Think Before You Drink
As Britain staggers through another long, hot summer, our consumption of mineral water is set to break all records. We do need a lot of water to stay healthy - but does it have to come out of a bottle?

Aida Edemariam
The Guardian
July 13, 2006

Morning rush hour on a sultry, clammy July day in King's Cross, London. It's been getting hotter for days, and though the forecast is that the weather will break soon, no one is taking chances. In the queue at WH Smith a dapper man in dark glasses clutches three one-litre bottles of Volvic, 1.49 each. A middle-aged woman stands in front of the refrigeration unit comparing waters and water prices; finally she goes for a smaller bottle, at 1.29. Much of the refrigeration unit is given over to water, but already, at 9am, it needs restocking - even though today water has a bit of competition. Strategically positioned by the steps down into the Underground (which a day earlier achieved temperatures of 41C), bouncy young things are handing out free cans. "Pepsi Max, guys! Free Pepsi Max! Ice cold!" A hurried businesswoman grabs two as she runs for a train. A slender woman with carefully curled white hair also takes two, then secretes a third in her leather rucksack.

By platform four, a low trolley is piled high with bottled water. I ask the nearest man in uniform how much one costs, expecting the usual on-board price of 1.20 or so, but he says he doesn't know. Then - I must be looking peaky - "Do you need one? Are you thirsty?" That wasn't the point of my question, but as he's offering, sure. He wanders down the idling train and two minutes later emerges with a bottle, and hands it over for free. Which, though I worry a little about what his bosses might say, is sweet of him. More importantly, I'm interested by the instinct he betrays - that drinking water should be freely available in public spaces. In this age of Vittel and Volvic, Malvern and Blue Water, this seems rarely to be the case.

An organisation called the Water for Health Alliance - a loose affiliation of bodies includiung water companies, public health charities, the Royal College of Nursing, the Men's Health Forum, local authority caterers and the Schools Health Education Unit - is hoping to change this. Think about it: when was the last time you saw fresh, free drinking water in a public space? Whereas it's possible to stumble on water fountains, for example, in all manner of places in the US, Canada, and some of continental Europe, you have to go looking for them in Britain, and if you do, you'll often be disappointed. (Though at King's Cross, to my surprise, I found two in the ladies'. One proclaimed, "Drinking fountain out of order. Please do not use.") The borough of Westminster provides only seven drinking-water fountains.

This wasn't always the case. "The Victorians were quite keen on providing water in public places," says Anne Hardy, professor of the history of modern medicine at University College London and author of Health and Medicine in Britain Since 1860. Domestic water supplies in England were erratic until the 1860s and 70s, and even then water companies would provide water for only about two hours a day. Water fountains were scattered throughout cities mainly "in order to stop people from drinking just anything, and especially too much beer". Thus water provision was partly related to the temperance movement, though it was noticed that men in factories, who drank beer, were far less likely to be felled by diarrhoea than women, who were restricted to water, which at that point was not filtered or chlorinated.

The Victorians were particularly concerned with providing drinking water to the underclass - not the unemployed, who were sent to poorhouses or stayed at home, but the semi-employed: the costermongers and flower-girls, the dock workers and street-sweepers who were more likely to spend their spare time in the pub. But this underclass began to disappear in the Edwardian period, and street life became tidier. Levels of dust dropped with the disappearance of horses, licensing laws controlled drinking, and the spread of Lyons corner houses, which sold cheap tea and coffee and welcomed women, meant that alcohol was no longer the only non-water alternative. Tap water became available in homes, and the spread of tuberculosis, for example, raised worries about the sanitariness of drinking fountains (which was good news for the paper cup). Gradually, they dropped out of sight. For years drinking water became, in a very western, privileged way, a non-issue.

The popular idea that continuous hydration is necessary for health and especially that a specific quantity is required, is, says Hardy, "very, very recent, really appearing only in the past five or six years. Most people wouldn't have thought twice about it before. People have taught themselves to need water. I see that in myself. I never used to drink water except at mealtimes. But nowadays I'm constantly thinking, 'I'm thirsty, must have a glass of water.' " It is also, she notes, "a generational thing: the bottle-clutching classes are mostly the under-30s. People who matured before this fad by and large thought they could do without it. The bottle of water is now a visible symbol of 'I care about my health'."

And of course, water is integral to health. As we all learn at school, about 85% of the brain, 80% of blood and 70% of muscle is water. It removes toxins from the body, enables nutrients and oxygen to travel round it, regulates body temperature, cushions joints. But while contaminated water is no longer a big problem here, there are public health issues unrelated to cleanliness. Most are caused by not drinking enough of it.

It is next to impossible to measure the average dehydration levels of a national population, as it can vary from hour to hour in each individual, but there seems to be quite a bit of it about. It is both anecdotally observable and scientifically measurable (for example, in a study of the effect of water deprivation on cognitive-motor performance in healthy men and women published in the American Journal of Physiology last year) that dehydration adversely affects concentration. In older people, such dips in concentration contribute to the risk of falls, and thus bone breakage; a 2005 article in Nutrition Reviews, an American scientific journal, and a US Institute of Medicine panel on intakes of water and electrolytes argued that even mild dehydration could reduce the capacity for physical work by up to a quarter. It can cause headaches and depression. And a 1998 article in the Lancet even suggested that the low water content in cabin air might be among the reasons for the higher incidence of breast cancer in airline attendants. One 1996 study in Cancer Epidemiology, Biomarkers and Prevention, a publication of the American Association of Cancer Research, has suggested that drinking four to five glasses of water a day, rather than two or fewer, can reduce the risk of colon cancer by 45% in women and 32% in men. Oh, and skin tone seems to improve.

Hence the mantra that we should all drink two litres of water a day; hence the much-observed fact that no self-respecting celebrity is ever seen these days without a bottle of Evian. But it's not that simple. Experts caution that it is actually impossible to say how much a single person should drink in a day. Two litres of water could be too much for a small woman who eats lots of vegetables, and too little for a large man. How much we should drink depends on everything from body-weight to diet - because about 20% of hydration comes from what you eat. There is more water in 100g of tomato than in 100g of cola.

Furthermore, our obsession with hydration ignores the fact that we were plainly "designed to go quite long periods between drinking", says Ron Maughan, a professor of sport and exercise nutrition at Loughborough University, and an adviser to UK Athletics, the governing body of this field of sport in Britain. "Throughout most of evolution we didn't have nice plastic bottles to carry water around. People still work long hours in agricultural and industrial settings with no access to fluids except at meal breaks, and there's no evidence of harm to their physiological function." These days "you see people who are supping water continuously, and it may be providing them with no benefit whatsoever".

The perception now is that the more you can force down the better it is for you, but in fact too much water is dangerous because it dilutes the blood. "There will be people in the country who die because they allow themselves to become dehydrated," says Maughan, "but at the same time there will be people in this country who die because they have overhydrated themselves." Usually this happens during marathons - at least five have died in distance running events around the world in the past five years, because they have drunk up to 15 litres - but it can conceivably also happen in aggressive detox or dieting regimes.

The trouble is that blanket consciousness-raising drives among the public, such as that for lower salt consumption, risk reaching mainly those who are health-conscious already, "and leave untouched those who really need to change their behaviour," says Maughan. "That's what drives a large part of the organic market, and a large part of the supplements market - they're bought by people who already make healthy choices. Those who make poor food choices don't take them, because they're just not interested, or can't afford it. We usually don't hit the people we're aiming at. I fear the same might happen with the drink-more-water message."

The elderly are of course particularly vulnerable; every time there is a heatwave, there is an increase in mortality among the elderly, as was seen in France in 2003. But it's hard to keep the elderly hydrated, because with age their ability to absorb water decreases, and they are often on medicines that may have diuretic effects; according to a detailed fact-sheet produced by Hilary Forrester for Water UK, the water suppliers' industry body, "a recent survey of water provision in British care homes for the elderly found that residents consumed only two to four glasses of water a day", a quarter to half of the daily amount recommended by the Food Standards Agency. This contributes, she says, to the fact that 42% of patients admitted to geriatric wards are suffering from constipation - which in turn increases the possibility of bowel cancer. Dehydration doubles the mortality of patients admitted to hospital with strokes.

It has been found that it is generally the very disabled or ill who get the most water, because staff pay more attention to them; the less ill are of a generation inclined not to want to put anyone to any trouble; they are also of a generation that would probably prefer a nice cuppa to a glass of water. Water UK has sent hydration advice kits to nearly a thousand care homes so far, and the National Association of Care Catering and the Royal Institute of Public Health have begun training carers in how to persuade their charges to drink more H2O. Coffee, tea and hot chocolate are included on most menus, but they are caffeinated, and the former two at least are mild diuretics, which exacerbates the problem. If people insist on hot drinks, carers try to persuade them to take hot water and lemon, or to grow their own mint. If all else fails, there's always the argument that an enema is much less pleasant than downing a few glasses of water.

Children, with their larger ratio of surface area to volume, and thus a greater potential for water loss, are particularly prone to dehydration. Teachers taking part in a 40-school pilot project for Food in Schools, a joint venture between the Department of Health and the Department for Education and Skills to increase access to water, reported that "preference for drinking water over other drinks rose by 1.6 times in primary and 1.4 times in secondary schools, while preference for carbonated drinks fell. Teachers also reported that the enhanced water provision contributed to a more settled and productive learning environment, as well as helping instil good habits."

Dehydration can also be linked to increased levels of obesity, partly because thirst is often mistaken for hunger, leading to more frequent snacking, and partly because in digestion fat produces the most metabolic water when broken down, which in turn can mean that children prefer fatty foods because they compensate for their lack of water. Of course, water has to be part of a balanced diet, but the implications are obvious.

Schools were already concerned about obesity and nutrition - Food in Schools was in operation before Jamie Oliver's intervention - but after that the government pledged 220m to schools and local education authorities; set up a new School Food Trust, which has launched an online package of advice on healthy eating; and drew up tough new nutrition standards for school canteens. From September, these standards, which include the provision of free fresh water, preferably chilled, will be obligatory. This has apparently been a little tricky for schools where drinking water is available only in the toilets or from vending machines. Water coolers are a useful option: and Yorkshire Water has just installed its 900th water cooler free of charge in primary schools, says Nick Ellins, health policy adviser with Water UK. "The children like it, because it makes water special. They get to go up and get something. And they see going to a water cooler as an adult thing to do."

Water UK is one of the main partners in the Water for Health Alliance, and it is important to note that Water UK represents Britain's private water and waste-water companies, so promoting tap water is in its interest. But it is also true that far too much of the time, if you're not at home, the only options are sweet drinks, tea or coffee, or expensively bottled water, and this is a big reason why the other partners have signed on. "The marketing of bottled water is like the marketing of trainers," says Angela Mawle, chief executive of the UK Public Health Association. "There is peer-group pressure to see particular brands as more attractive and healthy, and I think it's really invidious to be doing that with something as basic as water." It exacerbates what she calls "health inequality", and she compares the effect to the often unintended exclusivity of the organic food movement, "which the chattering classes are pushing forward, without realising that they're complicit in increasing this inequality". A middle-class professional might feel it's neither here nor there to pay nearly twice a much for a couple of carrots with earth still clinging to them, or 1.49 for a bottle of water, but "one pound is a hell of a lot on a low income. I used to work in disadvantaged areas where mothers would have to use any spare pound they might have to buy two packets of biscuits so the kids could get some calories. They're not going to use it on water. The choice wouldn't even come up."

Of course, there are valid objections to water fountains. If they exist at all, they are often in toilets, which makes people squeamish about hygiene. In places such as railway stations, people might be worried about using fountains in poorly lit areas. So other options have begun to be explored. At present, cafes, restaurants and pubs are not obliged to serve free tap water on request, but many do so - albeit frequently with a measure of snootiness: tap water is cheap, and that makes you cheap. (New legislation will, however, make the provision of fresh water mandatory in Scotland from 2009.)

Free, or as near as possible to free vending machines are a possibility - the water filtration company Brita, for example, could be given council contracts; filtration and chilling would allay the fears of those who are still suspicious of tap water. Providing it in bottles or cups would create waste (another gathering argument against bottled waters: their impact on the environment, both in terms of long-distance shipping and the thousands of plastic bottles), but you could be given the option of using your own refillable receptacle. One company has launched vacuum-packed foil sachets for drinks; these could be used to dispense water. And you can market it, just like anything else: tap water is the official drink for the Sport Relief Mile this Saturday. Make good, free drinking water cool. It may be an uphill battle, but it's a good aim.

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