A STUDY OF THE RELATIONSHIP BETWEEN WATER HARDNESS AND HEART
DISEASE MORTALITY IN BRITISH COLUMBIA
by
MICHELE WIENS
A THESIS SUBMITTED IN PARTIAL FULFILMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER
OF ARTS
in
THE FACULTY OF GRADUATE STUDIES
GEOGRAPHY
We accept this thesis as conforming
to the required standard
THE UNIVERSITY OF BRITISH COLUMBIA
AUGUST 22, 1986
© MICHELE WIENS, 1986 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission.
Department of The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 ABSTRACT Several studies have indicated an inverse relationship between the hardness of community water supplies and deaths due to heart disease. In this thesis, studies of water hardness and heart disease are briefly reviewed; the role of water hardness in heart disease mortality is assessed; and, the hypothesis that soft water contributes to heart disease mortality is tested using data for 103 cities in British Columbia. The correlations of water hardness, waterborne calcium, and waterborne magnesium with sex-specific age-standardized heart disease mortality rates were not statistically-significant nor does the geographical pattern suggest any obvious relationship. The effects of water hardness on human heart-related mortality are difficult to separate from the effects of smoking, high-cholesterol diets, and other heart disease risk factors at the level of ecological correlation. it Table of Contents ACKNOWLEDGEMENT vii ABSTRACT U I 1 A. STATEMENT OF THE PROBLEM 1 B. PATHOLOGY OF HEART DISEASE 19 C. NUTRITIONAL CONSIDERATIONS 28 II iJ. 32 A. REVIEW .OF THE LITERATURE 3 2 III 40 A. OTHER HEART DISEASE RISK FACTORS 40 B. SUMMARY OF RISK FACTORS 53 IV 5 A. ASSUMPTIONS AND LIMITATIONS OF THE STUDY 59 B. DATA SOURCES AND COLLECTION 61 C. RESULTS AND ANALYSIS 75 D. SUMMARY OF RESULTS 146 E. CONCLUSION 149 BIBLIOGRAPHY 151 ABBREVIATIONS 159 APPENDIX 1: DEFINITIONS 161 APPENDIX 2: DETERMINATION OF WEIGHTED WATER HARDNESS VALUES 166 APPENDIX 3: WATER CLASSIFICATION OF SCHOOL DISTRICT 167 APPENDIX 4:INTERNATIONAL CLASSIFICATION OF DISEASES,7TH REV 173 Hi LIST OF TABLES Table Page WATER HARDNESS CLASSIFICATIONS 2 RECOMMENDED DIETARY ALLOWANCES, OR RDAs, 31 DEATHS DUE TO IHD LISTED BY SEX AND REGIONAL DISTRICT, B.C. 1 980 44 AGE-STANDARDIZED DEATH RATES FOR ISCHEMIC HEART DISEASE FOR SELECTED COUNTRIES 49 A RANKING OF WATER HARDNESS VALUES FOR B.C.SCHOOL DISTRICTS 62 A RANKING OF MORTALITY RATES FOR HEART DISEASE, MALES,B. c. 63 A RANKING OF MORTALITY RATES FOR HEART DISEASE,FEMALES,B. C. 64 THE 103 LARGEST CITIES IN BRITISH COLUMBIA 68 RESULTS OF CORRELATION BETWEEN WATER HARDNESS AND HEART DISEASE MORTALITY RATES, B.C 76 RESULTS OF CORRELATION BETWEEN WATERBORNE CALCIUM AND HEART DISEASE MORTALITY RATES, B.C 77 RESULTS OF CORRELATION BETWEEN WATERBORNE MAGNESIUM AND HEART DISEASE MORTALITY RATES, B.C 78 RESULTS OF CORRELATION BETWEEN WATER HARDNESS AND HEART DISEASE MORTALITY RATIOS 84 iv LIST OF FIGURES Figure Page BRITISH COLUMBIA SCHOOL DISTRICTS 7 WATER HARDNESS IN B.C. BY SCHOOL DISTRICT 8 MALE MORTALITY RATES FOR ALL HEART DISEASES COMBINED BY SCHOOL DISTRICT, B.C. 1956-1977 9 FEMALE MORTALITY RATES FOR ALL HEART DISEASES COMBINED BY SCHOOL DISTRICT, B.C. 1956-1977 1 0 GENERALIZED MAP OF WATER HARDNESS IN BRITISH COLUMBIA, BY SCHOOL DISTRICT 11 GENERALIZED MAP OF MALE MORTALITY RATES FOR ALL HEART DISEASES COMBINED, BY SCHOOL DISTRICT, B.C. 1956-1977 12 GENERALIZED MAP OF FEMALE MORTALITY RATES FOR ALL HEART DISEASES COMBINED, BY SCHOOL DISTRICT, B.C. 1956-1977 13 SCHOOL DISTRICTS IN B.C. WITH EITHER SOFT WATER AND HIGH RATES OF MALE HEART DISEASE MORTALITY, OR HARD WATER AND LOW RATES OF MALE HEART DISEASE MORTALITY, 1956-1977 14 SCHOOL DISTRICTS IN B.C. WITH EITHER SOFT WATER AND HIGH RATES OF FEMALE HEART DISEASE MORTALITY, OR HARD WATER AND LOW RATES OF FEMALE HEART DISEASE MORTALITY, 1956-1977 15 SCHOOL DISTRICTS IN B.C. WHICH, FOR BOTH MALES AND FEMALES, HAVE HIGH RATES OF HEART DISEASE MORTALITY AND SOFT WATER, OR LOW RATES OF HEART DISEASE MORTALITY AND HARD WATER 16 PHYSIOGRAPHIC REGIONS OF BRITISH COLUMBIA 17 GEOLOGIC DIVISIONS OF BRITISH COLUMBIA 18 SITES OF PREDILECTION FOR ATHEROSCLEROSIS 20 DIAGRAM OF AN ATHEROSCLEROTIC PLAQUE 21 PRINCIPLES OF THE PATHOGENESIS OF ATHEROSCLEROSIS 22 PROBABILITY OF DEVELOPING HEART DISEASE 41 DEATHS DUE TO DISEASES OF THE HEART IN SPECIFIED AGE GROUPS 42 MAP SHOWING REGIONAL DISTRICTS, BRITISH COLUMBIA 45 v DEATHS DUE TO IHD BY REGIONAL DISTRICT, B.C. 1980 46 BRITISH COLUMBIA SCHOOL DISTRICTS 66 A MAP OF THE 103 LARGEST CITIES IN BRITISH COLUMBIA 67 SCATTERGRAMS OF RESULTS .86 APPENDIX 3: WATER CLASSIFICATION OF SCHOOL DISTRICTS 167 VI' ACKNOWLEDGEMENT For all of their guidance, support, and kindness during the preparation of this paper, I would like to thank my thesis advisors, Mr. Richard Copley, Mr. Richard Gallagher, and Dr. Trevor Barnes. vii I. A. STATEMENT OF THE PROBLEM There is evidence from epidemiological investigations in Canada, England and Wales, the United States, and other countries, that the hardness 1 of drinking water may be inversely associated with heart disease mortality.2 Waterborne calcium and waterborne magnesium account for 95 per cent of the hardness of water. There is general agreement that a water with less than 100 mg CaC03 per liter can be classified as "soft," whereas waters with 100 mg CaC03 per liter or more can be regarded as "hard". In this study, waters with less than 75 mg CaC03 per liter are considered to be "soft," and waters with more than 100 mg CaC03 per liter are considered to be "hard." Many researchers use water hardness classifications that are similar to Stocks (1973) and Neri et al (1975). These classifications can be seen in Table 1. It has been hypothesized that deficiencies in calcium and magnesium ions, which result in softer water, are factors in heart disease mortality. This report documents and maps, for the first time, water hardness and heart disease mortality data for British Columbia (see maps at the end of this section, pp. 7-19). Map 2 is a description of water hardness in British 1A11 words in italics in this thesis are defined in appendix 1, which is a glossary of terms 2Hewitt, Neri 1980; Pocock et al 1981; Zielhuis, Haring 1981 1 TABLEt WATER. HF\RDIN)ES5 CLASSIFICATIONS EHV I RON ME NT fM- WATER •STOCKS PROTECTION CLASSIFICATION ( li75) ULTRA SOFT o- !4 VBR.Y SOFT SO FT 0-50 30 " 5fi 0-15 MoDEft.JATEL.-V SOFT 50-100 SLi G-HTL.Y HAR.D 100-150 /oo-;M MODERATELY K/MtD 7.S loo HARD .2£>o-3oo LbO 3oo VEfVY HAW) > 30O > 3oo > I So NioTE '- £ACH UNIT of (;ARi)NESs IS E&aiiift Lt sir To I riCv CVtOj PER. LirR£ 3 Columbia, by school district, using a five-category chloropleth mapping technique. Maps 3 and 4 show age-standardized heart disease mortality data for British Columbia. Maps 5, 6, and 7 show generalized water hardness and heart disease data for British Columbia. Comparing Maps 5, 6, and 7, we can use the geographical patterns to see the spatial association between water hardness and heart disease mortality. Maps 8 and 9 show the school districts which have soft water and high heart disease mortality rates, and the school districts which have hard water and low heart disease mortality rates. The school districts which have either (1) soft water and high rates of heart disease mortality1, or (2) hard water and low rates of heart disease mortality2 for males are: 1. Alberni 2. Burns Lake 3. Campbell River 4. Cariboo-Chilcotin 5. Central Okanagan 6. Hope 7. Kamloops 8. Kitimat 9. Nechako 10. Nelson 11. Powell River 12. Prince Rupert 13. South Okanagan 14. Terrace 15. Trail The school districts with either (1) soft water and high rates of heart disease mortality, or (2) hard water and low 1High rates of heart disease mortality are here defined as greater than 401 deaths per 100,000 2Low rates of heart disease mortality are here defined as less than 350 deaths per 100,000 4 rates of heart disease mortality for females are: 1. Cariboo-Chilcotin 2. Central Okanagan 3. Chilliwack 4. Fernie 5. Kitimat 6. Lillooet 7. Merritt 8. Nechako 9. Peace River North 10. Peace River South 11. Prince George 12. Powell River 13. Quesnel 14. South Okanagan 15. Vancouver Island North 16. Vernon 17. Windermere School districts with either (1) soft water and high rates of heart disease mortality, or (2) hard water and low rates of heart disease mortality for both male and female data are: Cariboo-Chilcotin, Hope, Kitimat, Nechako, Powell River, Central Okanagan, and South Okanagan. These are indicated in Map 10. About 5.7 per cent of the province's population lives in these 7 districts.1 Looking at Map 11, we see that the districts with soft water and high rates of heart disease mortality, for both males and females, are all located within the Coastal Mountain Physiographic Region of British Columbia, and the districts with hard water and low rates of heart disease mortality are all located within the Intermontane Physiographic Region. The Geologic Region associated with the Coastal Mountain Region is the Coast Plutonic Complex, ^here are only 66 school districts because 8 were excluded due to a lack of information. 5 which is composed mainly of metamorphosed granitic rock; the Geologic Region associated with the Intermontane Region is the unmetamorphosed sedimentary and volcanic strata of the Intermontane Belt. These geologic regions are shown in Map 12. One could suggest, as Masironi did, that a region's geology is related to the geographical pattern of heart disease mortality.1 The general pattern in British Columbia lends some support to Masironi's argument. However, in single physiographic regions, there are some school districts which lend support to the hypothesis that water hardness is inversely associated with heart' disease mortality, and there are some districts which do not. Both Rogot and Masironi stated that extreme climatic conditions may be related to heart disease mortality, but this study does not show any relationship between heart disease mortality and extreme climatic conditions.2 Heart disease mortality rates in British Columbia do not vary in any consistent way with climate. If heart disease were aggravated by extreme climatic conditions, one would expect the highest rates of heart disease mortality to occur in the northern school districts in British Columbia, and the lower rates to occur in the south and southeast parts of the province, where the climate is often more moderate. In fact, the relatively high rates of the climatically-moderate coastal districts contradict the arguments of Rogot and Masironi. 1Masironi, Shaper 1981 2Rogot, Padgett 1976; Masironi, Shaper 1981 6 There are other risk factors for heart disease, such as dietary habit, lifestyle, and smoking. In this thesis I will test whether a relationship can be detected in British Columbia between heart disease mortality and water hardness. I will also try to detect the separate contributions of waterborne calcium and magnesium to heart disease mortality. Age and sex, which are major heart disease risk factors, will be controlled in this study: mortality rates will be age-standardized and sex-specific. I have divided my study into four main sections, namely: (Part 1) a comment on the plausibility of the suspected relationship between heart disease and soft water; (Part 2) a review of the literature on water hardness and heart disease; (Part 3) a comment on suspected heart disease risk factors; and (Part 4) an investigation of whether there is a statistically-significant relationship between water hardness and heart disease mortality in 103 cities in British Columbia. Ii/\P I : BRITISH COLUMBIA SCHOOL DISTRICTS 59 PEACE P1vEf 32 HOPE 63 PEACE R:VE1 33 CMRLIWACK 61 GREATER 3-1 iGDOTS^OnO VICTORIA 35 UNCUT 62 SOCKE 36 SURREY 63 SAANICH 3 7 DCL'A $4 &m_f ISl AN[ 3a PiCMnOttO 65 COWILHAN 39 VANCOUVER EG L*ft COHICl 40 HE" 60 rJANAlHO WESTMINSTER DUAL I CUM 4 1 8'JRNADY 70 ALDCRNI 42 MAPLE RIOCE. 7 1 COUHTENAY <3 COQUITLAM 72 CAMPBELL 44 H VANCCLiVER RIVER *5 M VANCOUVER 75 MISSIOH <6 SUNSHINE 76 AGASSIZ - COAST HARRI50H 47 POWELL RIVER 77 SUMKEBLANO 49 HOWE SOUND PO KITI MA T 43 CCHT1UL COAST Bi FORT NELSO 50 DUEEN 64 VAN ISL WE CHARLOTTE B5 VAN ISL NO 52 PRtHCc RUPERT 65 CHESTQM-KA 54 SHI1HERS B7 STIKINE 55 OURNS LAKE. BO TERRACE 56 N£OU<0 89 SHUSWAP 57 PRINCE S2 NI5MGA GEORGE j 5QUR.CC ; THE: VA>!£OU\/CR SCHOOL, ao^^n cmcr 8 MAP 2X V/rVTER. HARDtvjESS IH BMTI5H COLUMBIA BY SCHOOL DISTRICT MOTE: WATLR. &UM_ITY D«.TA WM oaTHiUhD Ffto^ nuWiciPAi. RLC MAP3'- AfrE-STANDARDIZED MORTftLlTY RATETS FOR AU_ KCART DISEASES fl1St-in«) FOR MflL« , 8Y SCHOOL DISTRICT ,rJ B-C. STANDARD II ED MORTALITY «.ftTETS ^7.1 <. 30O (per lo ISSSTtTS fit >45° ~T DI5TMCT5 MoT INCLUDED I _iI IKIK|| THITHISS WJMJkNM_fSt-fllSS MOTE; HEAIT DISEASE MOO-THLITY INFORMATION WAS 00™,WHO FROM THE CAtrtEt CCNTR.OL ft&eMCY OF B.C., ft* SPECIAL A RRAN&En C.MT* 10 A&E- STANDARDIZED MORTAL .TV RATES TOR ALU HEART MAP '• DISEASE'S COM^NfD ( 19 56 - I ?7«) FoR. FEMALES QY SCHOOL DISTRICT IN 3.C. *GE-STANDARDIZED Pi0 RJT ALI T V fLATCS ESij 30I-3SO \^ 351-Hoo DISTRICTS MOT INCLUDED ,ti THIS Ar/ftL.V5 WoTE- HEART DlSE-ftSfc. MORTAL 1 TV lHH«HMIoM *AS OBTA.NED FKOfA TrtB OWCE* CO NTH*. AM-MCV Of B 1 , BY .SPECIAL ARRAW&EM^MT 11 MAPS-' &FNtRALiZ£D WATfH HftP-DAJh'SS flMTlSM COLUMBIA , HoTe •• WATER. au«irr PATA WAS OBTAINIFO r«-<"i HUW:C,P FRaM THE CAN1LER_ conrttL A-&£*)CY OF ac, BV SPECIAL AWLAKjS-eHCrJT 13 MAP 7:GENERALIZED AGE- STPSMDAR.DI2.ED MiUmLirv RATES Fog. ALL HEART DISEASES COMBINED ( 19 5L-I 8 V SCHOOL DISTRICT INI B-C. ME- STANDAR-Dixeo MORTALITY FU\TES <( 350 ('per too, ooo) DISTRICTS MoT If/CuuDED • W T^is AMALVSIS NoT£ HEART DlSC^i* MOtTALiTV I NFdft M ATI (7 * "M;* 6l3T/\I^Ef> FROM THE CANCER. C«>ITR.OL /s&eMcV OP B.C., BY SPECIAL ARRAM&CMEWT MAP 8- SCH-OOL. Dl5rK.ic.TS IN 3-C w/T»f EirHk'R. SOFT ^rE« AMD HUH RATES OP hHTKKT D'S£*S£ l^oRTAuiTy oR/ HAfLD WATeK ArJD L-OW KrM£5 OF l*1r\i~t~~ tfCART £>/5£A5ET t^[dR Jflui ry, KEY: K§3 DI5TRICT5 WiTH SOFT WATER MO HIGH RATES OF rt£ARrDlS£*S£ LICD 7l4oo- Hfctf) .^*o3 DISTRICTS WITH HrARD WATER. AMD A-ATES OP H-EAftT QlSEAsC 15 MAP ^SCHOOL DIST^ICIS IH B-C WITtf E I THER SOFT ^TfR flrJ V W.TER ANJ> LoU RArrS OF F£M«UT HEART US** SET M. OR. TA L-iTV) >', • ? » o „• • o »' . 9 0 8 o 0 " - o o e o »" o 0 o o 0° KEY' - 0 i DISTRICTS WITH SoFT WATCR. AMD HI&H RATES OP Hi-ARTDlSEAS^ ^1 (iCDI 1 HOo-Hk-i) ^ DISTRICTS WITH H-ARO WATER MD Low RATES OF HCART J>ISE/\S£ K\AP 10: ,5CMOOL DISTRICTS ,N ec WHICH, FO*. BOTH M.LCS AH F L MVS H,&H RATES OF: - ^ "' ' DISEASE A^D SOFT W^ OP- LOW HA res OF HEART ^5Cft5E AH Cl HARD WATE^ PIS; KiCT-S WITH SoFT WM ftND 'riitH RATES OF HE-A it" "•oi Dl-SYR.VC.TS WITH HARD AfJQ U>uJ RATE'S OF ii £A£LT rMSE"A.SE. HO M A L IT Y MAP H PKY5IO&RAPHIC. REGIONS OF BRITISH COLUMBIA MftP lj. M/VTbR. G-EDLfi< REGIONS Or BK\T1S H CoL-Ur1£>)A 19 B. PATHOLOGY OF HEART DISEASE Let us now consider whether the role of calcium and magnesium ions in heart disease mortality is biologically plausible. Heart disease develops as cholesterol, calcium and connective tissue thicken the lining of those arteries which nourish the heart muscle. 1 Coronary atherosclerosis, a special type of thickening and hardening of the medium-sized and large arteries, accounts for a large proportion of heart attacks and cases of heart disease. Thickening of the arteries involves the accumulation of fatty deposit called plaque on the arterial walls. These developments are illustrated in Figures 1-3, which are taken from Braunwald. The major components of the atherosclerotic plaque are cells and lipid.The lipid is represented by a soft, necrotic core which is rich in cholesterol esters. Plaques are characterized by rough edges which irritate the smooth lining of the arteries. In heart disease development, scar tissue forms on the arterial lining, arteries become hard and narrow, and the flow of blood through the arteries decreases. The transformation of the elastic artery walls into rigid artery walls causes the heart to pump all blood without arterial assistance. Effects of atherosclerosis result mainly from the lack of blood in body parts supplied by the diseased arteries. In plaques of the medium-sized arteries, stenosis often results in an obstructing thrombus which forms on the wall of the 'Braunwald 1980:1221 2£ : Fl&UR£ 1 SiTES OF PREDICTION! FOP. ATHE:w>scL.Eft.osis_> iM USUAL R.A.MK. QPJ5ER- FIGURE 2.' DIAGRAM OF AN ATHEROSCLEROTIC PLAQUE FIBROUS CAP DJUUI£SQU& BECAUSE OF — SIZE, TENDENCY TO FRACTURE AND ULCERATE NECROTIC CORE HAHGEfiOUS BECAUSE OF — SIZE, CONSISTENCY AND THROMBOFXASTIC rv-0-7 SUBSTANCES 7~» °\ .«> / / a THE COMPONENTS CP THE AVDVANICEQ (C.L I NIC ALL.V IM P 1 KTANT) ATH£ieorc LFUDTIC PLAOUS. CHARACTERISTICS OF TH-E ADVAMCFB PUOUE AM D fTS C.L1MIC.AL. EFFECTS IN/ IMEDIUM- >Si2.ETO LJHUSCULAR.) ARTETRIES FIGURE: 3 : PRINCIPLES OF THE PATHOGENESIS OF ATHEROSCLEROSIS •MYOCARDIAL CEREBRAL GANGRENE OF ABDOMINAL AORTIC INFARCT INFARCT EXTREMITIES ANEURYSM [ CLINICAL HORI2^0Nj CALCIFICATION COMPLICATED LESION- HEMORRHAGE, ULCERATION, THROMBOSIS FIBROUS PLAQUE FATTY STREAK t I I THE" NATuRA.i_ HISTDRV OF ATU.ERj)SCLEH.asis , PLA&UETS L15UALL I' .DEVELOP SLOWLY AJ\I.D iNsmuoniLY OVER. MAMY yEPJL-s) A MO THE*' «EI\/£RAI_L.Y PRo.sft.E5s FROM A. FATTV JiTdEAK Ta A FlSiecuS PLAQUE Al\/D TK£NI TO A C_oMPULCAT£"D PLAGUE: THAT /= LIKELV TO ££AB TO CLIAI/HAL. effects* 23 blood vessel. Thrombus in a coronary artery can lead to sudden coronary occlusion and myocardial infarction. A lack of blood in the brain may cause a stroke. Partial obstruction of the coronary arteries' blood supply to the heart muscle may cause angina pectoris. In plaques of the aorta, the major effects of atherosclerosis are more likely caused by thinning of the media between the plaques, weakening of the arterial wall, aneurysm formation, and rupture.1 Theories of pathogenesis of atherosclerosis suggest that plaque development begins early in life, with the process continuing over many years. It has been suggested that excess cholesterol in the blood, primarily caused by a diet high in animal fats and dairy products may promote atherosclerosis.2 Cholesterol is insoluble; it must be carried through the bloodstream in packets of fat and protein known as lipoproteins. In a popular model of atherosclerosis, high-density lipoprotein cholesterol carriers (HDL) may help remove cholesterol from blood circulation; low levels of low-density lipoprotein carriers (LDL) have been linked to atherosclerosis.3 Normally, the LDL bind to and remove particles carrying cholesterol. The production by the liver of beneficial LDL is hampered by high cholesterol diets. " While the exact process by which atherosclerosis occurs is not well understood, there is no 1Braunwald 1980:1221 2Kannel,Castelli,and Gordon 1979 3Ibid "Huyghe 1985:34 doubt that without cholesterol it does not occur. 1Ibid:34 25 a. THE SPECIFIC ROLE OF CALCIUM IN HEART DISEASE Calcium, in addition to its role as an essential element for skeletal integrity and regulatory function of skeletal muscle contraction and relaxation, plays a role in tissue processes that regulate cardiovascular physiology and blood pressure.1 Epidemiologic evidence supports an hypothesized link between level of calcium intake and blood pressure regulation.2 An animal study by McCarron supports the theory that deficient dietary calcium is a contributing factor in the genesis of hypertension.3 The most widely studied genetic model of hypertension, the spontaneously hypertensive rat (SHR), manifests human-like abnormalities of calcium metabolism. In the SHR experiments it was shown that rat hypertension could be ameliorated by supplementing the diet of the SHR with calcium. Calcium supplementation in the normotensive control for the SHR strain also controlled blood pressure levels. Studies which have assessed the effects of calcium supplementation on blood pressure regulation in normotensive and hypertensive humans indicate that dietary calcium supplementation may be an effective means of reducing blood pressure in hypertensives, or preventing blood pressure increases in those at risk for developing hypertension." 1Parrott-Garcia, McCarron 1984 2Schroeder l960a;Stitt et al 1973; Masironi, Shaper 1981 3McCarron 1983 "Calabrese et al 1980 26 Recent evidence has further proposed a connection between calcium and sodium metabolism in blood pressure regulation.1 Several societies which have a low prevalence of hypertension also consume diets high in sodium and calcium.2 Animal evidence involving the SHR supports the theory that sodium restriction may blunt the positive effect of high calcium intake or exacerbate blood pressure in both hypertensives and normotensives.3 With respect to biologic mechanisms, both animal and human studies have supported the claim that deficiencies in calcium can play a role in heart di sease. 1Huyghe 1985 2Marier et al 1979:57 3McCarron 1983 27 b. THE ROLE OF MAGNESIUM CONSIDERED Epidemiologic studies suggest that magnesium may be a factor which helps prevent heart attack.1 Magnesium ions help maintain the functional and structural integrity of the myocardium. Magnesium deficiency sensitizes the myocardium to the toxic effects of various drugs, while magnesium is protective.2 Variations in magnesium might be critical for hearts that are already damaged or malfunctioning {arrythmia). Heggtveit et al , in 1969, reported that ischemic, non-infarcted hearts tend to be deficient in magnesium, a factor that could predispose such hearts to fatal arryt hmi as. 3 Anderson, in 1973, stated that magnesium deficiency can also predispose hearts to ventricular fibrillation. " The findings of Heggtveit and Anderson suggest that magnesium's role in heart disease mortality is important. 1Revis et al 1980 2Singh, Singh, Cameron 1981 3Marier et al 1979 "Anderson et al 1973 28 C. NUTRITIONAL CONSIDERATIONS The belief that water is a significant source of calcium and magnesium has been given support.1 Generally, more than ten per cent of the human daily need for waterborne elements (particularly calcium, magnesium, lithium, fluorine, copper, iron, and zinc) may be supplied by tap water and may make the difference between poor and good health.2 Some researchers, however, have raised concerns about the physiological significance of water hardness, calcium, and magnesium.3 These same researchers have cited that: (1) the amount of water people drink daily varies; (2) the ingestion of minerals such as calcium and magnesium varies with one's self-selected diet; and (3) calcium and magnesium metabolism differs among individuals. For ecological analyses of the type to be carried out in this thesis, individual differences in both water consumption and metabolism are not expected to be important. The specific amounts of calcium and magnesium which drinking water can contribute to one's diet will now be examined. 1Marier et al 1979 2Altura 1979 3Hammer, Heyden 1980:2400 29 a. GENERAL CONSIDERATIONS OF MINERAL INTAKE FROM WATER CALCIUM The daily intake of calcium for most western adult populations ranges from 360 to 1,200 mg, depending on age (see table 2, which appears in Drinking Water and Health, 1980). Drinking water could contribute an average of 52 mg of calcium per day and a maximum of 290 mg of calcium per day if the average adult drinks two liters of water which has a calcium concentration of 26 mg/L or a maximum of 145 mg/L. 1 The Quesnel school district has an average waterborne calcium value of 51 mg per liter (see Appendix 3); if the average person in Quesnel drinks two liters of this water per day, then drinking water in this district could contribute over 100 mg of calcium to one's daily intake. This contribution would represent 8 to 12 per cent of the adult recommended daily allowance of calcium. Where diets are deficient in calcium, therefore, waterborne calcium contribution may be crucial. 1Walker 1972 30 b. MAGNESIUM The average daily magnesium intake for most western adult populations ranges from 60 to 400 mg, depending on age (see table 2). Drinking water can provide nutritional benefit for individuals consuming an otherwise magnesium-deficient diet.1 In the diet of South African Bantu, the maize meal is high in magnesium, which has been cited to explain why cardiac disease is seldom seen among the Bantu.2 In Canada in 1975, Neri and Johansen found that drinking water with a high magnesium content may contribute up to 20 per cent of the total daily magnesium intake. Water data gathered for this British Columbia study also indicates that waterborne magnesium can, in some districts, contribute almost 20 per cent of the total daily magnesium intake. This amount of magnesium may be important especially under circumstances where elevated amounts might be needed by individuals undergoing stressful situations.3 1Safe Drinking Water Committee 1980:275 2Masironi, Shaper 1981 3Marier et al 1979:94 31 TABLE X- Recommended Dietary Allowances (RDA's)0 RDA, mg/day Group Age, yr Weight, kg Calcium Magnesium Phosphorus Iodine Iron Zinc Infants 0.0-0.5 6 360 60 240 0.035 10 3 0.5-1.0 9 540 70 400 0.045 15 5 Children 1-3 13 800 150 800 0.060 15 10 4-6 20 800 200 800 0.080 10 10 7-10 30 800 250 800 0.110 10 10 Males 11-14 44 1.200 350 1,200 0.130 18 15 15-18 6) 1,200 400 1,200 0.150 •18 15 19-22 67 800 350 800 0.140 10 15 23-50 70 800 350 800 0.130 10 15 5H 70 800 350 800 0.110 10 15 Females, not pregnant 11-18 44-54 1,200 300 1,200 0.115 18 15 19-50 58 800 300 800 0.100 18 15 51 + 58 800 300 800 0.080 10 15 Females, pregnant 1,200 450 1,200 0.125 18+6 20 Females, laclaling 1.200 450 1,200 0.150 18 25 " From National Academy of Sciences, 19S4. The allowances are intended to provide for individual variations among most normal persons as they live in the United States under usual environmental stresses. Diets should be based on a variety of common foods to provide other nutrients for which human requirements have been less well defined. 6 This increased requirement cannot be met by ordinary diets; therefore, the use of supplemental iron is recommended. II. A. REVIEW OF THE LITERATURE Many studies have revealed an inverse relationship between hard water and heart disease mortality. The first evidence of a connection between human health and water quality was given in Japan in 1957 by Kobayashi, who found a parallel between the geographic distribution of stroke and the acidity of river water. It was not until 1960 in the United States that Schroeder identified a specific connection between water hardne'ss and heart disease.1 Schroeder reported a statistically-significant inverse correlation (e.g. -0.29: p=<0.0l) between the total hardness of drinking water and the death rate from heart disease. Schroeder obtained no significant correlation for non-cardiovascular causes of death. In this same study, a highly significant correlation coefficient of -0.30 was obtained for waterborne magnesium, and -0.27 for calcium. It is interesting to note that in another 1960 report by Schroeder, several mortality variables other than water hardness were studied in relation to heart disease mortality.2 Schroeder reported significant negative correlations of water hardness with cardiovascular mortality, cancer mortality, cirrhosis of the liver, population density, and per cent nonwhite population. Conversely, Schroeder reported significant positive 'Schroeder 1960b 2Schroeder 1960a 32 33 correlations of water hardness with motor vehicle accidents, other accidents, and congenital malformations. It was, however, Schroeder's identification of a negative correlation between water hardness and cardiovascular mortality which was to be further studied by researchers in other regions - many of whom subsequently reported a similar correlation. In 1961, Morris et al studied 83 county boroughs in England and Wales, and reported inverse correlations between various forms of cardiac-related mortality and total hardness (-0.36 to -0.55), carbonate hardness (-0.40 to -0.54), and waterborne calcium (-0.45 to -0.65). 1 Morris et al -- unlike Schroeder -- did not obtain a statistically-significant correlation with waterborne magnesium.2 In 1962 in England and Wales again, Davies noted a fact that was in contradiction to earlier British studies which had found a relationship between water hardness and heart disease.3 It was found that Midland had hard water and low cardiovascular mortality (as British researchers such as Morris might expect), but Birmingham had soft water and also low cardiovascular mortality. However, it appears that Davies did not consider the different socio-economic conditions of Midland and Birmingham. 1Morris, Crawford, Heady, 1968 2Marier et al 1979 3Davies 1962 34 In 1962, Sauer et al studied 92 United States metropolitan areas. Among whites ages 45 to 64 and 35 to 74 years, they found significantly negative association between hardness and all cardiovascular-renal causes combined and also for coronary heart disease.1 In a 1969 study of 116 of the 163 standard metropolitan statistical areas in the United States, Dudley et al found a negative association between hardness and coronary heart disease in white males aged 45 to 65 years.2 In 1970, Winton and McCabe, who studied 135 central counties in the United States, found a negative association between water hardness and diseases of the heart, but disagreed with Schroeder (1960b), who had reported a positive association betweem water hardness and strokes.3 A study by Anderson and LeRiche in 1971 found a negative association between sudden cardiac death and water hardness in 34 medium-sized cities and towns in Ontario." Anderson in 1975 showed that the hearts of cardiac ischemia subjects contained 22 per cent less magnesium than was found in hearts of non-cardiac cases, and that the hearts of soft-water area residents contained 6 to 7 per cent less magnesium than found in residents of hard-water localities.5 'Sauer 1962 2Dudley et al 1969 3Winton, McCabe 1970 "Anderson, LeRiche 1971 5Anderson 1975 35 In the Netherlands in 1975, central water softening was discouraged by the public health council because of the statistically-significant negative association found by Zielhuis and others between the hardness of drinking water and death rate from heart disease over the period 1958 to 1970.1 In a 1980 report in the United States, Greathouse and Osborne stated that water hardness and calcium apppeared to follow the trend of negative associations with the mortality rates for most groups of cardiovascular disease, while copper and lead in water were positively associated.2 In 1980, Hewitt and Neri related water exposure to heart disease mortality of individual subjects; myocardial tissue of residents of soft-water and hard-water areas was compared, and this comparison confirmed that insufficient magnesium intake is a likely cause of higher heart disease mortality in soft-water areas.3 Masironi, Pisa, and Clayton in 1980 studied the relation between water hardness and myocardial infarction in fifteen European cities. Higher rates of myocardial infarction were usually found in cities with softer water. In a 1981 study in New Guinea, Masironi investigated the relationship between blood pressure in villagers along the Wagupmeri River and the calcium content of the drinking water at these villages. The calcium content of the water 1Zielhuis, Haring 1981 2Greathouse, Osborne 1980 3Hewitt, Neri 1980 36 decreased downstream, yet blood pressure of the villagers was found to increase.1 In 1981, Masironi found a negative relationship between hard water and arteriosclerotic heart disease in populations living along the Colorado, Columbia, and Ohio rivers.2 In a study in the United Kingdom, Pocock et al had reported in 1981 that a significant association exists between water hardness and heart disease mortality; towns with soft water tended to have higher death rates than towns with hard water.3 Although the relationship was somewhat weakened after allowing for climatic and socio-economic factors, it remained statistically-significant for both coronary heart disease and stroke. After adjustment of other factors, soft-water areas had a 10 to 15 per cent higher cardiovascular mortality than areas of medium hardness. " A study in Finland by Luoma et al, published in 1983, assessed the risk of myocardial infarction in two populations distinguished by different levels of fluoride, magnesium and calcium concentration in drinking water. The results of this case-control study were consistent with the hypothesis that both a low fluoride and a low magnesium intake are conducive to atherosclerosis and acute myocardial infarct ion. With the exception of the study of Davies, the preceding literature supports the hypothesis that soft 1Masironi, Shaper 1981 2Masironi, Shaper 1981 3Pocock, Shaper, Packham 1981 "Ibid 1981:1 37 drinking water contributes to heart disease. Not all researchers, however, have had similar statistically-significant study results in support of the hypothesis. For example, Mulcahy in Ireland could not find any significant correlations between water hardness and heart disease.1 However, reports published after Mulcahy's study may be more reliable because newer and more accurate methods of measuring water constituents have been used. The hypothesis that soft water may contribute to heart disease received least support from studies done within cities or counties. For example, three communities in the Los Angeles area were matched for age, sex, race, income, socioeconomic status and stability by Allwright et al .2 No association could be found between water hardness and heart disease. The authors did point out that their "soft" water communities had water which would have been called "hard" by most British researchers. Klusman and Sauer found no significant association between water hardness in all counties in Indiana, but the range of hardness in these counties was small.3 Connor noted in 1970 that the arteriosclerotic heart disease death rate among males was higher in Edinburgh with its hard water, than in Glasgow, which has soft water." This discrepancy may be explained by the fact that both towns actually have soft water according to the classifications of 1Mulcahy 1973 2Allwright et al. 1974 3Klusman, Sauer 1975 "Conner 1970 38 water hardness used in most reports. Furthermore, the differences in death rates in Edinburgh and Glasgow were slight. In a case-control study by Comstock in 1971, persons in Washington County, Maryland, who had died from arteriosclerotic heart disease were compared with controls drawn from the same general population. Water hardness values were determined from water samples obtained from the home water taps of cases and controls. No significant association of arteriosclerotic and degenerative heart disease deaths could be found with water hardness. The water samples obtained from the home water taps of subjects were taken at time of death, and the water supplies may have differed in earlier life. This study was able to take into account the effects of important demographic, socio-economic, and personal characteristics which ecological studies are not often able to do, but the findings of this study must be regarded with caution because only 412 cases and controls were included in this study. According to Marier et al . , much of the confusion with regard to water hardness has resulted from inadequate experimental designs; e.g., small numbers of subjects were compared, the range of water hardness was too narrow (i.e. too narrow a range would be one which extends from, say, 70 mg CaC03 per litre to 130 mg CaC03 per litre; this range 39 would not provide values of very soft water of very hard water), adequate control populations were lacking, and mortality rates were not standardized.1 Hammer and Heyden cited "spatial autocorrelation" to explain inconsistencies in study findings. Spatial autocorrelation is the tendency for neighbouring geographical units to resemble one another in almost any attribute. Other heart disease risk factors will now be considered. 1Marier et al 1979 Ill. A. OTHER HEART DISEASE RISK FACTORS Magnesium and calcium deficiencies in people's diet are the heart disease risk factors under investigation within this report, but there are other heart disease risk factors which could be considered. The incidence of heart disease varies greatly according to age, sex, and race. High serum cholesterol, high blood pressure, gout, hyperglycemia, and smoking appear to increase the frequency of the disease. These relationships are illustrated in figure 4. Other researchers have identified 'Type A' personality as a heart disease risk factor. Lack of exercise, poor nutrition, stressful lifestyles, extreme climatic conditions, alcohol consumption, and hormonal and genetic differences are also suspected risk factors of heart disease. These factors will now be discussed. a. AGE Heart disease mortality shows a relationship to age. This relationship can be seen in figure 5. Figure 5 is an illustration by Braunwald which shows the probability of developing heart disease in 8 years according to age, sex, and risk category. We see that heart disease is rare among the young, especially women, but increases with older age. Heart disease becomes a major cause of death for men between the ages of 35 to 40 HI FlfrUKF H' PROBA8II_\TY OF rjtrVFL-OPlMG- KEAR.T SXSiTASC. w S)/i£ARS ACCORDING- TO A&E: ScX, Mo MSK. cAT£-&-6f=Ly . FIG hooo u Re 5 •• DEATHS t>oe TO DISeASeS OF THf He#KT Term. Dk'AWi IN eftCH SPf£.iri£t> A$E - GROUP, BRITISH COLUMBIA if BO. • TOTAL DEATHS 5ooo DEATHS TJUC To DISEASES or THE HEART 4777 T»7AL U/TAT'frJi 3000 306O • If/9 /f?S\ /oao: ! 231 1 rsmt ecmtis in ItJliJiL o-xf 3o-39 5t> S9 60-69 DATA FR.OK pB-QVl^Ce Off" fJl^C, MINISTRY Op HCALTH VlTP>L5TA"nSTlC_S. R.EPbftT'io<^ , HSQ 43 44 years.1 By ages 55 to 64, approximately 40 per cent of all deaths among men are due to heart disease.2 b. SEX In Canada, the heart disease rate for males is two to three times higher than the heart disease rate for females.3 This sex ratio exists in all age categories (see table 3 and figure 6). In the United States in 1976, the white male mortality rate from heart disease was 5.2 times greater than the rate in white females for the age group 35 to 44. This sex difference in mortality declined in the age group 65 to 74. " In the United States in 1974, the male heart disease mortality rate was 2.5 times greater than the rate for females for the 34 to 44 age group and 1.5 times greater for the 65 to 74 age group. The observed differences between males and females become less apparent with increasing age. c. RACE White males and non-white females have the highest heart disease mortality.5 Since 1968, non-white males have shown an increasing susceptibility to heart di sease. 6 'Province of B.C. 1983:36 2Province of B.C. 1983:37 3Ibid:36 "Havlik, Feinleib 1979 5National center for health statistics of the United States 6Havlik, Feinleib 1979 ( s m vo v&; ' I- (i ^ >- C-l oJ tvl — "v. i sjs -~ ro,' V, V 1 IT. 5 £ < I o s — f-O. 0>: rv ~> •* s Ml CO* 3 ro fv. rvf. u. u; cs. 1-4 ^ f in v > V ro, ;r tj-Vs cv\ cj^vv^o^^ -3- or\ Cj rv sV ijs. ~V- vO rA \v ^ |r-~»o,r- ~Csl ro. sj~ rs-, sj) vO —• (-— Vr> rv v. Ci "3- 3- ml 0oo-~--^c>o >~ 2>- f-- ^° t< *0 iv SQ *o —. m *vi I 00 tv o ]j> 00 iv co 3- s^- > sj d rtv \a ^ « J» ^0 I s» ! r* PI• SS >s "V 11 sS \ Vs 1 Vs 55 fcf. v, 3: ^< 3 >s . Qo . uj ,s> =4 5 5 I s h V-> vtj N «\ T lO ^6 r4 OvOvii rs M5 F i GURE: IV< MAP SHOWING REGIONAL DISTRICTS. BRITISH COLUMBIA REGIONAL DISTRICTS No. Name No. Name 1. Alberni-Clayoquot. lb. Greater Vancouver. 2. Bulkley-Nechako. 17. Kitimat-Stikine 3. Capital (Victoria urea). 18. Kootenay Boiindary. 4. Cariboo. 19. Mount Waililington. 5. Centra! Coast. 20. Nanairno. 6. Central Fraser Valley. 21. North Okanagan. 7. Central Kootenay. 22 Okanagan-Similkameen. 8. Central Okanagan. 23. Peace River-Liard. 9. Columbia- Shuswap. 24. Powell River. 10. Comox-Strathcona. 25. Skeena-Queen Charlotte 11. Cowichan Valley. 26. Sqtiainish-Lillooct. 12. Dewdney-Alouette. 27. S! i k inc. 13. East Kootenay. 28. Sunshine Coast. 14. Fraser-Cheam. 29. Thompson-Nicola. 15. Fraser-Flirt George. •SouR.ee; PROVINCE OF- fl.c_, MWISTR.Y of HEALTH^ yiTftL STATISTICS (t£Pan.-r itrt | ^ So ^7 SU ?o SO IL> £j %> SD aj Qj 9_> --- — — 48 d. STRESS In general, the countries that lead the world in heart disease mortality are: 1. English-speaking 2. Industrialized, and 3. European and North American This is apparent from the ranking in Table 4. It is uncommon to find a high rate of heart disease mortality in Asia, the Near East, Africa, or South and Central America. Low heart disease rates in Japan, however, indicate that industrialization need not always be associated with high rates of heart disease. On the other hand, Israel and Uruguay are two countries outside of Europe with rather high heart disease mortality rates. Mortality rates from heart disease can vary within countries as well as between countries. For example, in the United States, high mortality rates occur (1) in counties along the southeastern Atlantic Coast, (2) across a southern belt through Georgia and Alabama, and (3) in the industrialized states of the midwest and northeast.1 Lower heart disease mortality rates are found in the Great Plains and mountain states. It is difficult to explain these regional differences in heart disease mortality rates. 1Meade 1979 HI c TABLE: 4- AGE-STANDARDI ZED DEATH RATES FOR ISCHEMIC HEART DISEASE FOR SELECTED COUNTRIES COUNTRY RATE LATEST AVAILABLE YEAR (per 100,000) 1. U.K.:Northern Ireland 209 .9 1981 2 .U.K . :Scot land 187 .9 1984 3 . S1ngapore 186 . 3 1981 4 . Czechoslovakia 179 . 7 1983 5 . Ireland 176 . 7 1981 6. F1nland 167 .2 1983 7 .Ne w Zealand 160 .5 1983 8. Sweden 158 . 4 1984 9 . Maur111 us 158 . 2 1982 10..Mait a 157 .0 1982 1 1.U.K.:Eng . l and and Wales 154 . 7 1982 12 . Denmark 153 .4 1982 13 .Hungary 151 .0 1984 14 .Iceland 148 .5 1983 15..Austra l 1a 146 . 3 1983 16 .Canada 145 . 1 1982 17 .United States 144 . 4 1982 18 .. Cuba 134 . 6 1981 19 .Norway 126 .4 1983 20 .Bulgaria 124 . 2 1983 21 .Israe1 1 19. 0 1983 22 .Romania 1 10. 0 1983 23 .Austr1 a 104 .0 1983 24 .Nether 1ands 103 . 4 1983 25 .Germany, Federal Repub. 102 . 5 1984 26 .Kuwa1t 99. 9 1982 27 .Venezuela 87 .7 1980 28 .Costa Rica 84 .6 1980 29 .Belgium 81 .4 1982 30 .Italy 79 .6 1980 31 .Puerto Rico 75 .1 1982 32 . Panama 75 .0 1983 33 .Po1 and 70. 8 1984 34 .Sw1tzer1 and 69 .8 1984 35 .Yugos1avia 56 .2 1982 36 .Portugal 50. 8 1982 37 . France 47 .3 1981 38 Dominican Republic 42 .5 1982 39 .Hong Kong 39 .6 1984 P/kTA Wo«.i_B RERL.TH STATISTICS ftWMOAL, 1185 50 e. CHOLESTEROL Cholesterol may be the leading risk factor in heart disease.1 The determination by pathologists that the main constituent of the atherosclerotic lesion in heart disease is cholesterol strengthened the concept that cholesterol in the circulatory blood is deposited on the arterial wall. The hypothesis has been strongly supported by many studies.2 One study, for example, of Japanese men in Hawaii and California revealed that men with lower cholesterol levels have lower heart attack rates.3 In industrialized countries such as Japan, the incidence of cigarette smoking and high blood pressure is as high as the incidence in the United States, but one sees an eighth to a tenth as many heart attacks; this may be explained by the fact that cholesterol levels of Japanese and Americans differ greatly." f. SMOKING HABITS Most people are not aware that cigarette smoking greatly affects one's cardiovascular system as well as one's lungs.5 About half of the 350,000 deaths attributable to cigarette smoking each year in the United States result from a heart attack.6 Those who argue that smoking is the most important risk factor in \ 1Braunwald 1980 2Dawber 1980:121 3Marmot et al 1975 "Ibid 5Rogot 1974 6Huyghe 1985:84 51 heart disease mortality point out that the 170,000 heart attack deaths in the United States each year due to smoking account for 39 per cent of all deaths that are caused by coronary heart disease.1 Studies have shown that smokers have a 70 per cent greater risk of dying from a heart attack than non-smokers, and the risk of dying doubles in the heavy, or two-pack-a-day smokers.2 Cigarette smoking is known to increase the prevalence and extent of atherosclerosis in coronary arteries and aorta.3 Carbon monoxide, nicotine, and other substances may injure the cells of the blood vessels and cause an increase in lipid deposits which gradually narrow the arteries over the years. Smoking also increases blood platelet aggregation which serves to thicken blood and facilitate clotting." Animal studies have shown that cigarette smoke can lower the threshold for ventricular fibrillation, an electrical instability of the heart muscle that may lead to sudden death.5 1Ibid 2Ibid 3Rogot 1974 "Ibid 5Hugyhe 1985 52 The trend for heart disease mortality in Canada has been one of increase between 1950 and 1963.1 However, between 1963 and 1975, heart disease mortality has shown a significant decline (see Table 5 below). ; TABLE 5 D^CLI^B ;N AGE-SPCCIFIC C.OR.OIS/A.R.Y' Mc«.TA,L[TV t IW1-T?7 5 A6E % 35-HM a 7 2. M'5 -5H 21M 55-feH 23-5 65-71 253 75-gM Wl^iirny ol-- MtALTK AND WiLFARE C/Vw'AD^ '*?7 Cigarette smoking has declined over the last 15 years, which may partially explain the decrease in heart disease mortality. Changes have also taken place in eating habits; there has been a general decrease in the intake 1Minister of Health and Welfare Canada 1978 53 of saturated fat and cholesterol in the Canadian diet.1 This fact could also explain the decrease in heart disease mortality which was indicated in the previous table. Increased physical activity among Canadians may also help explain this decrease. g. HYPERTENSION Hypertension refers to abnormally high arterial blood pressure and is often characterized by a state of high emotional tension. Hypertension contributes to many heart attacks each year, and is the primary cause of stroke. Stroke, the climax of cerebrovascular disease, involves blockage or rupture of blood vessels that supply oxygen and nutrients to the brain.2 Diet may be important in the role of hypertension.3 h. GOUT, HYPERGLYCEMIA, AND DIABETES Gout, a disease which occurs predominantly in males, refers to a metabolic disturbance associated with an increase of uric acids in blood and body fluids. In the Framingham study, uric acid levels were positively associated with serum cholesterol. High levels of serum cholesterol, in turn, have shown a strong association with heart disease. Hyperglycemia, a condition of abnormally high glucose concentration in the blood, has also been associated with an increased risk of heart 1Walker 1977 2Province of British Columbia 1983 3Kannel et al 1979 54 disease1 Diabetes appears to be strongly associated with heart disease. According to Dawber, the average annual incidence rate of myocardial infarction was approximately twice the rate in diabetic men compared to those without this disorder. In diabetic women the rate was almost six times that in the non-diabetic women.2 i. PHYSICAL ACTIVITY Physical inactivity is also known to increase the incidence of heart disease, especially in those who smoke and have a diet high in cholesterol. 3 j. TYPE A PERSONALITY People with a Type A behaviour pattern have been thought to have a greater risk of heart attack." A person with a Type A behaviour pattern is unusually impatient and easily roused to hostility. Friedman believes that all three major risk factors - smoking, high blood pressure, and high serum cholesterol level - are a consequence of Type A behaviour. 5 It is not known exactly how Type A behaviour might predispose one to a heart attack, though there are mechanisms to explain why it might happen. Type A's react to challenges as if they were full-scale emergencies. This response leads to an excess secretion 1Braunwald 1980 2Dawber 1980:194 3Fox, Naughton 1972 "Friedman, Rosenman 1974 5Ibid 55 of three hormones - norepinephrine, ACTH and testosterone. When secreted to excess, at least two of these hormones are known to cause damage to arteries.1 The belief that Type A personality is a risk factor was rejected until it was reported by Havlik that men who modified their Type A behaviour after experiencing a heart attack suffered one-third as many second heart attacks as men who had only cardiological counselling.2 k. EXTREME CLIMATIC CONDITIONS Seasonal variations in heart disease mortality are said to demonstrate that climate affects disease frequency.3 Some studies have failed to show that temperature and weather are clearly connected with the occurrence of myocardial infarction.4 Elwood et al found almost no association between ischemic heart disease and temperature. And it has been noted by Crawford et al in the United Kingdom that there are large differences in mortality from ischemic heart disease, yet variation in climate across the United Kingdom is modest. Masironi found a relationship between water hardness and latitude. This relationship may have arisen from temperature changes with latitude, but Masironi claimed that this relationship has arisen from "geologic trends 1Huyghe 1985 2Havlik 1979 3Masironi et al 1980 "Elwood et al 1971; Crawford et al 1968 56 (sic) across the continent."1 World Health Organization data shows clearly that countries with extreme climates do not necessarily have higher mortality rates from heart disease. 1. ALCOHOL CONSUMPTION Excessive alcohol consumption has also been associated with an increased risk of heart disease.2 This association may be attributable to the fact that alcohol can deplete magnesium levels in heavy drinkers by increasing their renal loss of magnesium.3 Excessive drinking not only causes hearts to beat faster, but it also causes a general deterioration of health. m. HORMONAL AND GENETIC DIFFERENCES Some researchers believe that hormones may help protect females from heart disease until menopause." Females tend to excrete less magnesium, perhaps in response to hormonal functions. If females retain more magnesium, this may help to explain the lower heart disease mortality rates among females. With respect to genetic differences, Mitchell found an association between higher ischemic heart disease mortality and the frequency of occurrence of blood group 0 in the United Kingdom.5 Higher rates of heart disease Masironi et al 1980 2Yano et al 1977 3Safe Drinking Water Committee 1980:272 "Dr. Elaine Eaker, U.S.National Heart, Lung and Blood Institute, Framingham Heart Study, Framingham, Massachusetts 5Mitchell 1977 57 mortality in males as compared to females suggest that perhaps male body chemistry is influential in heart disease. 58 B. SUMMARY OF RISK FACTORS There appear to be many risk factors for heart disease. Soft water may be among these risk factors. It is difficult to control for many of the suspected risk factors, because personal information on variables such as smoking habits is not easily obtainable. The combined effect of several of the suspected risk factors may outweigh the single factor of soft water. For example, the result of insufficient physical activity combined with obesity, smoking, etc., may lead to heart disease mortality more quickly than would deficient quantities of magnesium and calcium in one's diet.'On the other hand, magnesium and calcium deficiency may be as important in contributing to heart disease mortality as any other single risk factor. IV. A. ASSUMPTIONS AND LIMITATIONS OF THE STUDY Some assumptions or limitations of this study may have rendered difficult the detection of an inverse relationship between hard water and age-standardized heart disease mortality rates. The assumptions of this study are: 1. There has been little or no migration of the study populations. Larger communities have populations which are more stable,1 and although the residency or location of heart disease cases may vary, by looking at the larger communities with stable population, differences in residency lengths should be reduced as a potential confounder. 2. Per capita consumption of water does not vary in British Columbia by school district. 3. Heart disease cases drank from the local water supply; they did not consume bottled water from another place. 4. Dietary calcium and magnesium are absorbed and excreted at similar rates by populations in each school district in British Columbia. 5. There is no significant difference in quality between tap water and water tested for hardness. Although it is recognized that water ingredients may alter their concentration during transportation from the water works to consumers, I assume this to be an insignificant 1Masironi, Shaper 1981:386 59 60 change. 6. Water quality has remained relatively constant over time; any seasonal and yearly changes should be insignificant. 7. Water CaC03 values which are greater than 100 mg/L were classified as hard, and CaC03 values which are less than 100 mg/L were classified as soft. Fortunately, few of the water samples of this study were on the border between hard and soft (e.g. near 100 mg/L). 8. Water mineral constituents have been measured and reported accurately by the governmental agencies. 9. Heart disease was reported reliably and accurately on death registrations. 10. The amount of water softening in British Columbia will be insignificant in this analysis. This study has some drawbacks associated with all studies of the ecological design; however, like them, it has the advantages of being inexpensive, fast, and efficient, when the study region and population is large. Although the correlation coefficient obtained from ecological studies is not sufficient to conclude causal associations, the ecological studies themselves are often important in generating and testing hypothesis. Consistent study results of ecological studies should prompt researchers to do further case-control or cohort investigations. 61 B. DATA SOURCES AND COLLECTION To test whether any association can be detected between any of seven categories of heart disease and water hardness, waterborne calcium, and waterborne magnesium, I gathered: (a) Water quality data for 103 cities of British Columbia and, (b) Residence data on all British Columbia deaths from heart disease for the period 1956 to 1978.12 The records include approximately 108,859 males and 67,395 females. I first generated age-standardized mortality rates from mortality data by sex; then, using the Spearman rank correlation method in the SPSS.X statistics package, I correlated age-standardized mortality rates with water hardness, waterborne calcium, and waterborne magnesium. In addition, I ranked water hardness values and heart disease mortality rates for both males and females (see Tables 6, 7, and 8). a. Water Quality Information I obtained water quality information from each of the six government water management offices within British Columbia. Data was available for 95 out of the 103 cities under consideration. Populations of these 95 cities represent most of the individuals in the province 1Cities will include towns, villages, and district-municipalities as recorded in The 1981 Census of Canada: Populations in Descending Order; Populations Cat al ogue E-845. 2Mortality information was obtained from the Cancer Control Agency of British Columbia by special arrangement. TABLE 6 : A RANKING FROM HARD TO SOFT OF: WATER HARDNESS IN BRITISH COLUMBIA BY SCHOOL DISTRICT SCHOOL DISTRICT WATER HARDNESS (mg CaC03/L) 1. CARIBOO-CHILCOTIN (27)* 446.6 2. FORT NELSON (81) 282 .0 3. SOUTH OKANAGAN (14) 231 . 7 4 . LILLOOET (29) 213.0 5 . WINDERMERE (4) 205.0 6 . PRINCE GEORGE (57) 201 . 9 7 . NECHAKO (56) 196.8 8 . OUESNEL (28) 189 .0 9. PEACE RIVER SOUTH (59) 179. 2 10. VERNON (22) 174 . 3 1 1 . FERNIE (1) 158 . 5 12. GOLDEN (18) 153.0 13 . SOUTH CARIBOO (30) 152 .0 14 . MERRITT (31) 142 .0 15. CHILLIWACK (33) 140.0 16 . SHUSWAP (89) 133 . 1 17 . KEREMEOS (16) 132 .0 18 . CENTRAL OKANAGAN (23) 115.3 19. CRANBROOK (2) 97 .O 20. SMITHERS (54) 96.6 21 . VANCOUVER ISLAND NORTH (85) 91.4 22 . PRINCETON (17) 89.4 23. QUALICUM (69) 75.4 24 . SUMMERLAND (77) 70.0 24 . PEACE RIVER NORTH (60) 66.4 25 . HOPE (32) 56.0 26 . ABBOTSFORD (34) 55 .0 27 . CASTLEGAR (9) 55 .0 28 . BURNS LAKE (55) 50. 8 29. QUEEN CHARLOTTE ISLANDS (50) 50. 8 30. TRAIL (11) 47 . 9 31 . ALBERNI (70) 45.6 32 . REVELSTOKE (19) 40.0 33 . KAMLOOPS (24) 36 . 2 34 . NANAIMO (68) 34 . 8 35 . GULF ISLANDS (64) 34 . 5 36 . SUNSHINE COAST (46) 29.9 37 . CRESTON-KASLO (86) 29.5 38 . COWICHAN (65) 22 . 5 39 . CAMPBELL RIVER (72) 20. 5 40. LAKE COWICHAN (66) 19.9 4 1 . COURTENAY (71) 17.4 42 . GREATER VICTORIA (61) 16.0 43. SOOKE (62) 16.0 44 . SAANICH (63) 16 .O 45. TERRACE-NISHGA (88) 13.4 46 . POWELL RIVER (48) 12.0 47 . VANCOUVER ISLAND WEST (84) 12.0 48 . PENTICTON (15) 10.4 49 . NELSON (7) 10.0 50. KIMBERLY (3) 10.0 51 . KITIMAT (80) 9.51 52 . PRINCE RUPERT (52) 9. 18 53. MISSION (75) 5.0 54 . LANGLEY (35) 5.0 55 . SURREY (36) 5.0 56 . DELTA (37) 5.0 57 . RICHMOND (38) 5.0 58. VANCOUVER (39) 5.0 59 . NEW WESTMINSTER (40) 5.0 60. BURNABY (41) 5.0 61 . MAPLE RIDGE (42) 5.0 62 . COQUITLAM (43) 5.0 63 . NORTH VANCOUVER (44) 5.0 64. WEST VANCOUVER (45) 5.0 65. HOWE SOUND (48) 4.61 *The number in parenthesis refers to the school district number. G3 A RANKING FROM HIGH TO LOW OF: AGE-STANDARDI ZED MORTALITY RATES FOR ALL HEART DISEASES COMBINED (1956-1977) FOR MALES, BY SCHOOL DISTRICT, B.C. SCHOOL DISTRICT MORTALITY RATE (PER 100,000) 1. FERNIE (1) 519 .0 2. CRANBROOK (2) 509 .0 3 . HOPE (32) 494 . 2 4 . PRINCE RUPERT (52) 477 . 3 5. KAMLOOPS (24) 452 .8 6 . VANCOUVER (39) 449 . 6 7 . QUESNEL (23) 444 . 7 8 . NEW WESTMINSTER (40) 442 .9 9 . NORTH VANCOUVER (44) 442 .6 10 . BURNS LAKE (55) 439 . 7 1 1.KITIMA T (30) 435 . 7 12 .RICHMOND (38) 426 . 1 13 .MAPLE RIDGE (42) 423 .0 14 .PEACE RIVER SOUTH (59) 422 .0 15 .TRAIL (11) 4 20 . 9 16 .CAMPBELL RIVER (72) 4 18 .6 17 .MERRITT (31) 414 .0 18 .PRINCE GEORGE (57) 412 . 9 19 .NELSON (7) 409 . 5 20 .TERRACE-NISHGA (88) 408 . 9 21 .ALBERNI (70) 408 . 7 22 .NANAIMO (68) 407 . 7 23 .LILLOOET (29) 407 .4 24 .BURNABY (41) 404 . 5 25 .POWELL RIVER (47) 404 . 5 26 . SURREY (36) 401 . 7 27 .LANGLEY (35) 401 . 3 28 .PRINCETON (17) 400 . 6 29 .WEST VANCOUVER (45) 393 . 9 30 .QUALICUM (69) 390 . 9 31 .OUEEN CHARLOTTE ISLANDS (50) 389 .4 32 .REVELSTOKE (19) 387 . 2 33 .VANCOUVER ISLAND NORTH (85) 386 . 3 34 .CASTLEGAR (9) 383 . 8 35 .KEREMEOS (16) 383 . 3 36 .GREATER VICTORIA (61 ) 382 .6 37 .COURTENAY (7 1) 381 . 1 38 .COWICHAN (65) 380 .9 39 .FORT NELSON (81 ) 380 .8 40 VERNON (22) 377 . 5 41 .SMITHERS (54) 377 . 1 42 .SUMMERLAND (77) 377 . 1 43 .PENTICTON (15) 376 .9 44 .SUNSHINE COAST (46) 372 .0 45..GOLDE N (18) 368 . 3 46 .SOUTH CARIBOO (30) 362 . 2 47 .CHILLIWACK (33) 359 . 7 48 .SHUSWAP (89) 359 . 7 49 .SOOKE (62) 357 . 7 50. WINDERMERE (4) 356 . 1 51 .DELTA (37) 354 .0 52 .GULF ISLANDS (64) 351 . 9 53 .ABBOTSFORD (34) 346.. 7 54 .PEACE RIVER NORTH (60) 346 .0 55 .MISSIO N (75) 339 .2 56. SOUTH OKANAGAN (14) 337 .7 57. CRESTON-KASLO (86) 336 .9 58 .CARIBOO-CHILCOTI N (27) 335. 1 59. LAKE COWICHAN (66) 330. 9 60. CENTRAL OKANAGAN (23) 330. 0 S1 .COQUITLA M (43) 329 .7 62. NECHAKO (56) 329. 5 63. SAANICH (63) 325. 5 64 .HOW E SOUND (48) 319. 8 65 :KIMBERL Y (3) 300. 0 66. VANCOUVER ISLAND WEST (84) 191 .8 TABLE 8' A RANKING FROM HIGH TO LOW OF: AGE-STANDARDI ZED MORTALITY RATES FOR ALL HEART DISEASES COMBINED (1956-1977) FOR FEMALES, BY SCHOOL DISTRICT, B.C. SCHOOL DISTRICT MORTALITY RATE (PER 100,000) 1. VANCOUVER ISLAND NORTH (85) 918 .0 2 . KITIMAT (80) 432 . 7 3. HOPE (32) 416 . 7 4 . PRINCETON (17) 401 . 7 5 . PEACE RIVER NORTH (60) 364 .0 6 . SOUTH CORIBOO (30) 363 . 7 7 . POWELL RIVER (47) 352 . 3 8 . NELSON (7) 339 . 5 9. QUEEN CHARLOTTE ISLANDS (50) 333 .6 10. CASTLEGAR 99) 323 . 4 1 1 .PRINC E RUPERT (52) 318 . 5 12. KEREMEOS (16) 318 . 3 13 . SOOKE (62) 308 . 3 14 . FERNIE (1) 297 .8 15. CRANBROOK (2) 293 . 2 16 . HOWE SOUND (48) 290 .0 17 . TRAIL (11) 289 .9 18 . CAMPBELL RIVER (72) 289 .8 19. NANA IMO (68) 287 . 7 20. TERRACE-NISHGA (88) 286 .8 21 . PEACE RIVER SOUTH (59) 280 .0 22 . DELTA (37) 275 . 9 23 . KIMBERLY (3) 275 . 1 24 . PENTICTON (15) 273 . 4 25 . NORTH VANCOUVER (44) 272 . 9 26 . VANCOUVER (39) 271 . 5 27 . SHUSWAP (89) 270 .9 28. LILLOOET (29) 268 .7 29. ALBERNI (70) 267 . 7 30. BURNABY (41) 267.. 4 31 . NEW WESTMINSTER (40) 265.. 6 32. VERNON (22) 264 .8 33. REVELSTOKE (19) 264 .4 34 . LAKE COWICHAN (66) 263 . 2 35. SURREY (36) 262 .9 36 . SOUTH OKANAGAN (14) 262 . 6 37 . LANGLEY (35) 261 . 3 38 . COWICHAN (65) 261 .2 39 . PRINCE GEORGE (57) 260. 1 40. RICHMOND (38) 259. 3 41 . MISSION (75) 258 .6 42. ABBOTSFORD (34) 256 .5 43 . KAMLOOPS (24) 255 .8 44 . SUNSHINE COAST (46) , 254.0 45. QUESNEL (28) 251 .5 46. COURTENAY (71) 251 .3 47 . NECHAKO (56) 250. 2 48. MAPLE RIDGE (42) 249. 3 49 . CRESTON-KASLO (86) 246 .2 50. CHILLIWACK (33) 243 .3 51 . MERRITT (31) 242 .5 52 . SMITHERS (54) 242 .3 53. GREATER VICTORIA (61) 235 .5 54 . WEST VANCOUVER (45) 235 . 4 55 . SAANICH (63) 229 . 9 56 . CARIBOO-CHILCOTIN 228 . 1 57 . WINDERMERE (4) 225 . 9 58 . GULF ISLANDS (64) 224 .0 59 . VANCOUVER ISLAND WEST (84) 222 .9 60. QUALICUM (69) 222 .0 6 1 . SUMMERLAND (77) 220 .0 62 . CENTRAL OKANAGAN (23) 2 12. 6 63 . GOLDEN (18) 202 .8 64 . FORT NELSON (81) 198 .5 65 . BURNS LAKE (55) 183 .5 66 . COQUITLAM (43) 176 .7 65 of British Columbia, and are well-distributed over the province's school districts, which is the geographical area for which heart disease mortality data was available (see Maps 1A, 13, and Table 9). The water quality data of these 95 cities was compared with the mortality data of the 74 school districts, because the place of residence of all heart disease decedents was completely avalable for school districts, and only partly available for cities. Only eight school districts lacked water information. These eight districts, Arrow Lakes, Grand Forks, Kettle Valley, North Thompson, Central Coast, Agassiz-Harrison, Stikine, and Armstrong-Spallumcheen, were excluded from all analyses in this report. There should be no distortion of information when water data and heart disease information is analysed by school district because a major proportion of each school district's population is drinking the water described accurately by the data supplied by the districts's major city or cities. For example, the Fernie school district has a population of approximately 10,000, and this district is represented by the cities, Fernie and Sparwood, whose combined population is 9,601. It is apparent that Fernie and Sparwood account for a substantial proportion of the Fernie school district's population. In districts such as Fernie, (which contain two cities with different water hardness, calcium and (oQ> MAP I A: BRITISH COLUMBIA SCHOOL DISTRICTS HERRIII PEACE ? Ci'iiNi'MCJOi-: 59 RIVE' 3.? Hnpr CO PEACE 3 KIfecni.Ef fllvEf 33 CuIlUrfACK Ol GREATER •< -iNOCf^er.t VICTORIA 7 NEC SC. 35 lANGLEY 6? SOCKE 3iJ ^L'f'C'EY 63 SAANICH 10 *nnuw LAKES 3' OELTA GJ GULP ISLANf 11 TRAIL 39 RICHMOND E5 COwlCHAN £1 LAKE COWIC) 13 KEITU 3D VANCOUVER 69 NiNAlMO v*i i.fr wcsiMiNsrrn OUALICUM i J :; (jc:i*i.-.r,*H 70 AI.OERNI rr.Niir.rrjK 4 1 B"i.'lNAHY '/! CClJRIENAT K>E SCUNO 2^ 00 KITIMAT vEriMCr; >o u ri.i.oor.: 5; PRINCE 02 n1 SHGA |30 3 CAf'UlGrj C£OMOC T'ne VPJVI CoU\/fc:R. SCHOOL fioAftn OPPICE (ol ; MAP!3 THE I03 LARGEST CITIES iH BRITISH COLUMfi/A} l^O, IWS1DE- School DiSTRlor ftoUfJ DARKTS \, .TABLE f,, •u THE 103 LARGEST CITIES*IN BRITISH COLUMBIA, 1980 /• VANCOUVER 414,281 2. SURREY 147,138 3- BURNABY 136,494 4- RICHMOND 96,164 %• DELTA 74,692 £>• PRINCE GEORGE 67,559 7. KAMLOOPS 64,048 COQUITLAM 61,077 KELOWNA 59,196 /O. NANA I MO 47,069 //. CHILLIWACK 40,642 /2- NEW WESTMINSTER 38,550 /3- WEST VANCOUVER 35,728 / /tr-MAPLE RIDGE 32,232 }(,. VICTORIA 31,543 /7 PORT COQUITLAM 27,535 /£. PENTICTON 23,181 / 20. VERNON 19,987 2/. PORT ALBERNI 19,892 ^2-PRINCE RUPERT 16,197 25- CRANBROOK 15,915 2-4-CAMPBELL RIVER 15,832 25-LANGLEY CITY 15,124 CITIES VJILU IMCLUDE T6V0MS, VILLAGE'S,At-m ni-iTRK_T-MUNICIPALITIES AS RecoRorD IN| THEl VlSM CE'NSUJ OF CAMADft : PoPU-LATtONj-S IN DESCEIvlCIMC <3 RD £ R. j Pp P UL^TI O M S 24. PORT MOODY 14,917 27-FORT ST.JOHN 13,891 Z?.WHITE ROCK 13,550 29-POWELL RIVER 13,423 30.KITIMAT 12,814 3/-ABBOTSFORD 12,745 ZZDAWSON CREEK 11,373 ^.TERRACE 10,914 ^.SALMON ARM 10,780 3$. SQUAMI SH 10,272 36-TRAIL 9,599 57. NELSON 9,143 COURTENAY 8,992 % WILLIAMS LAKE . 8, 362 Vo.QUESNEL 8,240 HSIDNEY 7,946 Y2- SUMMERLAND 7,473 i/^KIMBERLY 7,375 1ft. CASTLEGAR 6,902 COMOX 6,607 (^.COLDSTREAM 6,405 (ft. PITT MEADOWS 6,209 tfg.MERRITT 6,110 L# MACKENZIE 5,890 54. REVEL STOKE 5,554 t^FERNIE 5,444 5*. PARKSVILLE 5,216 53. PORT HARDY 5,075 5^, SMITHERS 4, 570 5f. LADYSMI TH 4,558 5b. DUNCAN 4,228 57. SPALLUMCHEEN 4,216 5% •CRESTON 4, 190 SPARWOOD 4, 1 57 LO. ROSSLAND 3,967 U. HOUSTON 3,921 42. FORT NELSON 3,724 £3- GRAND FORKS 3,486 GOLDEN 3,476 £S- KENT 3,394 bio. HOPE 3,205 lol. ELKWOOD 3,166 &jf. PRINCETON 3 ,057 PEACHLAND 2,865 lO. QUALI CUM BEACH 2,844 7/. OSOYOOS 2,738 72-ARMSTRONG 2,683 7?. LOGAN LAKE 2,637 TY.GIBSONS 2,594 ?£CHETWYND 2, 553 l(o• PORT MCNEIL 2,474 77.LAKE COWICHAN 2,391 H>. VANDERHOOF 2,323 ff, FORT ST. JAMES 2,284 &J.GOLD RIVER 2,225 $/.ASHCROFT 2, 1 56 %1.1NVERMERE 1 ,969 ^3-WARFI ELD 1 ,969 ^1/.CUMBERLAND 1 ,947 %. 100 MILE HOUSE 1 ,925 ff&.FRUITVALE 1 , 904 %1, OLIVER 1 , 893 S&-ENDERBY 1,816 g^,BURNS LAKE 1 ,777 %• CHASE 1 ,777 TAHSIS 1 ,739 °i1 LILLOOET 1 ,725 fa PORT ALICE 1 ,668 *,f.UCLUELET 1 ,593 fc. MASSET 1 , 569 %. FRASER LAKE 1 , 543 NAKUSP 1 ,495 °l %• STEWART 1 , 456 cfj. GRANISLE 1 ,430 /0O.HUDSON' S HOPE 1 , 360 /o/.CACHE CREEK 1 ,307 /02.-LUMBY 1,266 /o? MONTROSE 1 ,229 72 magnesium values), the water quality parameters were weighted according to the cities' populations to obtain greater accuracy in estimating the water hardness, waterborne calcium, and waterborne magnesium values for those school districts. The weighting technique is described in Appendix 2, and the water-hardness classifications of the school districts are included in Appendix 3. b. Heart Disease Mortality Information I examined the geographic distribution of deaths from heart disease in British Columbia during the twenty-three years from 1956 to 1978. Only decedents over twenty-one years of age were included in this study; those under twenty-one were excluded because their deaths may be due to congenital heart problems. The data for heart disease decedents which was used in this study includes year of death, sex, age, school district of residence, and cause of death. The registration of deaths and other vital events is the responsibility of provincial and territorial governments under appropriate Vital Statistics or other Acts. These Acts require that vital events be reported within a prescribed time and that cause of death, residence, sex, and age or birth date of the decedent be recorded on death records. The cause of death is recorded by a medical attendant on the registration form according to a format prescribed by the" World Health 73 Organization and specified in the relevant revision of the International Classification of Diseases (ICD). The recorded statement declares the underlying cause of death, which is defined as the disease or injury which initiated the sequence of events which led to death. The municipality or township of usual residence of decedents is also coded in provincial offices. Possible sources of error that may affect mortality data, and hence the completeness and reliability of mortality rates, include the following: 1. Completeness of registration: It is thought that registration approaches one hundred per cent. 2. Recording of data: Death registration forms are legal documents and are checked for content, both at the time of completion and at the time of filing in the provincial offices. It is likely that there are errors in completion of causes of death. However the proportion of misclassification should not differ a great deal from one school district to another. The accuracy of the cause of death information largely depends on the familiarity of the medical attendant, who records the cause of death, with the patient. 3. Coding and processing errors: Errors associated with coding of age and sex are insignificant. Errors in coding residency can be significant, especially in rural areas where postal addresses rather than place of residence may be recorded and are subsequently 74 coded. In this study, I included seven categories of heart disease that are listed in the International Classification of Diseases (see Appendix 4). These categories include: 1. Rheumatic Fever 2. Chronic Rheumatic Heart Disease 3. Arteriosclerotic and Degenerative Heart Disease 4. Other Diseases of the Heart 5. Hypertension with or without Heart Disease 6. Diseases of the Arteries, Veins, and Other Diseases of the Circulatory System 75 C. RESULTS AND ANALYSIS Sex-specific age-standardized mortality rates were calculated and these rates were compared with values of water hardness, waterborne calcium, and waterborne magnesium for each school district in British Columbia as described above. The results of the statistical analysis are shown in Tables 10, 11, and 12. a. Water Hardness: Table 10 Water hardness, by itself, was found to explain very little of the observed variation in heart disease mortality in British Columbia from 1956 to 1978. The alpha level for this study was 0.05. As in many other studies of the correlation between water hardness and heart disease, a negative statistical correlation was obtained for many heart disease categories. In fact, in this study the correlation was negative for all male heart disease categories except for category (4) Other Diseases of the Heart and (5) Hypertension with or. without Heart Disease. For females the correlation is negative for each category except for (5) Hypertension with or without Heart Disease. The observed correlation values were small and were not statistically-significant for any heart disease categories. A closer analysis of Table 10 will highlight the importance of the association between water hardness and heart disease mortality. Column 1 of Table 10 lists the correlation coefficients, which describe the association % TABLE 10 CORRELATI ON BETWEN WATER HARDNESS AND AGE-STANDARDI ZED HEART DISEASE MORTALITY RATES COLUMN 1 CORRELATION (R) R SQUARED SIGNIFICANCE CATEGORY (MALES) 1.400-402 -0.09158 0.00839 0.46813 .410-416 -0.02455 0.00060 O.84486 .420-422 -O.08529 0.00727 0.49594 .430-434 O.18194 0.03310 O.14372 .440-447 0.05122 0.00262 0.68296 .450-468 -0.14101 0.01988 0.25876 .400-468 -0.04872 0.00237 0.69769 CATEGORY (FEMALES) 1.400-402 -0.06227 0.00388 0.62219 .410-416 -0.06129 0.00376 0.62496 .420-422 05352 0..0028 6 O.66955 .430-434 06755 0..0045 6 0.58993 .440-447 00839 0..0000 7 0.94667 .450-468 10772 0..0116 0 O.38931 .400-468 06956 O..0048 4 O.57888 KEY : 400-402 RHEUMATIC FEVER 410-416 CHRONIC RHEUMATIC HEART DISEASE 420-422 ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE 430-434 OTHER DISEASES OF THE HEART 440-447 HYPERTENSION WITH OR WITHOUT HEART DISEASE 450-468 DISEASES OF THE VEINS, ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM 400-468 ALL HEART DISEASE CATEGORIES COMBINED TABLE 11 CORRELATION BETWEN WATERBORNE CALCIUM AND AGE-STANDARDI ZED HEART DISEASE MORTALITY RATES COLUMN 1 2 3 CORRELATION (R) R SQUARED SIGNIFICANC CATEGORY (MALES) 1.400-402 -0.14854 0 00221 0 24922 2.410-416 -0.02627 0 00069 0 83941 3.420-422 -O.06806 0 00463 0 59918 4.430-434 0.20992 0 04407 0 10151 5.440-447 -0.06777 0 00459 0 60074 6.450-468 -0.13152 0 01730 0 31233 7.400-468 -0.04231 0 00179 0 74405 CATEGORY (FEMALES) 1.400-402 -0.04711 0 00222 0 71618 2.410-416 -0.10206 0 01042 ' 0 42991 3.420-422 -0.06555 0 00430 0 61275 4.430-434 -0.09274 O 00860 0 47341 5.440-447 -0.12433 0 01546 0 33974 6.450-468 -0.17849 0 03186 0 16514 7.400-468 -0.10801 0 01 167 0 40338 KEY : 400-402: RHEUMATIC FEVER 410-416: CHRONIC RHEUMATIC HEART DISEASE 420-422: ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE 430-434: OTHER DISEASES OF THE HEART 440-447: HYPERTENSION WITH OR WITHOUT HEART DISEASE 450-468: DISEASES OF THE VEINS, ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM 400-468: ALL HEART DISEASE CATEGORIES COMBINED TABLE 12 CORRELATION BETWEN WATERBORNE MAGNESIUM AND AGE-STANDARD I ZED HEART DISEASE MORTALITY RATES COLUMN 1 2 3 CORRELATION (R) R SQUARED SIGNIFICANC CATEGORY (MALES) 1 .400-402 -0.07787 0.00606 0 54744 2.410-416 -0.06521 0.00425 0 61458 3.420-422 -0.14786 0.02186 0 25144 4.430-434 0.22360 0.05000 0 08063 5.440-447 0.01252 0.00016 0 92306 6.450-468 -O.12651 0.01600 0 32718 7.400-468 -0.10535 0.01110 0 41512 CATEGORY (FEMALES) 1 .400-402 -O.08323 0.00693 0 52012 2.410-416 -0.10462 0.01095 0 41837 3.420-422 -0.15821 0.02503 0 21939 4.430-434 0.00462 0.00002 0 97160 5.440-447 -0.03660 0.00134 0 77761 6.450-468 -0.13448 0.01809 0 29736 7.400-468 -O.15356 0.02358 0 23340 KEY : 400-402: RHEUMATIC FEVER 410-416: CHRONIC RHEUMATIC HEART DISEASE 420-422: ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE 430-434: OTHER DISEASES OF THE HEART 440-447: HYPERTENSION WITH OR WITHOUT HEART DISEASE 450-468: DISEASES OF THE VEINS, ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM 400-468: ALL HEART DISEASE CATEGORIES COMBINED 79 between water hardness and heart disease mortality rates. For example, the first number in Column 1, -0.09158, is the correlation coefficient which reveals that a negative association exist between water hardness and rheumatic heart disease mortality rates for males. The correlation coefficient obtained could have occurred by chance, and, for this reason, coefficients are tested to determine the likelihood that a real association exists. In Column 2, the R squared values highlight the amount of mortality attributable to water hardness. For example, the first number in Column 2, 0.00839, indicates that 0.8 per cent of mortality due to this cause can be explained by water hardness. The first number in Column 3 reveals that the calculated correlation (R) of water hardness and rheumatic fever could occur by chance about 46.8 per cent of the time. Also in Column 3 it will be observed that the strongest association occurs with Other Diseases of the Heart (males).'' However, the association is a positive one, contrary to what might be expected. Category (6), Diseases of the Arteries, Veins, and Other Diseases of the Circulatory System, showed the strongest negative relationship with water hardness. This category of heart disease, which accounts for about eight per cent of the heart disease deaths in British Columbia, has not been 1Other Diseases of the Heart include endocarditis, myocarditis, pericarditis, and functional disease of the heart, such as arrythmia, heart block, and ventricular fibrillation. 80 shown by other researchers to vary with changes of water hardness. In this study, the correlation coefficient which measures the relationship between water hardness and the death rate for all heart disease categories combined is -0.04872 for males and -0.06956 for females. The correlation coefficient of this same relationship for both sexes in Schroeder's study was -0.29 (and this was statistically-significant).1 The correlation coefficients obtained by Morris et al were also much higher than the coefficients obtained in this study.2 In this British Columbia study, the suggestion of a positive association between water hardness and hypertension is in direct contradiction to the finding reported by Masironi.3 It might have been expected that the strongest negative associations would occur between water hardness and category (3), Arteriosclerotic and Degenerative Heart Disease, or with category (4), Other Diseases of the Heart, or with category (5), Hypertension. These categories of heart disease were noted by many researchers to vary with water hardness." Arteriosclerotic and degenerative heart disease includes aneurysm, myocardial infarction or thrombosis, arteriosclerosis, coronary occlusion, embolism, and 1Schroeder 1960b 2Morris, Crawford, Heady 1968 3Masironi, Shaper 1981 "Masironi, Shaper 1981; Winton, McCabe 1970; Luoma et al 1 983 81 ischemic heart disease. And other diseases of the heart include ventricular arrythmia and fibrillation. It was postulated previously in this paper that deficiencies in calcium and magnesium ions could predispose individuals to any of the above-mentioned occurrences, such as aneurysm or myocardial infarction. Both Anderson and Heggveit stated that a magnesium deficiency can trigger arrythmia.1 McCarron presented animal evidence to support the theory that deficient dietary calcium is a contributing factor in the development of hypertension.2 None of the results of Table 10, however, indicate that stronger negative associations exist between water hardness and categories 3, 4, or 5. Furthermore, Table 10 suggests that water hardness does not appear to be a major factor in any type of heart disease mortality. The major constituents of water hardness - calcium and magnesium - were considered separately to see whether either had an independent influence on mortality. b. Waterborne Calcium: Table 11 In general, the correlation between waterborne calcium and heart disease mortality is negative, although it is not statistically-significant. The strongest inverse association appears between calcium and the female heart disease category (6), Diseases of 1 Anderson et al 1975 2McCarron 1983 82 the Veins, Arteries and Other Diseases of the Circulatory System. It is not a significant association; furthermore, it is surprising because it would be anticipated that the protective effect of calcium would manifest itself more strongly in Category (3), Ar t er i os cler ot i c and Degenerative Heart Disease, where (1) the heart muscle is more involved, and where (2) it might be expected that calcium played a role in strengthening the heart muscle to prevent disease. c. Waterborne Magnesium: Table 12 The results of this table are quite interesting. The two strongest negative associations occurred between waterborne magnesium and category (3), Ar t er i os cler ot i c and Degenerative Heart Disease for both males and females. This independent consideration of waterborne magnesium enabled us to see that magnesium may possibly be protective against arteriosclerotic and degenerative disease. Although the associations are not statistically-significant in this report, they are consistent with findings of other researchers.1 One further statistical analysis which was done was a correlation of water hardness with standardized mortality ratios. The results are shown in Table 13, and can be contrasted to the results of Table 10, where the 'Marier et al 1979 83 correlation was done using age-standardized mortality rates instead of ratios. Standardized mortality ratio analysis produces a comparison of values for each school district with the mean of all school districts combined. In the table, with values above 100 are considered to have an excess of mortality, and districts with values below 100 are considered to have less than the expected number of deaths for a specified category. Age-standardized mortality rates, which are often more informative than standardized mortality ratios, yielded stronger negative correlations in more categories than did the ratios, although as expected, the same general trends in the statistical results can be observed in both tables 10 and 13. The scattergrams of the correlations which were done now follow. The scattergrams show scatter which is generally independent of the variable axes. If water hardness, waterborne calcium, or waterborne magnesium were negatively associated with sex-specific, age-standardized heart disease mortality rates, the scattergrams would have looked more like SH TABLE 13 CORRELATION BETWEN WATER HARDNESS AND AGE-STANDARDIZED HEART DISEASE MORTALITY RATIOS COLUMN 1 CORRELATION (R) R SQUARED SIGNIFICANCE CATEGORY (MALES) 1 .400-402 -0.13159 0.01732 . 29226 2.410-416 0.00363 0.00001 ,97690 3.420-422 0.13536 0.01832 .27851 4.430-434 O.17844 0.03184 .15173 5:440-447 0.08643 0.00747 49015 6.450-468 -0.24764 0.06133 04499 7.400-468 -O.11269 0.01270 . 36765 CATEGORY (FEMALES) 1.400-402 -0.05568 00310 .65703 2.410-416 -0.08274 00685 50895 3.420-422 -0.03326 001 1 1 7909 1 4.430-434 -0.00397 00002 97475 5.440-447 0.03015 00091 81006 6.450-468 -0.02032 00041 87135 7.400-468 -0.03539 00125 77787 KEY : 400-402 RHEUMATIC FEVER 410-416 CHRONIC RHEUMATIC HEART DISEASE 420-422 ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE 430-434 OTHER DISEASES OF THE HEART 440-447 HYPERTENSION WITH OR WITHOUT HEART DISEASE 450-468 DISEASES OF THE VEINS, ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM 400-468 ALL HEART DISEASE CATEGORIES COMBINED 85 this: AN EXAMPLE" t>T M ASSOCIATION WiTH A C0fU<£LATlori C06FFlcrEl*T OP — O.HS ANP A R£&R£S5IM>I COEFPIC-tENT OF ~oa% In this study, there were no distinct negat ive relationships shown by the scattergrams. SCATTERS RAMS OF RESULTS CORRELATION BETWEEN WATEff> HARDriESS AMD S>£X~ SIC A&g-STAND ARPtZLE-D MORY^LITV fiVrVTE-S Pflft. SEVElvl CATE1QOK.IES OF HO\ft.T PlStTASE slftTE; THf FiRST SEV.EVM 5 C A TTE ft A M.S A'R.E F&K MALES J AN!? THE LATTER. STEVEN ScATT£"R.G.*sAM5 Age Fo.R. PEMALETS 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HKRDNSLSS AKID sex.-S Pet l F ic ftfiC-STflNO MU>,z.£D M.RTALiTy RATES 20:50:03 University of British Columbia PoR. CHC-ONlC 2rtETUM/YTic HEAR T DISEflse'^/nB'-fiS DOWN: WH WATER HARDNESS /G»-Ce>3 ^/t-) ACROSS: STANDARDIZED MORTALITY RATE (per [00,000*) 2 6 ^ 10 14 18 22 26 30 34 38 k + 454 409 409 354 319 274 229 184 139 94 49 * * 2 * * 2 * * * 2**3»2 * 12 20 28 32 40 OO A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HftRDrJESS MVID sen.-SPEC I Fi c AGE -.STANTDARD IZ.EO MOK.rfli.iry KATE3 University of British Columbia Foft RKSUMA-TIO PIEART DISEASE/MALE'S DOWN: WH WATER HARDNESS (caCO >*j/l-) ACROSS: STANDARDIZED MORTALITY RATE 1 3 5 7 9 11 13 15 1 f 19 409 409 184 94 CO 6 T 1 20 BETWEEN WATER M to M C !:«?aS 5n^™r ?r£lh*Z% J£iir '' * " — A«-«™^«Q Mo^Liry _s DOWN WATER HARDNESS ACROSS: STANDARDIZED MORTALITY RATE 6-/0^ 2 2 21S 307 } _l + _ _ _l +_ + + 335 363 391 4 19 447 454 " * * ^ ^ .... 454 409 364 319 274 229 184 139 49 265 321 349 377 405 433 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HARDNESS Ma SEX-SPEC IFI c /\GEt-J.TMa AUDiiEO rioRTALcrv RATES 20:51:17 University of British Columbia — OTH-ER. D! 5 CASES CF T/+£~ REftftr/ MALE^ DOWN: WH WATER HARDNESS ( C*CO> ACROSS: STANDARDIZED MORTALITY RATE (p^ttr 100,00a) 2 6 10 14 18 22 2G 30 34 38 454 409 409 3S4 319 274 229 229 184 139 139 94 94 49 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HACDWess 2 MAR 86 ftNfl SEX'SPea Pie A 1 DOWN: WATER HARDNESS ^Co.C03 ^j/ -) ACROSS: STANDARDIZED MORTALITY RATE (p*s- loejooo') 3 9 15 27 33 39 45 51 57 454 409 409 364 319 274 274 229 184 184 139 94 94 49 * * * * ***** *2* * 2*2 2** - 12 18 24 30 36 42 48 54 60 31 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER rtneOrvltSS Ar DOWN: WH WATER HARDNESS (ccuC03 rng/L) ACROSS: STANDARDIZED MORTALITY RATE (_pe.r- {00,000) 5 15 25 35 45 55 65 75 85 95 454 409 364 319 274 274 229 184 139 94 49 49 . » 2 * * * * * * * 2 * 2 2* * 4 2 30 40 60 70 80 90 100 33 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER rfnK.Drt£SS AMD SEX-5PETC1FIC l\CF-SYm\tmR.DIJFD MoRrfli.ir» IWTE: 20:52:42 University of British Columbia ^ Au_ H6Mr Di5e«f o!nain(fD/M^ES DOWN: WATER HARDNESS (C«.C&-?> <^$/l~) ACROSS: STANDARDIZED MORTALITY RATE ('per loo^oo) 208 242 276 310 344 378 412 446 480 514 454 409 + + 409 364 + + 364 319 + + 319 I * I 274 + + 274 229 + * + 229 I * I I * * I I * * I 184 + + 184 I * * I I * * I 139 + * . + 139 I * * I I * I . 94 + * * * + 94 I * I I * I I * * I I » * * I 49 + * * * * +49 I * * I I * * * * I I * * * I T * ****2*2* * I 4+ * * . « *2***2" + 4 191 225 259 293 327 361 395 429 463 497 531 3H 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER ArtD SEX-SPECIFIC Ai.£-ST**IDftRD.£ ED H(*T«LITV RATES 20:53:15 University of British Columbia FoK. RttETu.rf'VTie KEft^-T" SIseASE /f&iA\-ES DOWN: WH WATER HARDNESS ^Co-COj, >->q/l-) ACROSS: STANDARDIZED MORTALITY RATE £f«r- l»o,ooo) 1 3 5 7 11 13 15 17 19 409 274 274 229 229 184 184 139 49 49 35 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER UflrRD klcTSS ft*lD SEX •SPgci Fi C AaF-STfti*DftRDi2fI> rteRTTVLiTv 20:53:43 University of British Columbia (LHR^c HUEUMATIC HETrtR.T DiseWs^/ FteriAtrS DOWN: WH WATER HARDNESS (CtJiOj, / O ACROSS STANDARDIZED MORTALITY RATE £p£r |oo,00£>^) 27 33 39 45 51 57 454 409 409 364 319 274 274 * * * * 94 94 * * 49 * * * * * «*2*2**** **2* 2 4 * » 12 18 24 36 54 60 35 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER WARDfJSSS AN/D SCA-SPCXI FtC ft«T-5Tft^DftROIZ£"D M oftTft UI TY fto-TTS 20:54:08 University of British Columbia prKxo^asca.£au>Tic AIMTJ DeG£TW£T 409 + + 409 364 + + 3S4 319 + + 319 I * I 274 + + 274 229 + * + 229 I * I I * * I I * * I 184 + + *84 j * * I I * * I I * I 139 + * * +139 I * * I I * I 94 + * * * + 94 I * I I * * I j * * * I 49 + * * * * +49 I * * I j * * * * I I 2 * I 1********2** I 4 + * * 2233* + + + + + + + + + + + + + + + + + + + + +. 130 188 246 304 362 420 478 536 594 652 7 10 97 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER l4ft«0NE:s.'S ATJD ^cX-SffciFiC flcr-«Tfln/DflMin.EomRTftur y R*TETS 20:54:40 University of British Columbia ._ / _ t-oR. DT »f(L Pl«Se7VStT5 op- THE- H-EM.T / FfMAUTS DOWN: WH WATER HARDNESS ( Cfl-COA "VJ/L^) ACROSS STANDARDIZED MORTALITY RATE 100,000.^ 15 27 39 57 454 454 409 409 364 364 3 19 319 274 229 184 139 94 49 4 «22 3* * * 6 12 18 48 54 60 38 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HftRx>MESS Arte SEX -SPEtiPic A DOWN: WH WATER HARDNESS ACROSS: STANDARDIZED MORTALITY RATE (r<-'~ '••••so) 4 12 20 36 44 52 60 68 76 454 409 409 364 364 319 319 229 184 139 49 49 * * * * 2 *»» 2 * 222 * 24 32 40 56 64 80 3d 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HAHDNE5S AMD SOL^ SPETOFIC A6f-STrt^CA-fLD^FP MBRTA LI TY RATES 20:55:38 University of British Columbia ^ BlsE^rs oPTltr mrfR.es Ve^sIS AUD .TI,^ t»,3D,5e3 oP TWdRu^m.iV SVST DOWN: WATER HARDNESS £a.&>3 ^7/<-) ACROSS: STANDARDIZED MORTALITY RATE Cp^ l°°,«<*>) F£f1ficLE~5 a 14 8o 2n8o —' 1 Q ji O E;Q 68 78 409 + + 409 364 + + 364 319 + + 319 I * • I 274 + + 274 229 + * + 229 I * I I * * I I * * I 184 + + 184 I * * I I * * I I * I 139 + * * +139 94 + * * * + 94 j * I T * I I * * ^ J * * * I 4g + * * * * +49 j * * I j * * * * I I * * * I I **2*2*** * * I 4+ * * 34 * * • * +4 + + + + + + + + + + + + + + + + + + + + +. 3 13 23 33 43 53 63 73 83 93 103 100 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER rfftR0M£5S S£X-5PE-CJFic fV^c-s-r>viMi>ft«T>izED noRrftLirv RATCJ5 20:56:07 University of British Columbia p^P-. all. ItfARr DISEJUC crt-TE-djRIES c»nOi>jEi>/FfMflLE^ WATER HARDNESS (CsJJS-*, I *-) ACROSS: STANDARDIZED MORTALITY RATE (per- loo.ooo) 214 290 366 442 518 594 670 746 822 898 454 409 364 364 319 319 274 274 229 229 184 139 94 49 * 2 * * 4 +* • 423 * . +- 176 252 404 480 632 708 860 SCATTERS RAMS OF RESULTS CL^RRELKTIOINI BETTWEEtsl WATE"RBofi^ET CALHUM At\iD SEX-5P£CjFlC AG-E-STANDARD IZ-EJD MOR.-rAL.irV RArT&S FOR SEVElst CATGSQRlETS OF HEART DISEASE 101 2 MAR 86 A PILOT STUOY OF THE. RELATIONSHIP BETWEEN WATERBORNE CALCJUr-l AND .3 EX.-S PACIFIC A&E-STANDARDIZ.ED MORTALITY RflTCi 20:43:12 University of British Columbia fcf^ 1'«?tteu'n(=mc_ H"EBR.T TJ \se~f*SE /MfiiLES WATERBORNE CALCIUM ^l/L) ACROSS: STANDARD IZEO MORTALITY RATE (ffer loo,Coo") 1 3 J /7o 9 11 13 15 17 19 81 8 1 73 65 57 49 33 25 17 103 2 MAR 8G A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE 73 + +73 65 + * +65 57 + +57 T * I T * * * I 49 + +49 I * I I * I 4 1+** +41 I * I 33 + +33 JI ** * * I 25 + c * * +25 I * * I 17 + " * * 17 I * I I * * * I I * * * I 9 + +9 I * * * * * I I * I I**«*2*** I I * 2*2323 * I 1 + * +1 .+ + + + + + + + + + + + + + + + + + + + +. O 4 8 12 16 20 24 28 32 36 40 I OH 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE C^UCitiM AND SEOC-SPfraF-iC ftiiT-STANDARD ,-z.ef) MORTALITY* RATES 20:44:55 University of British Columbia r._ .„ _ , „ / DOWN: CA WATERBORNE CALCIUM AjM ACROSS: j. ; STANDARDIZED MORTALITY RATE (_pe.< loo, ooo) 195 223 251 " v 279 307 335 363 39 1 419 447 81 + +81 I * I 73 + +73 65 + * +65 57 + +57 I * I f I * * * I 49 + +49 T * I I * I 41 + « * +41 T * I I * I 33 + * * +33 I 2 * I 25 + * * +25 I * * I I * I 17 + * +17 T * * * J J * * * J 9 + +9 I ***** j I * ******** j I * * * * * ** * + ** *** * j 1 + » + 1 + 1 + + + + + + + + H h + ^ 1 -< + + + + +. 181 209 237 265 293 321 349 377 405 433 46 1 [05 RELATIONSHIP BETWEEN WATERBORNE CALc^M Mo IftLCS A PILOT STUDY OF THE of: mf H-erASr 2 MAR 86 A r-iuu. Br1t1sn Columbia 20:45:24 University of Britis STANDARDIZED MORTALITY RATE^^r 38 ACROSS. 30 DOWN: CA WATERBORNE CALCIUM \ J)' 1 >4 ,8 22 26 Bt S 10 8 1 65 57 33 17 3 * * 36 40 28 32 20 24 12 106 2 MAR 8S A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE CALCi ltr"l AND 5fX-SPfTOFcc A&e-STiwonf>.Diz£D M>R.TrtHTV RATETS 20:45:49 University of British Columbia =r0R_ H-i-PEX-trw s 10 rvl C "ALtT^ DOWN: CA WATERBORNE CALCIUM ACROSS: STANDARDIZED MORTALITY RATE (f*r loo.-ooo) 3 9 15 V 21 27 33 39 45 51 ' 57 73 G5 57 33 25 * * * * 2*2 *2* 18 24 36 107 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE CflLUlirt ArJT, 5ex-S PEOFIC AG ET-ST/vNDrtftDliEm MDft.ALiW IWIt-: MsirAsiTS AscrETLi NS , fTC • / . r-lAi_£-S 20:46:27 University of British Columbia Fo(t OP ThC es, V!T> (C./^ ACROSS: STANDARDIZED MORTALITY RATE e i°°.0Oo) DOWN: WATERBORNE CALCIUM J CP ' 5 15 25 ' 35 45 55 65 75 85 95 81 73 57 49 49 33 25 25 17 •2* 2 4 2 0 10 20 30 40 50 60 70 80 90 100 W 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE CALCI UK! AND S rX-SProF lc A£T- A(LDVi€T> MART* I irv /U=FT££ 20:46:58 University of British Columbia . rofi, /Uu DlScftSc- cATreueiES Ca-a.rtcD / .ViAurs 1 CA WATERBORNE CALCIUM (^V-) ACROSS: STANDARDIZED MORTALITY RATE loO;6o'o) 208 242 276 310 344 378 412 446 480 514 81 73 + +73 65 + * +65 57 I +57 I * * * I 49 + + 49 jt* I 41+ * * +41 T * I I * I 33 + * * +33 T * I J * * * .1 25 + * +25 I * * 1 T * I 17 + * +17 T * I T * * * I T * * * I 9 + 9 T ***** I T * i T* ******2 I j * *** *2****2* * I 1 + * + 1 + + + + + + + + + + + + + + + + + + + + +. 191 225 259 293 327 361 395 429 463 497 531 103 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE CALCIUM AislB SEX-SPECIFIC AG £T--STANDARD I^ETD TOR.TW.ITY RATETS 20:37:33 University of British Columbia PoR. _ Rtf-rU^A-ric tr£WR1 Di5t'.flSE"/F£MHi-£S DOWN: MG WATERBORNE " " /L) ACROSS: SMR STANDARDIZED MORTALITY RATE IOO,OOOJ) 1 3 5 7 9 11 13 15 17 19 81 81 73 65 57 49 33 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE Wuiurt AND ASriA's HA 20.38:05 University of British Columbia PbR Ch-R.orJiC- Rtte-a^Arric HETAR.T DissASE-/FO-IALCS DOWN: MG WATERBORNE CALCIUM ACROSS: " STANDARDIZED MORTALITY RATE ^f^f_ 10o,OOo") 4 10 22 28 34 40 46 52 58 81 73 33 25 /// 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE Ovuciu^i AMD Asrlf.1* 20:38:39 University of British Columbia For^ AR.ToR.ioscLeRe.rft AND De&errJFRA-n ve-H-CTH^T DiserYStr- DOWN: MG WATERBORNE CALCIUM (^/L) ACROSS: STANDARDIZED MORTALITY RATE (per 100,006) 159 217 07?; 333 391 449 507 565 623 68 1 81 81 73 65 57 41 33 25 17 130 188 246 304 420 7 10 2 MAR 86 A PI LOT STUDY OF THE RELATIONSHIP BtlWttN WA I c KBUKNt OALClun flrVD A;5MR- 3 I I ' 20:39:12 University of British Columbia pop^ other disease's »FTH£ ft-E-ftRrr/FETiAUErs / ( Z) WATERBORNE CALCIUM • (nfl/O ACROSS: STANDARDIZED MORTALITY RATE^per 100,000*) DOWN: MG 3 9 "15 J 21 27 33 39 45 51 57 73 65 57 33 25 17 * * * * 2 •22 3* « 30 MAR 8S A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE CALtW" ArJ0 «Sn».\ 39:4 1 University of British Columbia E&K^ ^ yp fR-rpJ s i o r-I / fEMAcfS MG WATERBORNE 8 1 65 57 33 22" 15 24 32 40 48 56 64 72 80 IIH 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE CftlXlun AND Asr\R. S" 20:40:15 University of British Columbia p^R. Disovsers oF THE fR-reTye^, TONS, e"-ro / FE>~ DOWN: MG WATERBORNE .CALX! UK (T^J/lJ) ACROSS: STANDARDIZED MORTALITY RATE Cper <00,00o) 8 18 28 38 48 58 68 78 88 98 73 65 49 33 25 \\5 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE CALCIUM /Wt> A-SM*'S 20:40:48 University of British Columbia Pop, ALL. HE-ART Sltrftsc CAT e-G-ay. vers aortoxJe-D/FEWAce-S DOWN: MG WATERBORNE C^i-CIU^ .(T^M ACROSS: STANDARDIZED MORTALITY RATE ^P-c <»«,ooo\ 214 290 366 442 518 594 670 746 822 898 _ + + + - 73 65 57 33 25 * 2 2 * * * * * « * * *424 176 252 328 404 480 556 632 708 784 860 936 SCATTER GRAMS OF RESULTS CORRELATION! BETWfeeN WATER6DP.ME MAGNESIUM AND S^-SPFC\FIC £\G~£-- ST A N DA RD \ UE D M&RTALITV RATE-S FO R. S EV/CKJ C/.TE&fl R.1-ES OP rte^fvr DISEASE R 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE M(\GM£"S(UM AND specific AGe-.S77WOA :11 University of British Columbia f0l< RHc^r.c . HERRX wsovsr /MALE-. 1 WATERBORNE l"]A-GrJ£:siUr\ .('•jl -) ACROSS: STANDARDIZED MORTALITY RATE looj^oo^ 1 3 5 SO R 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE MiyJ-Jcsiun AND A5 MG WATERBORNE MAGNESIUM .(r^jl^ ACROSS: STANDARDIZED MORTALITY RATE (pur IOaOOC>) 2 6 10 14 18 22 26 30 34 38 + + + + + + + + + + + + + + + + + + + + + . 60 + +60 54 + +54 I * I 48 + +48 42 + +42 36 + +36 30 + +30 I * ^ 24 + +24 I * I I * 1 18 + * * +18 I 2 * * I 12 I +12 T * * I I * * I j * * I g + * * * +6 I * * * * I I * * I I 2 * I 1**2****222 I 0 + * * 3**422 2 + O + + + + + + + + + + + + + + + + + + + + + 0 4 8 12 16 20 24 28 32 36 40 R 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE MA&*lCSHA.r\ AMD /VII-I«.XS :22 University of British Columbia FOR, AHxewic.scL.t~R.o-nc A-NT> Dee-snJEr-A-rixtr H-£)tRT-i>(.sSfi,Sxr/Mf\Le^ MG WATERBORNE MAGNESIUM . (r^M ACROSS: ..: STANDARDIZED MORTALITY RATE (per loooOcA 195 223 251 279 307 335 363 391 419 447 60 60 3*»* * * * * * 181 209 237 265 321 349 405 461 AR 8G A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE nftfeTsmn fvrjp Asn«'3 0:51 University of British Columbia Pop. ontrK. pisenors df- "TH-er ftSVR.T /WALE'S MG WATERBORNE MAGNESIUM ' (^j/O ACROSS: STANDARDIZED MORTALITY RATE £per (00,000) 2 6 10 14 18 22 26 30 34 38 + + + + + + + + + + + + + + + + + + + + + . 60 + +60 54 + +54 I * I 48 + +48 42 + +42 36 + +36 30 + +30 I * I 24 + +24 T * I T * I 18 + * * +18 T * * * * I I * I 12 + * +12 J * * I I * * I T * * I 6 + * * * +6 T * * * * I T * * I J * * * * I j* * 3*****2 * * I Q 4. 2********* **+ * * r+ 0 + + + + + + + + + + + + + + + + + + + + +. O 4 8 12 16 20 24 28 32 36 40 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE WSIES.UM /"rSi-if^'s University of British Columbia PoR- KVP^^TTEriMSio^i / MA-UETS WATERBORNE MAGNESIUM . /"WO ACROSS: STANDARDIZED MORTALITY RATE (f"~ ico^oo) 3 9 15 21 27 33 39 45 51 57 GO 60 * *2**2*** * * 2 2 2*** 2 *** 12 36 54 60 «R 8G A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE MA ::13 Unwerslty of British Columbia p0Ri SiSEVvseTS •»=- THE" AArrtrR ies, v/rirJs, ETTC • //"><•> <-6"S MG WATERBORNE MAGNESIUM (-Wl-) ACROSS: STANDARDIZED MORTALITY RATE (per- too,ooo^ 5 15 25 35 45 . 55 65 75 85 95 60 60 * * * * * * * * * * * ** * **+*2*2 *2* 2* 3 *2 * 10 20 30 40 50 60 70 80 90 100 1R 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE ("V««^rsiwM ArJD ASn«.S 2:57 University of British Columbia fo-a ftu_ H-fflRT Pi5e"«se WATERBORNE MAGNESIUM (^/O ACROSS: STANDARDIZED MORTALITY RATE ^pc W6,ooo) 208 242 276 310 344 378 412 446 480 514 60 60 * * * * * *222 ** * 2 * + - y + L 191 225 259 327 395 429 463 497 MAR 8G A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE H MG WATERBORNE MAGNESIUM ACROSS: STANDARDIZED MORTALITY RATE (per loo,oo0\ 1 3 11 13 15 17 19 GO GO 18 +2 I 14 12 +* 12 I 12 12 6 +3 14 12 13 19 O +9* 10 12 18 20 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE ^AG-rJCSiurt AMD Asnfi.5 \l5 University of British Columbia F-oR. CfrRoUic RHEUMATIC HEART DisrASET /fffn WATERBORNE MAGNESIUM (T^/1-) ACROSS: STANDARDIZED MORTALITY RATE (p*r loo,ooo) 4 10 16 22 28 34 40 46 52 58 60 48 30 12 * * * * * * ** * * * * 2 22** *** 2 22**2 32 ** 2 13 25 31 37 49 55 IIS) 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE MA6-fJe"s>u.M »«= «5n«'s oiK«e 20:21:29 University of British Columbia DOWN: MG WATERBORNE MAGNESIUM f-j/O ACROSS: STANDARDIZED MORTALITY RATE (p*<- (Oo,ooo) 159 217 275 333 391 449 507 565 623 68 1 60 48 36 30 24 1Ef * * * * * * ****2*2*** * *233** 2 130 188 246 304 362 420 478 536 594 652 710 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORN!NEE ri/ttfjersiuf-Mftl DOWN: MG WATERBORNE MAGNESIUM ACROSS: STANDARDIZED MORTALITY RATE (per 100,000) 3 9 15 27 33 39 45 5_1 57 60 54 36 30 24 12 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE i-|PrC-*t «iui-l AND ASMR s IZ8 20:22:56 University of British Columbia FOK KYPfTftT-tTNs.ori / FfnALfS r DOWN: MG WATERBORNE MAGNESIUM... ACROSS: STANDARDIZED MORTALITY RATE (pz 100,000) 4 12 20 36 44 52 60 68 76 60 54 48 42 36 30 24 18 \Z3 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE MA DOWN: WATERBORNE MAGNESIUM ACROSS: STANDARDIZED MORTALITY RATE CW ""V000) 8 18 28 48 58 68 78 88 98 60 .30 18 130 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE MWiJKiun /vr>/D *SMR 5 20:26:40 University of British Columbia FOR. /^C HETBR-T" T>.Sfc-7*se- CA-TE.R.E"S cnR.^p/Fm^S DOWN: WATERBORNE MAGNESIUM . ("J /-) ACROSS: STANDARDIZED MORTALITY RATE (per 100,000) 214 290 366 442 518 594 670 746 822 898 60 54 42 36 30 * 24 18 12 *** 23*2 2 * *323 2 176 252 328 404 480 556 632 708 784 860 936 13] SCATTER.G-RAMS OF RESULTS CORRELATION! BETWEEN! WATE<^HAR>Dlsl£SS> AND SEX. "SPflCl F | C AG-E- STTXNDftR-PIZ-EP HOPCTPKU )TV RATIOS F&R. S£V£l\l C AT-EXSOR,igS OF HEftRr DISEASE 22 OCT 8.5 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF DRINKING WATER AND HEART D15EASC 09:45:24 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR STANDARDIZED MORTALITY RATIO 124 372 G20 868 1116 1364 1612 1860 2108 2356 + 8f\SeO ON r-JALET DEATHS DUE To ICO 7 CATEGORIES, MCO-M03. (VrtEUMATlC HETAB.T DISETfl-Se) FOR. THE ygAR,* IT5S-I178 364 319 + 2 2 2 3 + 4 * 4 3 9 + 6 1240 1736 1984 2232 STANDARD HE'D Mo;Vr7U-iTr RATIOS I33 22 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF DRINKING- wftTER. AND HEPiR.r DISEASE "09:44:44 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR STANDARDIZED MORTALITY RATIO 20 60 100 140 180 220 260 300 340 454 t BASED ol4 MAXe DEATHS Due To I <-0 7 CATEGORIES HlO - Hit L'C.HAONIC RHCUrlATlC HrEftfcT Dl S^ftSE^ 409 FOR r*tr ytTAR.* 1154.-197 8 409 364 319 274 274 229 229 £ 184 184 I" O i3g 139 49 4 + 2 *3 ** 3 * •* + + + + + + + + + + + + + + + + + + + + + +. 0 40 80 120 160 200 240 280 320 360 400 22 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF DRihlKlNG WATER. AND HEART DISEASE 09:43:52 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR1 STANDARDIZED MORTALITY RATIO 104 210 31S 422 528 634 740 846 952 1058 454 454 + BASED ofi MAIX DEATHS CUE To ItD 7 CATeG-0«l£S H AO - H10. (^ARTERiO SCLE R.OTK A^D vece^CM-kilB FOR. THE ') 409 409 yeARs l95t-/<)78 3 19 3 19 274 274 229 229 < 184 184 O <-< 139 94 *333 « 2263 5 1 157 263 369 687 793 1005 22 OCT.85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF- DR.1NK1NG- WATER, ArJD HEART DISEASE" 135 09:42:53 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR STANDARDIZED MORTALITY RATIO 15 45 75 105 135 165 195 225 255 285 _ H i + H h -) H + - 454 454 +" BASED ON MALE DEATHS DUE To ICD7 CATE&OR.ICS, H30-H3H [ OTHER DISEASES OF THEf rttTARi ") FoR THE y EARS 1156-1478 409 409 274 274 229 O 184 184 139 94 49 49 * * 2* * *2 30 60 90 120 150 180 210 240 270 300 22 UCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF DR.INK.IM6- WATER. AND HEART DISEASE '09:42:05 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR"1" STANDARDIZED MORTALITY RATIO 15 45 75 105 135 165 195 225 255 285 454 + 454 + BASED ON MUZ. DEATHS DUE: TO ICO 7 CATETS-Otiers, i 409 FOR THE yeARS 1954 -I1T9 409 364 319 3 19 274 229 229 184 U 139 94 2 * *2 * *» . * 3 60 90 120 150 180 2 10 240 22 OC'f 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF PRII-JK.IN&- WATER AND HEART DISEASE; 137 09:41:08 University of British Columbia DOWN: OWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR1 STANDARDIZED MORTALITY RATIO 9 27 45 63 81 99 117 135 153 171 454 454 BASED OH f-IALET DEATHS DUE To ICQ 7 tATftf «RICS, HSo -M « (DISEASES oF TKST ARTERIES, iris , Ere) < Po*. TRE" ye"rtR.s /95i>-|?79 409 364 3 19 319 274 229 ~~1 184 n 184 o 139 139 + L. 18 54 90 108 126 162 180 158 30 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF DRINK-IMG VJRTER. AMD HEAR.T DISEASE USlivffr 08:37:55 University of British Columbia STANDARDIZED MORTAL,™ JRATUS DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR"*" STANDARDIZED MORTALITY RATIO 51 59 G7 75 83 91 99 107 115 123 454 454 t BASED OM MALE: DETATrtS DUE To |CD T CATE &OR.IES, Hoo - % "3 (rtLL HEART UREASES COI-IOINED) FoR. THE VKARS IISt-1178 409 364 274 229 184 * * 94 49 4 + . +- 111 119 127 47 63 71 87 103 STANDARDISED MORTALITY RATIOS 22 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OP ORINKIM& WATER AND HEART DISEASE: USiMG- C9:40:21 University of British Columbia STAIN/DARD IIED haftrdLirv RATIOS DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR STANDARDIZED MORTALITY RATIO 172 51G 860 1204 1548 1892 2236 2580 2924 454 + 8ASED Of-J FEMALE" DEATHS X>UE" To IC07 CATT»OK.IE;S , HOO - HOa. (JJHEUMATIC H-£ AR.T D IS EAS FOR THE ytARS H54>-l')78 409 364 319 274 n 184 O 12 12 + 4 12 14 13 19 +9 344 1032 1376 1720 2064 2408 3096 3440 5TArNDP.R.DlZE"D MORTALITY RATIOS .IHO 22 0<"T 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF DRI^KlMG- WATER AMD HEART DISEASE 09:s5":01 University of British Columbia DOWN: OWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR1" STANDARDIZED MORTALITY RATIO 12 36 60 84 108 132 156 180 204 228 _+ + j. K . y +. ( . 4. + + + k -i 1 y h 1 4- .. - . 454 + * 454 ft I ^ 0 S£O ON PEMAUT DEATHS Dus To ICD7 C A TETG-0 K.I ES, 4lO-4(fc> (j-!fROf'IC RtiEUMArit IrtART DlSOSc) 40g + FoR, TH ET yETARS Il5t-|l78 + J09 364 + ' + 364 3 19+ +3 19 I * I 274 + + 274 229 + + 229 -J I I If1 \ • - ! fl 184 * +184 I " I ^ 139 + * « + 139 94 * . • + 94 49 +« « + 49 I 2 * * t 4 t ...... 2 . . «. j + 4. 1 4 + 1 i • + + + 1 4 + ^ + t + + + 4. O 24 48 72 9S 120 144 168 192 216 240 22 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF Dftl*lKIM& WATER. A.ND HEART- DlsrftSET 09:38:09 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR STANDARDIZED MORTALITY RATIO 53 7 1 89 107 125 143 161 179 197 454 ^ BASED Or) FEr^ALST DEATHS 0\x£~ To ,CD7 <^Tir&<)/?JErS, 41o-flO. (n«.re P*WSCi£P-ST\C A.\lD P eCENFRA-, l MC) HEART- PISEASr 1 11 409 Fo A. THC V6AR.S 1 5fo "1 409 364 319 229 229 184 184 O 139 94 94 49 4 + * - 32 23 * + + 4- + + + + + 4. + 4- + 4. 4- 4- 1- + + 4. 4. 4- 4.. . 44 62 80 98 116 134 152 170 188 206 224 22 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OP DRlrJKlMG- WATECFk MO HGArRJT DISECA-.SE: M2i 09:37:07 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR~^ STANDARDIZED MORTALITY RATIO 20 60 100 140 180 220 260 300 340 380 .4- + + + + + + + + + + + + + + + + + + + +. 454 454 + + + T DKrAS £ART I BASED ON FEMftir DEATHS DUE To , cD 7 H 3 o -H 3 4 (° ^ " °" " ^ 409 I Foa THE" y^**5 list -i 364 364 319 319 274 274 229 r. 184 3 139 139 94 94 49 49 '2 * 2* 40 80 120 22-OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF DRINKING- WATER- AND HEAB-T DISEASE 09:35:43 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR ' STANDARDIZED MORTALITY RATIO 22 6G 110 154 198 242 28G 330 374 4 18 454 + SASETO ON FEMALE DEATHS DUE To |CP1 CATE«*lESy HlO-^Hl Lj+YPiTRTeNS v6INl) 409 FoP- THE ye:ARS \15 3G4 319 274 274 -4 229 O 184 184 O 139 139 * * 2 2 * * 88 132 264 308 352 22 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF- DRlNXlNtV WATER- ANO HEART DISEASE 00:13:01 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR ' STANDARDIZED MORTALITY RATIO 5G 74 92 110 128 146 164 182 200 218 454 1"pAseO oN FCrlRLE BEATriS DUE To I CD 7 CATE60R1C.S , t S O -4-G ? LDlS E"A5 F/S OF THE" ARTERIES,VEt N?, ETt) 409 FOR. THE- yeA«-S llSto-I^S 274 o 2 2 4 + 3 4 • 47 65 83 101 137 209 227 -30 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS 0F DRINKING- WftreR AND H£Ae.r DlSfcftSE IH5 08:39:19 University of British Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR + STANDARDIZED MORTALITY RATIO 75 91 • 107 123 139 155 171 187 203 454 3A3ED ON FEMRUT DEATHS DUE: To I CD 7 tRTe«»R|ES, 4 0 O ~4 6 $ (jiLL H £ART~ D 13 EASE'S tun-lQjNrtO 409 F»R THE ySTARS IT 56> "IT 78 409 364 364 319 319 274 274 229 * * 184 184 O 139 94 94 49 * * + 4 + * •22*23 67 83 147 163 195 21 1 227 46 D. SUMMARY OF RESULTS The pattern of heart disease mortality in British Columbia is not adequately explained by the hypothesis that water hardness is inversely associated with heart disease mortality. There were, of course, a number of limitations to the data used in this study, and a number of assumptions were made in order to deal with the available data. These were detailed previously in Part IV, and it may be that several of the assumptions were not correct. In addition, there are suspected risk factors for heart disease in addition to water hardness. These other factors may be more important. Diet and lifestyle are noted heart disease risk factors. Would differences in diet or lifestyle account for heart disease mortality variations in British Columbia, or would these factors be masking any relationship between hard water and heart disease mortality? Comstock's study, which was mentioned earlier in this thesis, involved 412 cases and controls in Maryland who were matched for age, socioeconomic status, marital status, and smoking habits.1 This is one of the few studies which tried to look at subjects similar in most respects, but who were exposed to different levels of water hardness. The water hypothesis was not supported by Comstock's study; Allwright's ecological study, also mentioned in the literature review, matched populations of three communities on socioeconomic status (a way to ensure comparable lifestyles), and, again, the water hypothesis was 'Cornstock 1971 147 not supported. This British Columbia study did not match populations with respect to lifestyle, and it may be that lifestyle factors are more important in determining heart disease mortality in British Columbia. To determine whether associations exist between these other risk factors and heart disease mortality, provincial-wide information for levels of physical activity, smoking, drinking, and serum cholesterol levels of school district populations should be gathered. This"" may help to elucidate the specific contributions of the various heart disease risk factors to heart disease mortality, and clarify the significance of water hardness in heart disease mortality. Many school districts where mining and pulp and paper industries are important (e.g. Kitimat, Trail, Powell River, etc.) have high heart disease mortality rates. One could speculate that perhaps there are higher rates of smoking, drinking, and cholesterol intake among the populations of these districts. The working population could be primarily men who have characteristics and habits which place them in a high risk category. More information on lifestyles and dietary factors would allow further analyses to be made. A major assumption of this study was that there was no migration of the study populations. If there were higher rates of migration to or from school districts which do not reveal the existence of an inverse association between water hardness and heart disease, then any association between water hardness and heart disease mortality might have been J 1 48 masked. The mobility statistics of the province do not suggest that migration is a significant factor.1 The ratio of movers to non-movers is similar, for example, in the school districts of Mission, Vancouver Island North, Peace River, Central Okanagan, and Nechako. \ Statistics Canada 1981b (vide bibliography) 14 D. CONCLUSION Heart disease is a major health problem in the world today. Heart disease is the major epidemic of modern times in the technologically-advanced countries, where it accounts for roughly 50 per cent of all causes of death.1 Owing to the multifactorial nature of heart disease, it is difficult to estimate exactly the specific contribution of each individual risk factor. For example, it is difficult to clarify the association between dietary cholesterol and heart disease because of the concomitant risk factors of obesity, hyperglycemia, and hypertension. There are many suspected heart disease risk factors and none are easy to assess individually. In this study, no relationship was found between water hardness and heart disease mortality. Information on patterns of smoking, drinking, stress, physical activity, and dietary habits should be sought to compare with the pattern of heart disease mortality in the districts. The relative importance of many heart disease risk factors might then be assessed. From the results of this study one can conclude that: 1. There appears to be no relationship between heart disease mortality and soft water, at least at the ecological level of analysis in British Columbia; 2. Other risk factors may be more important than water hardness in determining heart disease mortality; 1 World Health Statistics Annual 1985 1 50 3. If there is any relationship between hard water and heart disease mortality, more detailed methods of analysis are necessary to detect it. BIBLIOGRAPHY Alderson,M., International Mortality Statistics. Facts on File,Inc. New York 1981 Allwright,S.P.A., Coulson,A., Detels,R., et al., Mortality and water-hardness in three matched communities in Los Angeles. Lancet (2),1974 :860-64 Altura,B.M., Sudden-death ischemic heart disease and dietary magnesium intake--Is the target-site coronary vascular smooth muscle? Medical Hypotheses. 1979:1-6 Anderson,T,W., The changing pattern of ischemic heart disease. Can Med Assn J. (108), 1973: 1500-04 Anderson,T.W., A new view of heart disease. New Scientist (9),1978:374-76 Anderson,T.W., LeRiche,W.H., Sudden death from ischemic heart disease in Ontario and its correlation with water hardness and other factors. Can Med Assn J (105), 1971: 155-60 Anderson,T.W., Le Riche,W.H., MacKay,J.S., Sudden death and ischemic heart disease correlation with hardness of local water supply. N Eng J Med (280), 1973:805-07 Anderson,T.W. , Neri,L.C, Schreiber ,G.B. , et al. Ischemic heart disease, water hardness and myocardial magnesium. Can Med Assoc J (113) 1975: 199-203 Belanger,L.F., Variations in the mast cell populations of skin and bone marrow in magnesium-deprived rats--the influence of sex hormones./ Nutr(]07), 1977:2164-70 Braunwald,E. , Heart disease, a textbook of cardiovascular medicine, W.E.Saunders Company, Toronto, 1980 Calabrese,E.J., Tuthill,R.W.,et al., The role of elevated levels of sodium in diet and drinking water on the development of hypertension in animal models and humans. J Env Pathol Toxicol 4(2-3), 1980: 143-50 Clayton,D.G., Water hardness and cardiovascular mortality in England and Wales, Hardness of drinking water and public health. Permagon Press, Toronto, 1975:323-340 Comstock,G.W., Fatal arteriosclerotic heart disease, water hardness at home, and socioeconomic characteristics. Am J Epi d (94), 1971:1 Comstock,G.W., The epidemiologic perspective: water hardness 1ST7 1 53- and cardiovascular disease. / Env Pathol Toxicol 4(2-3), 1980: 9-25 Connor,R.C.R., The water story. Lancet (1), 1970:240 Crawford,M.D. Gardner,J.J., Morris,J.N., Mortality and hardness of local water supplies. Lancet 1968 1:827 Davies,D.G., Letter to the editor. Hardness of local water-supplies and mortality from cardiovascular disease. Lancet (2), 1962:882-3 Dawber,T.R., Kannel,W.B., Revotskie,N., and Kagan,A., The epidemiology of coronary heart disease. The Framingham enquiry. Proc Roy Soc Med (551), 1962:265 Dawber,T.R., The Framingham Study. The epidemiology of atherosclerotic disease. Harvard University Press, London, England 1980 Dawson,E.B., Frey,M.J., Moore,T.D., and McGanity,W.J., The relationship of metal metabolism to vascular disease mortality rates in Texas. Amer J Clin Nutr (31), 1978: 1 188-97 Deutscher,S., Some factors influencing the distribution of premature death from coronary heart disease in Nova Scotia, Am J Public Health, (63), 1973: 160-67 Dudley,E.F., Beldin,R.A., Johnson,B.C., Climate, water hardness and coronary heart disease. J Chronic Dis (22), 1969:25-48 Durfor,C.N. and Becker,E., Public water supplies of the 100 largest cities in the United States. U. S.Geologi cal Survey Water-Supply Paper 1812. U.S.Government Printing Office, Washington,D.C. 1964 Elwood,P.C. St.Leger,A.S., Morton,M., Mortality and the concentration of elements in tap water in country boroughs in England and Wales. Br J Prev Soc Med (31), 1977:178 Environment Canada, Inland Waters Directorate, Water Quality Data, British Columbia 1961-1971. Ottawa, Canada, 1974 Farley,A.L.,The atlas of British Columbia. University of British Columbia, Vancouver 1979 Fisheries and Environment Canada, Canada Water Yearbook 1977 Fodor,J.G., Pfeiffer,C.J., Papezik,V.S., Relationship of drinking water quality (hardness-softness) to cardiovascular mortality in Newfoundland. Can Med Assn J (108), 1973: 1369-73 153 Fox,S.M., and Naughton,J.P., Physical activity and the prevention of coronary heart disease. Prev Med (1), 1972:92 Friedman,H., and Rosenman,R.H., Your heart. Knopf Co., New York, 1974 Garcia-Palmiere,M.R. et al., Risk factors and prevalence of coronary heart disease in Puerto Rico. Circulation (42), 1970:541 Gillies,M.E., Paulin,H.V., Variability of mineral intakes from drinking-water: a possible explanation for the controversy over the relationship of water quality to cardiovascular disease. Int J Epid 12(1), 1983:45-50 Greathouse,D.G., Osborne,R.H., Preliminary Report on nationwide study of drinking water and cardiovascular diseases, J Env Pathol Toxicol 4(2-3), 1980: 65-76 Hammer,D.I., Heyden,S., Water hardness and cardiovascular mortality. An idea that has served its purpose, JAMA 243 (2-3) 1980:2399-2400 Hankin,J.H., Margen,S., Goldsmith,N.F., Contribution of hard water to calcium and magnesium intakes of adults. J Am Diet Assoc (56), 1970:212-23 Havlik,R.J., and Feinleib,M., Proceedings of the conf er ence on the decline in coronary heart disease mortality. U.S.Dept Health, Education, and Welfare, (Publ No 79-1610), 1979:399 Health Interview Survey Procedure, Vital and Health Statistics. Series 1, No 11. Washington, D.C, DHEW Publ No. (HSM) 73-1311, 1957-1974 Hewitt,D., Neri,L.C., .Development of the water story: some recent Canadian studies. / Env Pathol Toxicol 4(2-3), 1980: 52-63 o Heyden,S., The hard facts behind the hard-water theory and ischemic heart disease. JChron Dis (29), 1976:149-57 Huyghe,P., Your heart: a survival guide. Sci Di , Apr 1985 Kannel,W.B., Castelli,W.P., and Gordon,T., Cholesterol in the prediction of atherosclerotic disease. New perpectives based on the Framingham Study. Ann Intern Med (90) , 1979:85 Kannel,W.B., Hjortland,M.C., McNamara,P.M., and Gordon,T., Menopause and risk of coronary heart disease: The Framingham Study. Ann Intern Med (85), 1976:447 1 5-4' Keys,A., Coronary heart disease in seven countries. Ci r cul at i on 41 (suppl.1), 1970:211 Klusman,R.W., Sauer,H.I., Some possible relationships of water and soil chemistry to cardiovascular diseases in Indiana. Trace element geochemistry in health and disease. Geological Society of America. Special paper 155, 1975: 27-40 Kobayashi,J., Geographical relation between the chemical nature of river water and death-rate from apoplexy. Ber Ohara Inst landwirtsch, Biol, Okayama Univ (11), 1957:12-21 Lacey,R.F., Shaper,A.G., Changes in water hardness and cardiovascular disease rates. Int J Epid Mar 1984 Last,John M. , A dictionary of epidemiology. Oxford University Press, New York 1983 Lindemann ,R.D. , Assenzo,J.R., Correlations between water hardness and cardiovascular deaths in Oklahoma counties. Am J Public Health (54), 1964:1071-77 Luoma,H., et al., Risk of myocardial infarction in Finnish men in relation to flouride, magnesium and calcium concentration in drinking water. Acta Med Scand 1983:213 McCarron,D.A., Hypertension, Ann Intern Med (98), 1983: 800-805 MacKinnon,A.U., Taylor,S.H., Relationship between 'sudden' coronary deaths and drinking water hardness in five Yorkshire cities and towns. Int J Epi d 9(3), 1980: 247-9 Marier,J.R., Neri,L.C, Anderson,T.W., Water hardness, human health, and the importance of magnesium. National Research Council of Canada, Ottawa, Ontario, 1979. Report 17581 Marmot,M.G., et al., Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: Prevalence of coronary and hypertensive heart disease and associated risk factors. Am J Epi d (102), 1975:514 Masironi,R., Pisa,Z., Clayton,D., Myocardial infarction and water hardness in European towns. J Env Pathol Toxicol 4(2-3), 1980:77-87 Masironi,R., Shaper,A.G., Health effects of water, Ann Rev Nutr 1981 Meade,M., Cardiovascular mortality in the southeastern 1 55 United States: The coastal plain enigma. Soc Sci Med (13D), 1979:257-65 Meyers,D., Ischaemic heart disease and the water factor. A variable relationship. Br J Prev Soc Med (29), 1975:98-102 Minister of health and welfare, Mortality atlas of Canada, Vol.3 Urban mortality, 1984 Minister of health and welfare, Trends in health issues. Canada 1978 Mitchell,J.R.A., An association between ABO blood-group distribution and geographical differences in death-rates. Lancet (1), 1977:295-97 Monger,J.W.H., Tectonic accretion and the origin of the two major metamorphic and plutonic welts in the Canadian Cordillera. Geology, Vol. 10, Feb 1982:72 Monthly Vital Statistics Report. National Center for Health St atistics, Washington, D.C. Vol 26 No 12, Mar 30,1978 Morris,J.N., Crawford,M.D., Heady,J.A., Hardness of local water supplies and mortality from cardiovascular disease in the county boroughs of England and Wales. Lancet (1), 1968:827-31 Mulcahy,R., The influence of water hardness and rainfall on cardiovascular diseases in the county boroughs of England and Wales classified according to the sources and hardness of their water supplies, 1958-1967. / Hyg (71), 1973:237-52 Muss,D.L., Relationship between water quality and deaths from cardiovascular disease. J Am Water Works Assoc (54), 1962:1371-78 National Academy of Sciences: Recommended dietary allowances. Publ by Nat Acad Sci, Wash, D.C. (8th rev) Norusis,M.J. , SPSS.X Introductory statistics guide, McGraw-Hill Book Co., Montreal, 1983 Parrott-Garcia,M., McCarron,C.A., Calcium and hypertension, Nutr Rev Jun 1984 Parsons,R.S., Butler,T.C., and Sellars,E.P. 1961., Hardness of local water-supplies and mortality from cardiovascular disease. Lancet Jul 22, 1961:213 Pocock,S.J., Shaper,A.G., Packham,R.F., Studies of water quality and cardiovascular disease in the United Kingdom, Sci Total Env (18), 1981: 25-34 156 Pond,W.G.,and Walter,E.F., Effect of dietary calcium and cadmium level of pregnant rats on reproduction and on dam and progeny tissue mineral concentrations. Proc Soc Exp Biol Med (148), 1975:665-68 Province of B.C., Ministry of Environment, Waste Management Branch, A trend study of water quality in British Columbia, Clark,M.J.R., Peppin,P.A., Victoria, B.C. (Jan) 1984 Province of B.C., Ministry of Health, Vital st at i st i cs of the Province of B.C., Report 109, 1980. Queen's Printer, Victoria, 1983 Renaud,S., et al., Dietary fats and platelet function in French and Scottish farmers. Nutr Metab 24 Suppl 1, 1980: 90-104 Revis,J.W., Major,T.C., Horton,C.Y., The effects of calcium, magnesium, lead, or cadmium on lipoprotein metabolism and atherosclerosis in the pigeon. / Env Pathol Toxicol 4(2-3), 1980: 293-303 Roberts,C.J. Lloyd,S., Association between mortality from ischemic heart disease and rainfall in South Wales and in the county boroughs of England and Wales. Lancet (1), 1972:1091-93 Rogot,E., Smoking and general mortality among U.S. veterans, 1954-1969, Wash,D.C.,DHEW Publ No (NlH), 1974: 74-544 Rogot,E., and Padgett,S.J., Associations of coronary and stroke mortality with temperature and snowfall in selected areas of the United States. 1962-1966. Am J Epid (103), 1976:565 Safe Drinking Water Committee, Drinking water and health, Vol.3 National Academy Press, Washington,D.C. 1980 Sauer,H.I., Epidemiology of cardiovascular mortality-geographic and ethnic. Amer J Public Health (52), 1962: 94-105 Schroeder,H.A., Losses of vitamins and trace minerals resulting from processing and preservation of foods. Amer J Cl i n Nutr (24), 1971: 562-73 Schroeder,H.A., Relations between hardness of water and death rates from certain chronic ^and degenerative diseases in the United States. / Chronic Dis (12), I960a:586-91 Schroeder,H.A., Relationship between mortality from cardiovascular' disease and treated water supplies. 157 Variations in states and 163 largest municipalities of the Unites States. JAMA (172), 1960b:1902-08 Seelig,M.S. and Bunce,G.E., Contribution of magnesium deficit to human disease. In: Proc Symp "Magnesium in the Environment -- soils, crops, animals, and man", Fort Valley, Georgia. Oct 5-6, 1972 Sharrett,A.R., The role of chemical constituents of drinking water in cardiovascular diseases. Am J Epi d Vol 110, No 4, 1979:401-18 Singh,R.B., et al., Magnesium in atherosclerotic cardiovascular disease and sudden death. Acta Cardiol 36 (6), 1981:411-29 Statistics Canada, Census of Canada, Census subdivisions in decreasing population order. Catalogue E-845, 1981a Statistics Canada, Census of Canada: Population mobility status Catalogue 92-907 Vol.1, 1981b Stitt,F.W., Clayton,D.G., Crawford,M.D., Morris,J.N. Clinical and biochemical indicators of cardiovascular disease among men living in hard and soft water areas. Lancet (1), 1973:122 Stocks,P., Mortality from cancer and cardiovascular diseases in the county boroughs of England and Wales classified according to the sources and hardness of their water supplies, 1958-1967. / Hyg (71), 1973: 237-52 Suda,T., et al . , Direct control by calcium of 25- hydr oxychol e cai ci fer ol-I - hydr oxyl as e activity in chick mitochondria. Biochem Biophy Res Commun (54), 1973:512-18 Sullivan,J.M., et al., Interrelationships among thiazide diuretics and calcium, magnesium, sodium and potassium balance in normal and hypertensive men. / Clin Pharmacol, Nov-Dec 1978:530-43 Takahashi,E., Geographic distribution of cerebrovascular disease and environmental factors in Japan. Soc Sci Med Vol 15D, 1981:163-72 Talbott,J.H., Gout and gouty arthritis. Grune and Stratton, New York 1953 Thouez,J., Beauchamp,Y., Simard,A., Cancer and the physicochemical quality of drinking water in Quebec. Soc Sci Med Vol. 15D, 1981:213-23 Tyroler,H.A., Epidemiologic studies of cardiovascular 158 disease in three communities of the southeastern United States. The community as an Epidemiologic Laboratory. Edit by M.L. Levin. Baltimore, The Johns Hopkins Press. 1970:100-21 Walker,A.R.P., The human requirement of calcium: should low intakes be supplemented? Am J Clin Nutr (25), 1972: 518-30 Walker,W.J., Changing United States lifestyle and declining vascular mortality:Cause or coincidence? New Eng J Med Jul 21, 1977: Winton,E.F., McCabe,L.J., Studies relating to water mineralization and health. / Am Water V/orks Assoc (62), 1970:26-30 World Health Organization, Health effects of the removal of substances occurring naturally in drinking-water. Copenhagen, 1979a World Health Organization, International Classification of diseases, Seventh Rev. Vol 1, Palais des Nations, Geneva, 1957b. World Health Statistics Annual, 1985 Yano,K., Rhoads,G.G., and Kagan,A., Coffee, alcohol and risk of coronary heart disease among Japanese men living in Hawaii. New Eng J Med (297), 1977:405 Zielhius,R.L., Haring,F.J., Water Hardness and Mortality in the Netherlands, Sci Total Env,(]8), April 1981: 35-45 ABBREVIATIONS Acta Cardiol: Acta Cardiologica Acta Med Scand: Acta Medica Scandinavica Am J Clin Nutr: American Journal of Clinical Nutrition Am J Epid: American Journal of Epidemiology Am J Publ Health: American Journal of Public Health Ann Intern Med: Annals of Internal Medicine Br J Prev Soc Med: British Journal of Preventive Social Medic ine Can Med Assn J: Canadian Medical Association Journal Int J Epid: International Journal of Epidemiology JAMA: Journal of the American Medical Association J Amer Diet Assoc: Journal of the American Dietetic Association J Amer Water Works Assoc: Journal of the American Water Works Association J Chron Dis: Journal of Chronic Diseases J Clin Pharmacol: Journal of Clinical Pharmacology J Env Pathol Toxicol: Journal of Environmental Pathology and Tox icology J Hyg: Journal of Hygiene J Nutr: Journal of Nutrition New Eng J Med: New England Journal of Medicine Nutr Metab: Nutrition and Metabolism 1 59- 1 hO Nutr Rev: Nutrition Reviews Prev Med: Preventive Medicine Proc Roy Soc Med: Proceedings of the Royal Society for Medic ine Sci Total Env: Science of the Total Environment Soc Sci Med: Social Science and Medicine 16 1 APPENDIX 1: DEFINITIONS 1. ANEURYSM: a pathological blood-filled dilatation of a blood vessel 2. ANGINA PECTORIS: pain in the chest region due to an inadequate blood and oxygen supply to the heart 3. AORTA: the large vessel arising from the left ventricle and distributing arterial blood to every part of the body 4. ARRYTHMIA: irregular beating of the heart 5. ATHEROSCLEROSIS: a chronic disease in which thickening and hardening of arterial walls interferes with blood circulation 6. ARTERIOSCLEROSIS: thickening of arterioles or smallest arter ies 7. CARDIOMYOPATHY: any disease of the myocardium 8. CARDIOVASCULAR DISEASE: disease pertaining to or involving the heart and the blood vessels or circulatory system. It is defined by the International Classification of Diseases codes 330-334, 410-468 (6th/7th revisions) and 393-458 (8th revision) 9. CASE-CONTROL DESIGN: groups are selected as to whether they do (cases) or do not (controls) have the disease of which the etiology is to be studied, and the groups are compared with respect to existing or past characteristics which are judged to be of relevance to the etiology of the disease 10. CEREBROVASCULAR DISEASE: pertaining to disease of the 1 63- blood vessels of the brain 11. CONTROL: individuals who do not have the disease of which the etiology is to be studied, but have the potential for being exposed to the same putative causal factors of the disease 12. CORONARY: of or pertaining to vessels, nerves, or attachments that encircle a part or an organ; pertaining to coronary arteries 13. CORONARY ARTERY DISEASE or CORONARY HEART DISEASE: a condition that reduces the blood flow through the coronary arteries to the heart muscle 14. CORONARY ARTERIES: blood vessels that envelop and nourish the heart muscle 15. CORONARY THROMBOSIS: the occlusion of a coronary artery by a blood clot, often leading to destruction of heart muscle 16. CORRELATION COEFFICIENT: a measure of the interdependence of two random variables that ranges in value from -1 to +1, indicating perfect negative correlation at -1, absence of correlation at 0, and perfect positive correlation at +1. 17. DIASTOLIC BLOOD PRESSURE: arterial blood pressure during expansion of the cavities of the heart 18. DISORDERED CALCIUM METABOLISM: normal calcium metabolism has been changed 19. ECOLOGICAL CORRELATION: a correlation in which the units studied are populations rather than individuals. 1&3 Correlations found in this manner may not hold true for the individual members of these populations.1 20. HARDNESS, WATER: an index of the lather that forms in laundering, waterborne calcium and waterborne magnesium account for 95 per cent of the hardness of water. The measurement of hardness is generally "milligrams of calcium carbonate per liter", or mg CaC03 per liter. 21. HEART DISEASE: an abnormal organic condition of the heart or of the heart and circulation 22. ICD:international classification of diseases 23. ISCHEMIC HEART DISEASE (IHD): local anemia caused by mechanical obstruction of the blood supply and abnormal functioning of the heart There are three major forms of heart disease: one major form is atherosclerosis which involves the progressive hardening of the arteries, including the coronary arteries. A second form is cardiomyopathy where the damage is spread throughout the heart, and may lead to myocardial infarction, The third major form is characterised by damaged valves, caused by infection or a congenital defect 24. LIPOPROTEIN: any of a class of conjugated proteins consisting of a protein combined with a lipid 25. MORTALITY RATE: the proportion of deaths in a given year and area to the mid-year population of that area, usually expressed as the number of deaths per 1000 of populat ion 1Last 1983 16*t 26. MYOCARDIAL INFARCTION: a necrotic area of tissue resulting from failure of a local blood supply 27. MYOCARDIUM: muscle tissue of the heart 28. NECROSIS: the death of a living tissue in a plant or animal 29. PATHOGENESIS: the development of a diseased condition 30. REGRESSION FUNCTION: given two dependent random variables, regression function measures the mean expectation of one relative to another 31. RELATIVE RISK: defined as the ratio of the incidence rate of disease for persons exposed to a factor to the incidence rate for those not exposed. The probability of acquiring the disease. 32. RETROSPECTIVE: that which is directed backwards or to the past 33. STENOSIS: narrowing of cell walls 34. STENOTIC-THROMBOTIC: a combination of stenosis and thombus 35. STROKE: sudden loss of muscular control with dimunation of loss of sensation and consciousness resulting from rupture or blocking of blood vessels in the brain 36. SURFACE WATER: that which is found on the land surface 37. SYSTOLIC BLOOD PRESSURE: arterial blood pressure during contraction of the cavities of the heart 38. THROMBUS: a blood clot occluding a blood vessel or formed in a heart cavity 39. ULCERATION: the development of an inflammatory lesion on the skin 40. UNCOMPLICATED ANGINA PECTORIS: angina without a preceding myocardial infarction 41. URBAN RESIDENCE: in this report it refers to residence in a community with a population of more than 1000 persons 42. VASOCONSTRICTORS: causing constriction of the blood vessels 43. VENTRICULAR ARRYTHMIA OR FIBRILLATION: an electrical instability or disturbance of the heart muscle that may lead to sudden death 44. VULNERABLE MYOCARDIUM: muscle tissue of the heart susceptible to injury of any kind 16.6 APPENDIX 2: DETERMINATION OF WEIGHTED WATER HARDNESS VALUES For school districts with more tnan one large city within, a weight, based on the population of these cities, will be used to find average water hardness values. TO CALCULATE WEIGHTED VALUE: (population of cityA) (water hardness value of cityA) + (pop B)(water value B) divided by (pop A + pop B) e.g. School district #1 (Fernie) which has two major cities within it: City A: Fernie ( Popula t i on = 5-1 44 ; water hardness value=142.Omg/L) City B: Sparwood (Population=4157; water hardness value=l80.0 mg/L) To calculate weighted value: (5444)(142mg/L) + (4157)(180mg/L) divided by (5444 + 4157) = 773048 + 748260 divided by 5444 + 4 157 = 1521308 divided by 9601 = 158.5 mg/L Weighted hardness values for the other school districts are listed in Appendix 3: Water Classification of School Districts. APPENDIX -3/ ; WATETf^ CLASSIFICATION OF SCHOOL DISTRICT'S SCKoOL DISTRICT T£- MAMET WETlCrHTED WEICrHTED WClG-t+TED ^ LAA&EST CITY WATER. WATER WATERBORMC WATEWBORME VJiTHI*! DISTRICT HARDINIESS KftRDr-l&S6, CALC|U;N\ MAGNCSIUM VALUE mj/u VALUE; ' VALUE r*)/l- VALUGT ^LETTER. trJ PARErlXHESlS REFERS To THE WATER. OLA-SSI fr CflTIOrJ-i OP TttG SCHOOL. P\STR|CT^ H-- H-AR.D , S - SOFT , 6LAI^K « E^lfeU-ReOr.- I, FEXNlE (H) A- FE-RrJiEr 15?. 5 46.7 lo. 2.. CRflrJSRooK (rt) CRAMBROOK 3, KIM3E:R.LV (S) KIH&EKLV /0. O 3.1 H- WllslDERr-lERX (H) |MV,£R(V1ERE 205-O 3S 7- NELSON (S) NELSON C\3I I 0-0 10.0 3.5 % CASTLEGAR, (S) CASTLEGAR 55". o 55~.0 a.I rvl.A. 10. ARR.OVAI LAKES MAKUSP HoT AVAILABLE rJ/A 11. TRAIL, £s) TRAIL R&S5LAMD 13.-7 FRUITVAUC .MoNTROSE" IZ GRftf^D FORKS CRAND FORKS M.A. f^-A- N.A. M.A tf.A. 13 KETTLE VAL-LEY MIDWAY N/.A. ISJ.A. IH- SOUTH OKANA&AisI OLIVER. 133 |6.o 231-7 65.3 OSoVOOS 3°° 15. PEMriCTot^J (s) PENTlcToM iO.H 10. H 3-M 0.71 )lo, KEREMETOS (tf) KE-RfTMEOS 132. 132- 7.5 APPENDIX 3: coNfiwueo:- W/VTETR. CLASSIFICATION OF Stf+ooL. DISTRICTS SCH-OOU PI STRICT j» , WEIGHTED WEIGHTED W£|&HTED Jff- MAME. ^ LARGEST CITY WATER WnW WfrT*X8.ft/S MET W*TTEK8oK.J!r WiTrtiH DISTRICT H*«J3.N«S f+AApNESS CALCIUM MA&WCStun V^LUE VALUE: .^/L vTYLu.er I^A/U VALUE" "-3 A- 17.. P^iNceTOrJ (H) PrViMCETorJ S^.H 7J . H[ iT.M 5-1 IS.. 1% REVETUSTOKe 6s) REVELSTOKC HO.O HQ. 0 ) 3, SpAU-umCHEEM J 174.3 WO.'? 1-7.7 LUM0Y 2.IO Coi_D5TR.Eflr-\ 23 OrMTRAt-OKANAG-AM ('u') KELOWMA: 117 15.3 32.x- 34.Z 10.6 i-7 Ct-tArSET Ho.o 26. r4be.TH T"iTOMf>5or-i CLfT^WflTER. IN/.A. N.A. M.ft- 27- CARlfioo-CH-ILCOT/M (v\\ |Oo MI LEI House" HZ3 ^ ' jr-, . r H46.6 5z.?> 5-2.0 WILLIAMS UAKE" 452- ) 2-0". anersrtEL (v\) OUESMEL / Z 3o. SouTH C/VRiSoo (H) CACHE" CR£EK. 3LJI I52.0 34. H l<»\ ASHCROPT 37.5 \(p3 APPENDIX 3 corJTlrJyEP •, WftTER c L.A SS I F I CAT 10 rJ OF SCrrOOL. P'-TST-RlOPS W£|&(fTCI> LARGEST Ciry WITH-lr* DISTRICT 31. nrRRi-rr (V) flERRlTT 42. I H3L, s 31. Hope: (S) HOPE 56 2C- i 56 5o,i 33. CWILLIWACK (h) CHILUIWACK mo 3. HI I Mo N.A - 3H. AGBOTSFORD (s") ABBOTSFORD -S? o. 16 35 LAM&LEY (S) LAMGLEV CITY 5 5 -36 SURREY (s) 6uR.eev 5 WHlTEB.OC< 5 37 DELTA (s) T3EUTA 5 5 .2.0 0,16 3?" RlCHMbMD (S) RlCttMoMO 5 5 0,16 3*}. VAfslcouv.erR. (s) VANCOUVER. 5 Ho. MEW WESTM>NSTER(S) Nl. WtSTK IUSTE-R. -5" -5" 3..0 0,16 1-0 HI- BUR.MAGY (s) 8URMASY 5 Q./6 Hi MAPLC RIDGE (s) t+AMey 5 3" .a.o 0-16 ^ CO Q.Ut-TLA (s) COQUITLAM .5 PORT MootiV 5 Ol6 PORT D?(SUITLAH 5 PITT MEADOWS 5 ^ 70 APPENDIX 3 CoMTitvlUED ', WATCR. CLASSIFICATION OF SCtrOOL. DISTRICTS SCHOOL DISTRICT" WE/G-HTED. W&I&HTE. D WEIUHTCD 4fc WMng LATEST CITy ^TER WATER WAT E RB0»CN E WATtR&ORwe WITI+IN DISTORT ITARDNESS h+ARoMESS CALDIUM I-lA&KlESIUf-l VALUE" ^/L V/VLUC "j/l- VAUUE «H- M. VANCOUVER, fe) VANCoiWETR 5 5 ^.Q H5. VJ- VANCouv/eR^s) VI. VANCOUVER 5 O.Ik M.5 %. SurJSrtiME COAS-TC5) G-iBSoWS 2?.? O. bl "-(7. PCIWELL RJVER.CS) PGWULL Riv/eR, 13. O ia, o 1.63 0.13 H?. HOWE SoutslD^s) 5QuAMi$H l'^' rJ. A.. 4<^. CENTRAL COAST HACEN'SE>©R& fV.A. N.A. Kl.A. 56. (SUEENl CHARLOTTE(5) MftSSerT 3o. 3 So. 2 Tsl. <°\ • 0.31 51. PRINCE: RuPE:R.-r(/S) PRirJcC RuPeRT ' $ 5H. 5MiT*+er<5 (n) SMITHCRS hfOUSTOi-J GRAIN 1 S LET 5o. 3 5o. •? 13.H 55 BUR.M5 LAKECS) BURN'S uAKE 56. NECHAKO (ht) VANDJTRH-06F 3d • 5o,X FRASER. LAKE: 3 57. PRINCET Cs€oK FOPT ST. JOHN 33? 5^ PETACrr SOUTH (H) DAWSOhJ CREEK. I £>2 - /7 - 7 a GC.l 5, «} CH ETWYMD .22?, 71. /^PPETNDi;* 3 COMT.NUED: WATER CLASSIFICATION OF SettoO L_ DISTRICTS SCHOOL- PI STRICT weis-HTep WFIG-WTETJ W£ISHTED $ NAME LAR6E-3T CITV WATER. WATER. Wi^TER&ORrJE WATERS ORNC WiTHIrsI- Dl5TRi<^r,- >+AN>iJi55 I+ARPKIES5 CAl-O MAGNESIUM VALUE- >^/L V^LUE (^/L. VALUE **^/L- VALUE:. r*y\- (oO. PLACET R:. KjORXH. (s) R>R-T ST-J&HNi ^ej. | to&.H 5-9 UUP^N'S H*P£ 3 61. &R,£A-T£T< VICT£>.RiPt(s) VICTORIA 6 U2. Soc-Ke^ SAAWICH £3, .SAAMICH ^5) SVDNIEV It. o 16.6 fetf. frULF ISLANDS (5) GANG• ES 34,5 34,5 M. A. rvi-A. 0.-7? i»5. CowicHAM LS) DwsJCP,^ Or. 5 22.5 - 5 o.G 66 LAKE C^WlOUArN (j ) LAK^ CoWlCHAtO 7 6?l OuALiCun (H) QuA-uCun BEACH S?.3 7 5.1 PARKSV.ILLE: 4^.3 70. ALBERjvIl ("s) PORT AL©ERI\M 45.4 10. °) M, A. UCLUELET I'S.H 71 C&UR.TE-WAY (S) COURXEr^AV I7..W 5.7 0,7& CMMSERLAM D I1-! C0, MO* '^•'^ 11. CAMPBELL. RjVER (s) CAMPBELL RIVER- ^0.5 2L6.5 .0.-73 1. ? /.O 15 MiSS^Mi (S) MISSION L-73L A*PPE"HDIX 8 coNTiMuep; WATER, CLASSIFICATION) of SCHOOL DiSTRt. C.T5 R T SCHOOL DIST JC WCICHTF.D WEIGHTED v\l £"IG-HTE D NA ME CITY WATC'S. WATER WATETSGoRlMET W/VTERB0R.Kie WITHIN 0I5TK.ICT HAR.DME"5-5 CAULIUJ-\ r-lASMES./Ufi VALUE P**^/L - v^Lue V^-L-UC "^A- v/*i_uer ^/ rsf./V N.A. . 77. SWrlMeRiANlD (^S) SHMMerR.LA-rJD ^° 70 32. 3.^ £o KIT (MAT (S) KITIMAT 9-5l $•-( VANCOUVER, ISLAND VJ. G-OLD K.IVE«. 15 3,17 <25. vA^coiwex. ISLAND N1. PORT HARDY' I 3.2, CH) 10.1 i .«gx PORT ncNfiL poRT Auce CReSTosI-KASL0(fs) CKfSTois) 2.T 5 PEASE" LAKE" M.A M.A. S7. SxiK-ine N.a- Nfi A. "X-?- TERRACET-K/SH&AC'S) TEftRACe: 13, M ^•3 0."75 STEWART 3*) 2% SHUSWAP ^H) 5ALM6NI ARM 133- 133.1 5.? APPENDIX T:INTERNATIONAL CLASSIFICATION OF DISEASES,7TH REV VII. DISEASES OF THE CIRCULATORY SYSTEM RHEUMATIC KEVEE (400—402) 400 Itlicuiiiulic fever without mention of heart involvement Arthritis, rheumatic, acute or Rheumatic fever (activo) subacute (acute) Meningitis, rheumatic (acute) Rheumatism, articular, acute Peritonitis, rheumatic (acute) or subacute Pleurisy, rheumatic (acute) Tonsillitis, rheumatic (acute) Pneumonitis, rheumatic 401 Ulieumulie fever with heart involvement This title excludes chronic heart disoaBos of rheumatic origin (410-410), unless rhoumatic fever is also prosont, or there is ovidonco of recrudesconco or activity of the rheumatic process. If no statement as to rheumatic activity at the time of death is available, the following procedure should lie used to decide whether to assign to <)01 or lo -||-| -I Hi I,ho terms carditis ", " endocarditis ", " heart dincase ", '' myocarditis ", and '* pan• carditis ", if desciihed as rhoumatic without further qualification (oxcept that the interval since onset may he stated) or if with mention of " rheumatic fever " without qualification : Assume activity if the interval since onset of rheumatic fever or of the " rhoumatic condition " was less than one year ; if the interval is not stated, assume activity at ages under 15 and inactivity at ages 15 and over. for the terms " pericarditis, aouto " and " pericarditis, rheumatic " without further specification, assume activity at any age. 401.0 Active rheumatic pericarditis Acute pericarditis : NOS rheumatic Rheumatic pericarditis (with effusion) (with pneumonia) Any condition in 400 with pericarditis 401.1 Active rheumatic endocarditis I'hulocarditis : Any condition in 400 with mitral, active or acute endocarditis or valvular tricuspid, active or acute disease, subject to the Rheumatic : limitations in the noto endocarditis, active or acute above valvulitis, active or acute 401.2 Active rheumatic myocarditis Rheumatic myocarditis, activo or acuto Any condition in 400 with myocarditis, subject to the limitations in the note above 401.3 Active rheumatic fever with other and multiple types of heart involvement Bheumatic : carditis (active) (acute) fever with heart involvement of unspecified nature heart disease, active or acute pancarditis (active) (acute) Any condition in 400 with other and unspecified types of heart involvement (comprising all terms in 434.1, 434.2, and 434.4) and with multiple types of heart involvement, subject to the limitations in the note above 402 Chorea This title excludes Huutington's chorea (355). 402.0 Without mention of heart involvement Chorea NOS ) without mention of heart involve- Rheumatic chorea (acute) > ment of any type classifi- Sydenham's chorea ) able under 401 402.1 With heart involvement Chorea NOS , ... , , . , , •p., .. , , , . / with heart involvement of any Rheumatic chorea (acute) , , , .„ , , Sydenham's chorea \ type cl^lfiaWe under 401 CHRONIC RHEUMATIC HEART DISEASE (410-416) 410 Diseases of mitral valve * Mitral (valve) (heart) (rheumatic) (inactive) (chronic): disease (fibroid) (double) obstruction endocarditis regurgitation incompetency sclerosis insufficiency stenosis This title includes the listed conditions whether specified as rheumatic or not ; it excludes them only if specified as non-rheumatic or as due to a cause other than rheumatic disease (see 421). 411 Diseases of aortic valve specified as rheumatic * Aortic (valve) : i insufficiency / .c , , stenosis specified as rheumatic valvular disoase ^ This title oxcludes diseases of aortic valve (421.1), unless specified as rhoumatio. * When more than one valve is mentioned, priority in classification follows the order of listing in numbers 410-413. 412 Diseases of tricuspid valve * Tricuspid (valve) (heart) (rheumatic) (inactive) (chronic) : disease regurgitation insufficiency stenosis obstruction Thin title includes l.lio listed conditions whether specified as rheumatic or not; it excludes them only if specified as non-rheumatic or as due to a cause other Quit* I'lieumafic disease (see 421). 413 Diseases of pulmonary valve specified as rheumatic * Pulmonary valve : i disease / . «, • spew lieu as rheumatic insufficiency i 1 stenosis ' This title excludes diseases of pulmonary valve (421.3), unless specified as rheumatic. 414 Other endocarditis specified as rheumatic Aneurysm of valve of heart, rheumatic Degeneration of cardiac valve, rheumatic Eheumatic : endocarditis (chronic) valvulitis (chronic) Valvular: j insufficiency > (chronic) (inactive) specified as rheumatic stenosis \ This title excludes chronic endocarditis (421.4), unless specified as rheumatic. 415 Other myocarditis specified as rheumatic Rheumatic degeneration, myocardium Eheumatic myocarditis (chronic) 416 Other heart disease specified ns rheumatic Adherent pericardium \ Eheumatic : Chronic : j NOS carditis, chronic or inactive mediastinoperiear- f or heart disease (inactive) ditis i rheu- (chronic) myopericarditis l matic pericarditis / * When more than one valve is mentioned, priority in classification follows the order of listing in numbers 410-413; 17 k ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE (420-422) 420 Arteriosclerotic heart disease, including coronary disease 420.0 Arteriosclerotic heart disease so described Arteriosclerotic heart (disease) This title includes the listed conditions when specified as due to any condition in 450. 420.1 Heart disease specified as involving coronary arteries Aneurysm of heart Coronary (artery) : Cardiac infarction or throm- occlusion bosis rupture Coronary (artery) : sclerosis aneurysm stricture arteriosclerosis thrombosis arteritis Kmbolism of heart atheroma Infarction of heart, myocar- disease dium, or ventricle embolism Ischemic heart disease infarction Rupture of coronary artery This title includes tho listed conditions with mention of any condition in 420.2, 422, 433, 440-447, or 450. 420.2 Angina pectoris without mention of coronary disease Angina : NOS i -4-v. * f without mention of coronary disease or pectoris > i-i- • tnn i r. • I anyJ condition in 420.1 Cardiac angina \ Vasomotor angina / This title includes the listed conditions with mention of any condition in 442, 433, 440-447, or 450. It excludes them with mention of any condition in 420.1 (420.1). 421 Chronic endocarditis not specified as rheumatic This title includes tho listed conditions when specified as hypertensive or duo to any condition in 444 or 447, or arteriosclerotic or duo to any condition in 450. It excludes them when specified as duo to other non- rheumatic underlying causes such as syphilis (023) or gonorrhoea (034). 421.0 Of mitral valve, specified as non-rheumatic Mitral (valve) (heart) (chronic) • ( disease (fibroid) (double) endocarditis incompetency insufficiency } specified as non-rheumatic obstruction regurgitation sclerosis Btenosis This title also includes the above conditions when reported with non- rheumatic tricuspid or other valvular disease. 421.1 Of aortic valve, not specified as rheumatic Aortic (valve) : \ disease, heart j endocarditis, chronic or NOS / not specified as rheumatic insufficiency | and without mention regurgitation I of mitral- disease stenosis 1 Atheroma of aortic valve / Aortic valvular sclerosis This title excludes diseases of aortic valve specified as rheumatic (411). 421.2 Of tricuspid valve, specified as non-rheumatic Tricuspid (valve) (heart) (chronic) : disease I specified as non-rheumatic insufficiency ( and without mention obstruction I of mitral or aortic regurgitation \ valve disease stenosis / 421.3 Of pulmonary valve, not specified as rheumatic Pulmonary valve. ) specified as rheumatic and without insufficiency } u stenosis ) mention of other valve 421.4 Other and ill-defined, not specified as rheumatic Aneurysm of valve of heart Atheroma of cardiac valve Degeneration of cardiac valve Endocarditis Endomyocarditis Endopericarditis Eupture of valve of heart . , . , , .„ , Valvular • > (chrome) not specified as disease' ' rheumatic endocarditis incompetence obstruction regurgitation stenosis Valvulitis NOS Tliia title excludes endocarditis (chronic) specified as rheumatic ('114). 422 Other myocardial degeneration This title excludes the listed conditions with mention of any condition in 420.1 (420.1), 420.2 (420.2), 433 (433),J:and 440-447 (440-443).. . 422.0 Fatty degeneration Patty degeneration : Fatty : heart heart myocardium infiltration of heart myocarditis in 4501"(49'Me) °XClU(1CS tllC liSt°fl con OTHER DISEASES OF HEART (430-434) 430 Acute and subacute endocarditis 430.0 Acute and subacute bacterial endocarditis Endocarditis : bacterial infective lent a malignant (acute) (chronic) (subacute) purulent septic ulcerative vegetative Mycotic aneurysm This title excludes acute endocarditis specified as rheumatic (401.1). 430.1 Other acute endocarditis Aortic endocarditis i Endocarditis r acute or subacute, not specified as rheu- Myo-endocarditis I matic Peri-endocarditis ) This title excludes acute endocarditis specified as rheumatic (401.1). 431 Acute myocarditis not specified as rheumatic Acute or subacute (interstitial) myocarditis ) , . „ , c ...... not specified as Septic myocarditis } . ^. . „ rheumatic Toxim c myocarditis ] This title excludes acute myocarditis specified as rheumatic (401.2). 432 Acute pericarditis speciiied as non-rheumatic Hasmopericardium Ilydroperieardiiim Med iastino pericarditis Myopericarditis )• acute, specified as non-rheurnatic Pericarditis Pleuropericarditis Pneumoperi carditis Pericardii is : infective pneumococcal f . . , , y . _ \ not specifie0 d as rheumatic purulent ' r suppurative Pyopericarilium This title excludes rlioiimatic pericarditis (acute 401.0, chronic 416, unqualified 4OI.0) and pericarditis of unspecified cause (acute 401.0, chronic 416, unqualified 434.3). 433 Functional disease of heart This title excludes functional heart diseases specified as psychogenic (315). It includes tho listed conditions with mention of any condition in 422 or 450, but excludes thoni with mention of anv condition in 420.1, 420.2 (120.1, 420.2) and 440-447 (440-443). * -: 433.0 Heart block > Arborization block Stokes-Adams syndrome Heart block (any degree) y 433.1 Other disorders of heart rhythm Arrhythmia (transitory) Fibrillation : Auricular flutter auricular Bradycardia (any type) cardiac Extrasystole ventricular Paroxysmal tachycardia Pulsus alternans 433.2 Other functional diseases of heart Disordered action of heart NOS • 434 Other and unspecified diseases of heart This titlo ox chid os tlio listed conditions with mention of any condition in 440-447 (440-443). 434.0 Kyphoscoliotic heart disease Any condition in 434.1, 434.2, 434.4, or 782.4 with mention of any condition in 745 434.1 Congestive heart failure Cardiac : Congestive heart: anasarca disease dropsy failure oedema This title excludes the listed conditions with mention of any condition in 745 (434.0). 434.2 Left ventricular failure Acute oedema of lung 1 with mention of any condition in Acute pulmonary oedema / 434.4 or 782.4 Cardiac asthma Left ventricular failure This title excludes the listed conditions with mention of any condition in 745 (434.0). 434.3 Other disease of heart Adherent pericardium Mediastinopericarditis, chronic • . „ , , Myopencarditis,r „ • , chroni, .c (> specifier d as non-rheumatic Pericarditis, chronic Constrictive pericarditis NOS Hydropcricardium NOS Haemopericardium NOS Pericarditis NOS This title excludes heart disease specified as rheumatic: acute (401, 402), chronic (410-416). 434.4 Unspecified disease of heart Cardiac: Cor pulmonale decompensation Enlargement of heart dilatation (acute) " Heart disease " NOS hypertrophy Morbus cordis NOS Carditis : Organic heart disease NOS Ventricular dilatation acute Other disease of heart not clas- subacute sifiable elsewhere This title excludes heart disease specified as rheumatic acute (401, 402), chronic (410-416). It also excludes the listed conditions with mention of any condition in 745 (434.0). HYPERTENSIVE HEART DISEASE (440-443) Numbers 440-443 include tho listed conditions with mention of any condition in 450. They also include combinations of any condition in 440-447 with any condition in 422, 433 or 434. They exclude the listed conditions with mention of any condition in 420.1, 420.2 (420.1, 420.2). When terms in more than one of the numbers 440-443 arc reported together, priority in classification should be in the order 441, 442, 440, 443. 440 Essential henign hypertensive heart disease Hypertensive: \ cardiovascular disease heart (disease) / , , . . , -r v i J i- ( it hypertension is de- Myocardial degeneration, or any con- ) -v. i ^ • / • ( scribed as benig& n ditioi-t- n i-n 422Ann, wit•iih. hypertensiou n I Any condition in 444 associated with ] conditions in 422, 433 and 434 / This title excludes the listed conditions with mention of any condition in 445 (441) or 440 (442). 441 Essential malignant hypertensive heart disease Any condition in 440 if hypertension is described as malignant Any condition in 442 if described as malignant 442 Hypertensive heart disease with arteriolar nephrosclerosis Arteriolar nephritis \ Arteriosclerosis of kidney j Arteriosclerotic nephritis / . , , . • „ . . „ . ., ( associated with conditions in 422, Hypertension of kidney 433 and 434 Nephrosclerosis Any condition in 594 with hypertension Cardiorenal (hypertensive) : Cardiovascular renal (hyper- arteriosclerosis tensive) : disease disease sclerosis sclerosis Nephritis, cardiovascular This title excludes the listed conditions with mention of any condition in 445 (441). 443 Other and unspecified hypertensive heart disease Any condition in 440 if hypertension is not specified as to whether benign or malignant This title excludes the listed conditions with mention of any condition in 445 (441) or 440 (442). OTHER HYPERTENSIVE DISEASE (444-447) Numbers 444-447 include the listed conditions with mention of any condition in 450. They exclude them with mention of any condition in 420.1, 420.2 (420.1, 420.2); 422, 433, 434 (440-443)'; and 440-443 (440-443). When terms in more than one of the num• bers 444-447 are reported together, priority in classification should be in the order 445, 446, 444, 447. Numbers 444 and 447 (but not 445 or 446) exclude the listed conditions when reported as the underlying cause of: hemiplegia, only, in 352 (334) any condition in 410 not specified as rheumatic (421.0) any condition in 412 not specified as rheumatic (421.2) any condition in 421 (421) and also exclude them with mention of any condition in 330-332, 334 (330-332, 334) ; 446 (446) ; and 590-503 (590-593). 444 Essential benign hypertension H Hyperpiesia Hypertension: Hyperpiesis essential Hypertension : primary (benign) NOS Any condition in 447 if arterial described as benign benign This title excludes the listed conditions with mention of any condition in 594 (44(i). 445 Essential malignant hypertension Malignant hypertension Any condition in 440 or 447 if described as malignant This title includes the listed conditions with mention of any condition in 590-594. 446 Hypertension with arteriolar nephrosclerosis Arteriolar nephritis Hypertension of kidney Arteriosclerosis of kidney Nephrosclerosis Arteriosclerotic nephritis Any condition in 594 with hypertension Bright's disease : \ NOS . , . . / specifier d as chronic ( £ ^ Nephritis (interstitial) : ( . . , -^Qg \ arteriosclerosis chronic j This title includes intercapillary glomerulosclerosis and Kimmelstiel's disease, unless diabetes is mentioned (200). 447 Other hypertensive disease without mention of heart Arteriosclerotic hypertensive vascular disease I ' . „ , Hypertensive vascular: ' not specified as degeneration hen?n °/ disease malignant This title excludes the listed conditious with mention of any condition in 594 (440). DISEASES OF ARTERIES (450-456) 450 General arteriosclerosis This title excludes the listed conditions when reported as the under• lying cause of: psychosis or domentia (334) any condition in 350 (350) hemiplegia, only, in 352 (334) any condition in 410 not specified as rheumatic (421.0) any condition in 412 not specified as rheumatic (421.2) any condition in 420.0 (420.0) any condition in 421 (421) any condition in 451 (451) chronic nephritis, chronic Bright's disease, and chronic interstitial nephritis, only, in 592 (442, 446) nephritis NOS and Rright's disease NOS, only, in 593 (442, 44G) interstitial nephritis NOS, only, in 594 (442, 446) and also excludes them with mention of any condition in: 330-332, 334 (330-332, 334) ; 420.1-, 420.2 (420.1, 420.2) ; 422.0, 422.2 (422.1) ; 433 (433) ; 440-447 (440-447) ; and, for morbidity classification, 306 (306). 450.0 Without mention of gangrene Arteriosclerosis, except cerebral Degeneration or sclerosis : and coronary aortic general arterial senile arteriovascular Arteriosclerotic vascular diseaso vascular Atheroma of artery, except Endarteritis deformans or obli- cerebral and coronary terans Calcareous degeneration of Senile: artery arteritis V \ endarteritis • ; 450.1 With mention of gangrene an a consequence , Senile gangrene Any condition in 450.0 with mention of gangrene as a consequence 451 Aortic aneurysm, non-syphilitic, and dissecting aneurysm Aneurysm, abdominal (aorta) Dissecting aneurysm of aorta Aortic aneurysm specified as Hyaline necrosis of aorta noDByphilitic Rupture of aorta NOS • Dilatation of aorta *. This title includes aneurysm of abdominal aorta and dissectiong an• eurysm, unless they are spocihed aB syphilitic (022). It excludes aneurysm of aorta, unspociflod (022). It includes tho listed conditions when specified as arteriosclerotic or duo to any condition in 450. 452 Other aneurysm, except of heart and aorta Aneurysm (rupture), except of aorta, heart, and coronary artery cirsoid - false miliary varicose Aneurysmal varix This title excludes: aneurysm of heart or coronary artery (420.1), of aorta (022, 451) ; ruptured cerebral anourysm (330); arteriosclerotic cerebral aneurysm (334) ; and arteriovenous aneurysm (754.6). 453 Peripheral vascular disease 453.0 Raynaud's disease Raynaud's disease or gangrene Raynaud's phenomenon (secon• dary) 453.1 Thrombo-angiitis obliterans Buerger's disease Thrombo-angiitis obliterans (general) 453.2 Chilblains Chilblains Pernio Dermatitis congelationis 453.3 Other Acrocyanosis Erythromelalgia Acroparesthesia Other or unspecified peripheral simple (Schultze's type) vascular disease not clas- vasomotor (Nothnagel's sifiable under 453.0- type) 453.2 Erythrocyanosis This title excludes frostbite (E932, N980.0) and immersion foot (E932, N980.1). 454 Arterial embolism and thrombosis Embolism ) of any artery except cerebral (332), coronary Thrombosis j (420.1), pulmonary (465), and mesenteric (570.2) Embolism (of) : NOS aorta septic (not puerperal) This title excludes embolism and thrombosis of puerperal origin (645.1, 651, 682, 684). 455 Gangrene of unspecified cause Gangrene, mortification, or phagedama (dry, moist, or unqualified) of unspecified cause, not classifiable elsewhere Gangrenous cellulitis or dermatitis Spreading cutaneous gangrene This title excludes : arteriosclerotic gangrene (450.1) ; diabolic gangrono (200) ; gas gangrene (00!J) ; senile gangrene (450.1) ; noma vulvie (O.'!0.2) ; gangrene of lung (521), appendix (550), omentum (578), gallbladder (5S5). 45G Other diseases of arteries Aortitis, non-syphilitic Disseminated lupus erythema- Artcritis NOS tosus (Libman-Sacks aorta, non-syphilitic disease) giant celled Endarteritis NOS temporal Peri-arteritis (nodosa) (any artery except coronary) Polyarteritis nodosa This title excludes lupus NOS (014.2) and lupus erythematosus (705.4). DISEASES OF VEINS AND OTHER DISEASES OF CIRCULATORY SYSTEM (460-468) 400 Varicose veins of lower extremities Phlebectasia Varicose veins (ruptured) (ulcer- lower extremity (any part) ated) unspecified site lower extremity (any part) Varicose ulcer unspecified site lower extremity (any part) Varix unspecified site lower extremity unspecified site 4C1 Ilaunorrhoids Haemorrhoids (rectum) (prolapsed) (thrombosed) (ulcerated) (stran• gulated) (bleeding) Piles (external) (internal) Rupture, varix, rectum Varicose veins, anus or rectum 4G2 Varicose veins of other specified sites 462.0 Varicocele Varicocele Varicose veins, scrotum 462.1 Varicose veins of oesophagus Phlebectasia, tesophagus Varix, oesophagus Varicose veins, oesophagus 462.2 Other Phlcbcctasia, any site except as classifiable in 460-462.1 Varicose veins, varix, and varicose ulcer, any site except as classi• fiable in 460-462.1 This title excludes varicose veins and varicose ulcer of unspecified sites (460). 463 Phlebitis and thrombophlebitis of lower extremities Endophlebitis Inflammation, vein Periphlebitis ', of any part of lower extremity Phlebitis (suppurative) (septic) \ Thrombophlebitis This title excludes the listed conditions if of puerperal origin (645. I 651, (i.H2) or complicating pregnancy (648.:!). 464 Phlebitis and thrombophlebitis of other sites Endophlebitis . .„ , ., , . .„ , Inflammation, vein °f »nRP 465 Pulmonary embolism and infarction Embolic pneumonia Puknonary (artery) (vein) : Pulmonary (artery) (vein) : infarction (hemorrhagic) apoplexy thrombosis embolism This title excludes those conditions if of puerperal origin (645.1, 651, 684) or complicating pregnancy (648.3). , 466 Other venous embolism and thrombosis Embolism, vein, any except cerebral, coronary, mesenteric, and pulmonary Thrombophlebitis migrans Thrombosis, vein, any except cerebral, coronary, mesenteric, and puknonary Thrombosis NOS This title excludes thrombophlebitis (463-464); embolism and throm• bosis of intracranial venous sinuses (334, 341), of mesentery (570.2), and of puerperal origin (645.1, 651, 682, 684) or complicating pregnancy (648.3). 467 Other diseases of circulatory system 467.0 Hypotension Hypopiesis Hypotension . 3- hi. rv( r-O, >- -6 : -Ocvl^W go «N i^rsia-