M 2002. Distribution of blood pressure and prevalence of hypertension in Tehran adult population: Tehran Lipid and Glucose Study (TLGS), 1999–2000. Journal of human hypertension. 16 (5): 305.
3. Azoicăi D, et al. 1996. Multidisciplinary epidemiological observations on the role of mineral elements and other environmental factors in inducing essential arterial hypertension. Revista medico-chirurgicala a Societatii de Medici si Naturalisti din Iasi. 100 (1-2): 88-93.
4. Bain LK, et al. 2015. The relationship between dietary magnesium intake, stroke and its major risk factors, blood pressure and cholesterol, in the EPIC-Norfolk cohort. International journal of cardiology. 196: 108-114.
5. Bostick RM, et al. 1999. Relation of calcium, vitamin D, and dairy food intake to ischemic heart disease mortality among postmenopausal women. American journal of epidemiology. 149 (2): 151-161.
6. Capurso A, et al. 1999. Increased bile acid excretion and reduction of serum cholesterol after crenotherapy with salt-rich mineral water. Aging clinical and experimental research. 11 (4): 273-276.
7. Chijiiwa K & Linscheer WG 1984. Effect of intraluminal pH on cholesterol and oleic acid absorption from micellar solutions in the rat. American journal of physiology-gastrointestinal and liver physiology. 246 (5): G492-G499.
8. Chijiiwa K & Linscheer WG 1987. Mechanism of pH effect on oleic acid and cholesterol absorption in the rat. American journal of physiology-gastrointestinal and liver physiology. 252 (4): G506-G510.
9. Cleeman J, Grundy S, Becker D & Clark L 2001. Expert panel on detection, evaluation and treatment of high blood cholesterol in adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP III). Journal of the American medical association. 285 (19): 2486-2497.
10. Coiro V, Volpi R & Vescovi P 1997. Choleretic and cholagogic effect of sulphuric sulfate water from the springs of Tobiano in cholestasis in alcohol related liver diseases. La Clinica terapeutica. 148 (1-2): 15-22.
11. Crawford T & Crawford M 1967. Prevalence and pathological changes of ischaemic heart-disease in a hard-water and in a soft-water area. The Lancet. 289 (7484): 229-232.
12. Cuomo R, et al. 2002. Effects of carbonated water on functional dyspepsia and constipation. European journal of gastroenterology & hepatology. 14 (9): 991-999.
13. Erceg-Rukavina T & Stefanovski M 2014. Effects of Sulphate-Sulphide Mineral Water “Mlječanica” in Patients with Hypertension. Materia socio-medica. 26 (6): 364.
14. Friedewald WT LR, Fredrickson DS. 1972. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. . Clinical chemistry. 18 (6): 499-502.
15. Grossi F, et al. 1996. Motility of the gastric antrum and the gallbladder following oral administration of sulfate-bicarbonate. La Clinica terapeutica. 147 (6): 321-326.
16. Jairath N 1999. Coronary heart disease & risk factor management: A nursing perspective. Saunders.
17. Luft FC, Zemel MB, Sowers JA, Fineberg NS & Weinberger MH 1990. Sodium bicarbonate and sodium chloride: effects on blood pressure and electrolyte homeostasis in normal and hypertensive man. Journal of hypertension. 8 (7): 663-670.
18. Motlagh B, O'donnell M & Yusuf S 2009. Prevalence of cardiovascular risk factors in the Middle East: a systematic review. European journal of cardiovascular prevention & rehabilitation. 16 (3): 268-280.
19. Musaiger AO & Al-Hazzaa HM 2012. Prevalence and risk factors associated with nutrition-related noncommunicable diseases in the Eastern Mediterranean region. International journal of general medicine. 5: 199.
20. Nerbrand C, Agréus L, Lenner RA, Nyberg P & Svärdsudd K 2003. The influence of calcium and magnesium in drinking water and diet on cardiovascular risk factors in individuals living in hard and soft water areas with differences in cardiovascular mortality. BMC public health. 3 (1): 21.
21. Potischman N 2003. Biologic and methodologic issues for nutritional biomarkers. Journal of nutrition. 133 (3): 875S-880S.
22. Ralapanawa U, Dharmaratne SD, Jayawickreme K & Ekanayake M 2017. Epidemiology of newly diagnosed hypertensives in a tertiary care hospital in a developing country. Clinical and experimental hypertension. 39 (3): 251-256.
23. Rylander R & Arnaud MJ 2004. Mineral water intake reduces blood pressure among subjects with low urinary magnesium and calcium levels. BMC public health. 4 (1): 56.
24. Shils ME, Olson JA & Shike M 1994. Modern nutrition in health and disease.

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