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DRINKING WATER HARDNESS AND CARDIOVASCULAR DISEASES

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gfcraun_at_verizon.net. Cardiovascular Disease (CVD) morbidity and mortality varies worldwide ... hard water or minerals, such as calcium (Ca) and magnesium (Mg) ... – PowerPoint PPT presentation

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Title: DRINKING WATER HARDNESS AND CARDIOVASCULAR DISEASES


1
DRINKING WATER HARDNESS AND CARDIOVASCULAR
DISEASES
  • A REVIEW OF EPIDEMIOLOGICAL STUDIES

2
REBECCA L. CALDERON National Health and
Environmental Effects Research Laboratory, U.S.
EPA GUNTHER F. CRAUN Gunther F. Craun
Associates gfcraun_at_verizon.net
3
Cardiovascular Disease (CVD)
  • morbidity and mortality varies worldwide
  • major risk factors do not entirely explain the
    variability
  • Is CVD associated with water hardness?

4
Hypothesis
  • hard water or minerals, such as calcium (Ca) and
    magnesium (Mg) found in hard water, may help
    decrease cardiovascular risks
  • constituents associated with soft waters (e.g.,
    corrosion products from distribution pipes,
    sodium from home softening units) may increase
    the risk

5
Epidemiological studies of CVD and water
hardness, Ca, and Mg
  • 60 ecological studies population based
  • 7 case-control studies individuals
  • 2 cohort studies individuals

6
Population-based studies
  • Geographical correlation, group, or aggregate
    studies
  • explore relationships between available health
    statistics (e.g., CVD) and population
    characteristics (e.g., environmental and water
    quality measures)
  • associations characterize population risks

7
Studies of individuals
  • Obtain information about disease and exposures
    from each study participant
  • Test specific hypotheses
  • Provide a quantitative estimate of the relative
    risk
  • Provide information to help scientists assess
    causality

8
CONCLUSIONS
Hardness, as such, and decreased CVD risk No
evidence for an association
Calcium in drinking water and decreased CVD
risk Limited evidence of an association
9
CONCLUSIONS
Magnesium in water and decreased CVD
risk Reduction in CVD risk with increasing Mg
levels in drinking water
Low intake of Mg from DW increases the risk of
dying from and possibly developing CVD or
stroke Findings supported by evidence
from toxicological and dietary studies
10
Geographical correlation studies
  • 60 in 21 cities and various countries including
  • U.S., England and Wales, Taiwan, South
    Africa, France, Canada, Sweden, Irish Republic
    and Northern Ireland, Netherlands, Norway,
    Finland, Italy, Rumania, Bohemia and Moravia,
    Scotland, Germany, Japan, Australia, and Hungary

11
Geographical correlation studies
  • Four studies estimated the effect of drinking
    water hardness

12
England and Wales
  • 7.5 reduction of CVD mortality (men) for 100
    mg/l increased water hardness

13
France
  • 10 reduction of the risk for CVD mortality for
    the highest Ca concentration (94-146 mg/l) and
    highest Mg concentration (11-34 mg/l) compared
    to the lowest concentrations

14
Finland
  • The risk of Acute Myocardial Infarction (AMI)
    decreased 1.1 for each 20 mg/l increase in water
    hardness

15
Taiwan
  • 10 increase in the risk of Ischemic heart
    disease (IHD) mortality with hardness compared to persons with 150 mg/l
    hardness

16
Case-control studies
  • 5 of 7 studies - a significant protective
    association between Mg levels in DW and mortality
    for AMI, stroke, or hypertension
  • One study a significant protective association
    between AMI and both Ca and Mg levels in DW
  • Studies in Finland, Taiwan, and Sweden

17
Finland AMI
  • AMI mortality risk decreased among men as
    drinking water
  • Mg levels increased from 3
    mg/l

18
Taiwan Stroke
  • Taiwan, 252 municipalities with single water
    source 1989-1993
  • 17,133 males and females dead for stroke (cases)
  • 17,133 males and females dead for other causes,
    excluding CVD (controls)
  • age50-69

19
Taiwan Stroke
Significant decreased risk of death from stroke
among men and women associated with drinking
water levels of Mg 7.4 mg/l
20
Taiwan Hypertension
  • Taiwan, 252 municipalities with single water
    source 1990-1994
  • 2,336 males and females dead for hypertension
    (HT) (cases)
  • 2,336 males and females dead for other causes,
    excluding CVD (controls)
  • age50-69

21
Taiwan Hypertension
Significant decreased risk of death due to
hypertension associated with Mg 3.8
mg/l Exposure-response relationship (p 22
Sweden AMI
  • Study conducted by Rubenowitz et al
  • Southern Sweden, 16 municipalities 1982-1983
  • 378 females dead for AMI (cases)
  • 1,368 females dead for cancer (controls)
  • age50-69

23
Sweden AMI
Significant decreased risk of death due to
AMI (women) associated with Mg levels 6.9 mg/l .
24
Sweden AMI
  • Study conducted by Rubenowitz et al
  • Southern Sweden, 17 municipalities 1982-1989
  • 854 males dead for AMI (cases)
  • 989 males dead for cancer (controls)
  • age50-69

25
Sweden AMI
Significant decreased risk of death due to
AMI (men) associated with Mg levels 6.9 mg/l.
26
Southern Sweden AMI
  • Rubenowitz et al also conducted a study of
    persons dying from and surviving an AMI
  • Conclusion Mg prevents AMI deaths rather than
    incidence

27
Sweden AMI
  • Rosenlund et al studied AMI risk in 1992-4
  • A small, not statistically significant,
    protective effect was associated with a DW Mg
    intake 1.86 mg per day.
  • Several limitations including the mean levels of
    Ca and Mg in DW, which were very low compared to
    the levels in other studies

28
Cohort Studies Finland
  • 15-year follow-up of 1711 men in two rural areas
    of Finland using private well water
  • Mortality due to coronary heart disease was 14.7
    in the area with 3-4 mg/l Mg in DW versus 8.7 in
    the area with 13-14 mg/l Mg.
  • Almost twice as many deaths with the lower Mg
    level!

29
Cohort Studies Maryland
  • 12-year study of 30,564 men and women in
    Washington County, Maryland (water hardness 0
    vs. 200 mg/l)
  • Water hardness 0 vs. 200 mg/l
  • A 14-31 reduced risk of mortality for AHD was
    found in men depending on length of exposure no
    reduced risk for women.

30
Epidemiological studies of demineralized water
  • Primarily foreign-language literature
  • Evaluated by Dr. F. Kozisek
  • Extreme case of soft water
  • Poses similar risks as soft water

31
Recommendation
  • Not removing Mg from or increasing Mg intake
    from drinking water may be beneficial -
    especially for populations with an insufficient
    dietary intake of the mineral

32
Discussion
  • Home softening
  • do not soften water at the tap used to obtain
    drinking and cooking water
  • Regulations
  • US EPA-none
  • Europe

33
European Guidelines
  • Directive (European Union 1980) established a
    requirement for minimum hardness for softened or
    desalinated water ( 60 mg/l as calcium or
    equivalent cations).
  • Requirement expired in December 2003. New
    Directive (European Union 1998) does not contain
    the requirement.

34
European Guidelines
  • Member states may still implement such a
    requirement. Several (e.g. the Netherlands) have
    included Ca, Mg, or hardness into their national
    regulations.
  • Four Central European countries that became part
    of the EU in May 2004 have included the
    requirements in their respective regulations but
    vary in binding power.

35
Czech Republic
  • Binding levels for softened water 30 mg/l Ca
    and 10 mg/l Mg
  • Guideline or suggested levels
  • 40-80 mg/l Ca and 20-30 mg/l Mg
  • (hardness as S Ca Mg 2.0-3.5 mmol/l)

36
Hungary
  • Binding - minimum required concentration (50
    mg/l) applies to bottled drinking water, new
    water sources, and softened and desalinated water
  • Guideline levels hardness 50 350 mg/l
  • (as CaO)

37
Poland
  • Guideline levels hardness 60 500 mg/l
  • (as CaCO3)

38
Slovakia
  • Guideline levels 30 mg/l calcium and
  • 10 30 mg/l magnesium.

39
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