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A study of the relationship between water hardness and heart disease mortality in British Columbia Wiens, Michele 1986

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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 i n THE FACULTY OF GRADUATE STUDIES GEOGRAPHY We accept t h i s t h e s i s as conforming to the r e q u i r e d 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 <zr£~Q£ fy^RH Y The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 ABSTRACT Se v e r a l s t u d i e s have i n d i c a t e d an i n v e r s e r e l a t i o n s h i p between the hardness of community water s u p p l i e s and deaths due to heart d i s e a s e . In t h i s t h e s i s , s t u d i e s of water hardness and heart d i s e a s e are b r i e f l y reviewed; the r o l e of water hardness i n heart d i s e a s e m o r t a l i t y i s assessed; and, the hypothesis that s o f t water c o n t r i b u t e s t o heart d i s e a s e m o r t a l i t y i s t e s t e d using data for 103 c i t i e s i n B r i t i s h Columbia. The c o r r e l a t i o n s of water hardness, waterborne calcium, and waterborne magnesium with s e x - s p e c i f i c a g e - s t a n d a r d i z e d heart d i s e a s e m o r t a l i t y r a t e s were not s t a t i s t i c a l l y - s i g n i f i c a n t nor does the g e o g r a p h i c a l p a t t e r n suggest any obvious r e l a t i o n s h i p . The e f f e c t s of water hardness on human h e a r t - r e l a t e d m o r t a l i t y are d i f f i c u l t to separate from the e f f e c t s of smoking, h i g h - c h o l e s t e r o l d i e t s , and other heart d i s e a s e r i s k f a c t o r s a t the l e v e l of e c o l o g i c a l c o r r e l a t i o n . it Table of C o n t e n t s ACKNOWLEDGEMENT v i i 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 I I I 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. A RANKING OF MORTALITY RATES FOR HEART DISEASE,FEMALES,B. c. 63 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 F i g u r e Page B R I T I S H COLUMBIA SCHOOL DISTRICTS 7 WATER HARDNESS I N B.C. BY SCHOOL DISTRICT 8 MALE MORTALITY RATES FOR ALL HEART DISEASES COMBINED BY SCHOOL D I S T R I C T , B.C. 1956-1977 9 FEMALE MORTALITY RATES FOR ALL HEART DISEASES COMBINED BY SCHOOL D I S T R I C T , B.C. 1956-1977 1 0 GENERALIZED MAP OF WATER HARDNESS IN B R I T I S H COLUMBIA, BY SCHOOL D I S T R I C T 11 GENERALIZED MAP OF MALE MORTALITY RATES FOR ALL HEART DISEASES COMBINED, BY SCHOOL DI S T R I C T , B.C. 1956-1977 12 GENERALIZED MAP OF FEMALE MORTALITY RATES FOR A L L HEART DISEASES COMBINED, BY SCHOOL DI S T R I C T , B.C. 1956-1977 13 SCHOOL DISTRICTS I N 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 DIS T R I C T S I N 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 I N B.C. WHICH, FOR BOTH MALES AND FEMALES, HAVE HIGH RATES OF HEART D I S E A S E MORTALITY AND SOFT WATER, OR LOW RATES OF HEART DISEASE MORTALITY AND HARD WATER 16 PHYSIOGRAPHIC REGIONS OF B R I T I S H COLUMBIA 17 GEOLOGIC D I V I S I O N S OF B R I T I S H COLUMBIA 18 SI T E S OF PREDILECTION FOR ATHEROSCLEROSIS 20 DIAGRAM OF AN ATHEROSCLEROTIC PLAQUE 21 P R I N C I P L E S OF THE PATHOGENESIS OF ATHEROSCLEROSIS 22 PROBABILITY OF DEVELOPING HEART DISEASE 41 DEATHS DUE TO DISEASES OF THE HEART IN S P E C I F I E D AGE GROUPS 42 MAP SHOWING REGIONAL DIS T R I C T S , B R I T I S H 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 a l l of t h e i r guidance, support, and kindness during the p r e p a r a t i o n of t h i s paper, I would l i k e to thank my t h e s i s a d v i s o r s , Mr. Ri c h a r d Copley, Mr. Ri c h a r d G a l l a g h e r , and Dr. Trevor Barnes. v i i I. A. STATEMENT OF THE PROBLEM There i s evidence from e p i d e m i o l o g i c a l i n v e s t i g a t i o n s i n Canada, England and Wales, the United S t a t e s , and other c o u n t r i e s , that the hardness 1 of d r i n k i n g water may be i n v e r s e l y a s s o c i a t e d with heart d i s e a s e m o r t a l i t y . 2 Waterborne c a l c i u m and waterborne magnesium account fo r 95 per cent of the hardness of water. There i s general agreement that a water with l e s s than 100 mg CaC03 per l i t e r can be c l a s s i f i e d as " s o f t , " whereas waters with 100 mg CaC03 per l i t e r or more can be regarded as "hard". In t h i s study, waters with l e s s than 75 mg CaC03 per l i t e r are c o n s i d e r e d to be " s o f t , " and waters with more than 100 mg CaC03 per l i t e r are c o n s i d e r e d to be "hard." Many re s e a r c h e r s use water hardness c l a s s i f i c a t i o n s that are s i m i l a r to Stocks (1973) and N e r i et al (1975). These c l a s s i f i c a t i o n s can be seen in Table 1. It has been hypothesized that d e f i c i e n c i e s i n c a l c i u m and magnesium ions, which r e s u l t i n s o f t e r water, are f a c t o r s i n heart d i s e a s e m o r t a l i t y . T h i s r e p o r t documents and maps, for the f i r s t time, water hardness and heart disease m o r t a l i t y data f o r B r i t i s h Columbia (see maps at the end of t h i s s e c t i o n , pp. 7-19). Map 2 i s a d e s c r i p t i o n of water hardness i n B r i t i s h 1A11 words i n i t a l i c s i n t h i s t h e s i s are d e f i n e d i n appendix 1, which i s a g l o s s a r y of terms 2Hewitt, N e r i 1980; Pocock et a l 1981; Z i e l h u i s , Haring 1981 1 T A B L E t W A T E R . H F \ R D I N ) E S 5 C L A S S I F I C A T I O N S WATER C L A S S I F I C A T I O N ULTRA SOFT VBR.Y SOFT SO FT MoDEft.JATEL.-V SOFT SLi G-HTL.Y HAR.D MODERATELY K / M t D H A R D VEfVY H A W ) •STOCKS 0-50 50-100 100-150 .2£>o-3oo > 3 0 O ( l i 7 5 ) o- !4 30 " 5fi /oo-;M<? > I So EHV I RON M E NT fM-P R O T E C T I O N 0 - 1 5 7.S loo LbO 3oo > 3 o o NioTE '- £ A C H UNIT of (;ARi)NESs IS E&aiiift L t sir To I riCv CVtOj P E R . LirR£ 3 Columbia, by s c h o o l d i s t r i c t , using a f i v e - c a t e g o r y c h l o r o p l e t h mapping technique. Maps 3 and 4 show age-standardized heart d i s e a s e m o r t a l i t y data f o r B r i t i s h Columbia. Maps 5, 6, and 7 show g e n e r a l i z e d water hardness and heart d i s e a s e data f o r B r i t i s h Columbia. Comparing Maps 5, 6, and 7, we can use the g e o g r a p h i c a l p a t t e r n s to see the s p a t i a l a s s o c i a t i o n between water hardness and heart d i s e a s e m o r t a l i t y . Maps 8 and 9 show the school d i s t r i c t s which have s o f t water and high heart d i s e a s e m o r t a l i t y r a t e s , and the school d i s t r i c t s which have hard water and low heart d i s e a s e m o r t a l i t y r a t e s . The school d i s t r i c t s which have e i t h e r (1) s o f t water and h i g h r a t e s of heart d i s e a s e m o r t a l i t y 1 , or (2) hard water and low r a t e s of heart d i s e a s e m o r t a l i t y 2 f o r males ar e : 1. A l b e r n i 2. Burns Lake 3. Campbell River 4. C a r i b o o - C h i l c o t i n 5. C e n t r a l Okanagan 6. Hope 7. Kamloops 8. K i t i m a t 9. Nechako 10. Nelson 11. Powell River 12. P r i n c e Rupert 13. South Okanagan 14. T e r r a c e 15. T r a i l The school d i s t r i c t s with e i t h e r (1) s o f t water and h i g h r a t e s of heart d i s e a s e m o r t a l i t y , or (2) hard water and low 1High r a t e s of heart disease m o r t a l i t y are here d e f i n e d as g r e a t e r than 401 deaths per 100,000 2Low r a t e s of heart d i s e a s e m o r t a l i t y are here d e f i n e d as l e s s than 350 deaths per 100,000 4 r a t e s of heart d i s e a s e m o r t a l i t y f o r females a r e : 1. C a r i b o o - C h i l c o t i n 2. C e n t r a l Okanagan 3. C h i l l i w a c k 4. F e r n i e 5. K i t i m a t 6. L i l l o o e t 7. M e r r i t t 8. Nechako 9. Peace River North 10. Peace River South 11. P r i n c e George 12. Powell River 13. Quesnel 14. South Okanagan 15. Vancouver I s l a n d North 16. Vernon 17. Windermere School d i s t r i c t s with e i t h e r (1) s o f t water and h i g h r a t e s of heart disease m o r t a l i t y , or (2) hard water and low r a t e s of heart d i s e a s e m o r t a l i t y f o r both male and female data are: C a r i b o o - C h i l c o t i n , Hope, K i t i m a t , Nechako, Powell R i v e r , C e n t r a l Okanagan, and South Okanagan. These are i n d i c a t e d i n Map 10. About 5.7 per cent of the p r o v i n c e ' s p o p u l a t i o n l i v e s i n these 7 d i s t r i c t s . 1 Looking at Map 11, we see that the d i s t r i c t s with s o f t water and high r a t e s of heart d i s e a s e m o r t a l i t y , f o r both males and females, are a l l l o c a t e d w i t h i n the C o a s t a l Mountain Physiographic Region of B r i t i s h Columbia, and the d i s t r i c t s with hard water and low r a t e s of heart d i s e a s e m o r t a l i t y are a l l l o c a t e d w i t h i n the Intermontane Physiographic Region. The Geologic Region a s s o c i a t e d with the C o a s t a l Mountain Region i s the Coast P l u t o n i c Complex, ^ h e r e are only 66 school d i s t r i c t s because 8 were excluded due to a lack of i n f o r m a t i o n . 5 which i s composed mainly of metamorphosed g r a n i t i c rock; the Geologic Region a s s o c i a t e d with the Intermontane Region i s the unmetamorphosed sedimentary and v o l c a n i c s t r a t a of the Intermontane B e l t . These g e o l o g i c r e g i o n s are shown i n Map 12. One c o u l d suggest, as M a s i r o n i d i d , t h a t a r e g i o n ' s geology i s r e l a t e d to the g e o g r a p h i c a l p a t t e r n of heart d i s e a s e m o r t a l i t y . 1 The g e n e r a l p a t t e r n i n B r i t i s h Columbia lends some support to M a s i r o n i ' s argument. However, i n s i n g l e p h y s i o g r a p h i c r e g i o n s , there are some sch o o l d i s t r i c t s which lend support to the h y p o t h e s i s that water hardness i s i n v e r s e l y a s s o c i a t e d with heart' d i s e a s e m o r t a l i t y , and there are some d i s t r i c t s which do not. Both Rogot and M a s i r o n i s t a t e d that extreme c l i m a t i c c o n d i t i o n s may be r e l a t e d to heart d i s e a s e m o r t a l i t y , but t h i s study does not show any r e l a t i o n s h i p between heart d i s e a s e m o r t a l i t y and extreme c l i m a t i c c o n d i t i o n s . 2 Heart d i s e a s e m o r t a l i t y r a t e s i n B r i t i s h Columbia do not vary i n any c o n s i s t e n t way with c l i m a t e . I f heart d i s e a s e were aggravated by extreme c l i m a t i c c o n d i t i o n s , one would expect the h i g h e s t r a t e s of heart d i s e a s e m o r t a l i t y to occur i n the northern school d i s t r i c t s i n B r i t i s h Columbia, and the lower r a t e s to occur i n the south and southeast p a r t s of the p r o v i n c e , where the c l i m a t e i s o f t e n more moderate. In f a c t , the r e l a t i v e l y h i g h r a t e s of the c l i m a t i c a l l y - m o d e r a t e c o a s t a l d i s t r i c t s c o n t r a d i c t the arguments of Rogot and M a s i r o n i . 1 M a s i r o n i , Shaper 1981 2Rogot, Padgett 1976; M a s i r o n i , Shaper 1981 6 There are other r i s k f a c t o r s f o r heart d i s e a s e , such as d i e t a r y h a b i t , l i f e s t y l e , and smoking. In t h i s t h e s i s I w i l l t e s t whether a r e l a t i o n s h i p can be de t e c t e d i n B r i t i s h Columbia between heart d i s e a s e m o r t a l i t y and water hardness. I w i l l a l s o t r y to de t e c t the separate c o n t r i b u t i o n s of waterborne c a l c i u m and magnesium to heart d i s e a s e m o r t a l i t y . Age and sex, which are major heart d i s e a s e r i s k f a c t o r s , w i l l be c o n t r o l l e d in t h i s study: m o r t a l i t y r a t e s w i l l be age-standardized and s e x - s p e c i f i c . I have d i v i d e d my study i n t o four main s e c t i o n s , namely: (Part 1) a comment on the p l a u s i b i l i t y of the suspected r e l a t i o n s h i p between heart d i s e a s e and s o f t water; (Part 2) a review of the l i t e r a t u r e on water hardness and heart d i s e a s e ; (Part 3) a comment on suspected h e a r t d i s e a s e r i s k f a c t o r s ; and (Part 4) an i n v e s t i g a t i o n of whether there i s a s t a t i s t i c a l l y - s i g n i f i c a n t r e l a t i o n s h i p between water hardness and heart d i s e a s e m o r t a l i t y i n 103 c i t i e s in B r i t i s h Columbia. Ii/\P I : B R I T I S H C O L U M B I A S C H O O L D I S T R I C T S 3 2 H O P E 3 3 CMRLIWACK 3-1 iGDOTS^OnO 3 5 U N C U T 3 6 SURREY 3 7 D C L ' A 3 a PiCMnOttO 39 VANCOUVER 40 HE" WESTMINSTER 4 1 8'JRNADY 4 2 MAPLE RIOCE. <3 COQUITLAM 44 H VANCCLiVER *5 M VANCOUVER <6 SUNSHINE COAST 4 7 POWELL RIVER 49 HOWE SOUND 43 CCHT1UL COAST 50 DUEEN CHARLOTTE 5 2 P R t H C c RUPERT 5 4 S H I 1 H E R S 5 5 OURNS LAKE. 5 6 N £ O U < 0 57 PRINCE GEORGE 5 9 P E A C E P 1 v E f 6 3 P E A C E R : V E 1 6 1 G R E A T E R V I C T O R I A 6 2 S O C K E 6 3 S A A N I C H $ 4 &m_f ISl A N [ 6 5 C O W I L H A N EG L * f t COHICl 6 0 rJANAlHO D U A L I CUM 7 0 A L D C R N I 7 1 C O U H T E N A Y 7 2 C A M P B E L L R I V E R 7 5 M I S S I O H 7 6 A G A S S I Z -H A R R I 5 0 H 7 7 S U M K E B L A N O PO K I T I MA T B i F O R T N E L S O 6 4 V A N I S L WE B 5 V A N I S L N O 6 5 C H E S T Q M - K A B 7 S T I K I N E B O T E R R A C E 89 S H U S W A P S 2 N I 5 M G A j 5Q U R . C C ; T H E : V A > ! £ O U \ / C R S C H O O L , ao^^n c m c r 8 MAP 2X V/rVTER. H A R D t v j E S S IH B M T I 5 H C O L U M B I A BY S C H O O L D I S T R I C T MOTE: W A T L R . & U M _ I T Y D « . T A W M o a T H i U h D F f t o ^ n u W i c i P A i . RLC<DR.DS 9 MAP3' - AfrE-STANDARDIZED M O R T f t L l T Y RATETS FOR AU_ KCART D I S E A S E S f l 1 S t - i n « ) FOR M f l L « , 8Y SCHOOL DISTRICT ,rJ B-C. STANDARD II ED M O R T A L I T Y «.ftTETS 7^.1 <. 3 0 O (per l o ISSTtTS f i t >45° ~T D I 5 T M C T 5 MoT I N C L U D E D _i IK| T H I S W J M-fllS I I | I S J k N M _ f S t  M O T E ; H E A I T D I S E A S E M O O - T H L I T Y I N F O R M A T I O N W A S 0 0 ™ , W H O FROM THE C A t r t E t C C N T R . O L ft&eMCY OF B . C . , ft* S P E C I A L A R R A N &En C.MT* 10 MAP '• A & E - S T A N D A R D I Z E D M O R T A L . T V R A T E S T O R A L U H E A R T D I S E A S E ' S C O M ^ N f D ( 19 56 - I ?7«) F o R . F E M A L E S QY S C H O O L D I S T R I C T I N 3 . C . *GE-STANDARDIZED Pi0 RJT ALI T V fLATCS ESij 3 0 I - 3 S O \ ^ 351-Hoo D I S T R I C T S M O T I N C L U D E D ,ti T H I S A r / f t L . V 5 < S WoTE- H E A R T D l S E - f t S f c . M O R T A L 1 T V l H H « H M I o M * A S O B T A . N E D F K O f A TrtB O W C E * C O N T H * . A M - M C V O f B 1 , B Y . S P E C I A L A R R A W & E M ^ M T 11 M A P S - ' & F N t R A L i Z £ D W A T f H HftP-DAJh'SS flMTlSM COLUMBIA HoTe •• W A T E R . a u « i r r P A T A W A S O B T A I N I F O r«-<",i H U W : C , P < M ( V I . ( A R B S N O T E : - ut/ve-r oiser^ie M O K T A L I T / I N F O R M A T I O N ! W A S o&Tmtjea FRaM T H E C A N 1 L E R _ c o n r t t L A - & £ * ) C Y O F ac, BV SPECIAL AWLAKjS -eHCrJT 13 MAP 7:GENERALIZED A G E - S T P S M D A R . D I 2 . E D M i U m L i r v R A T E S Fog. A L L H E A R T D I S E A S E S C O M B I N E D ( 19 5L-I <i")-?) F O R F E M A L E S , 8 V S C H O O L D I S T R I C T INI B - C . ME- S T A N D A R - D i x e o M O R T A L I T Y F U \ T E S <( 3 5 0 ('per t o o , o o o ) • DISTRICTS MoT If/CuuDED W T^is A M A L V S I S NoT£ HEART D l S C ^ i * MOtTALiTV I NFdft M ATI (7 * "M;* 6l3T/\I^Ef> F R O M T H E C A N C E R . C«>ITR.OL /s&eMcV O P B . C . , BY S P E C I A L A R R A M & C M E W T M A P 8- SCH-OOL. Dl5rK.ic.TS IN 3-C w / T » f EirHk'R. SOFT ^ r E « 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 D I 5 T R I C T 5 W i T H S O F T W A T E R M O H I G H R A T E S O F rt£ARrDlS£*S£ LICD 7l4oo- Hfctf) . ^ * o 3 DISTRICTS WITH HrARD WATER. AMD A-ATES OP H-EAftT QlSEAsC 15 M A P ^ S C H O O L D I S T ^ I C I S IH B-C W I T t f E I THER SOFT ^ T f R flrJ V W . T E R ANJ> L o U R A r r S O F F £ M « U T HEART US** SET M. OR. T A L-iTV) >', • ? » o „ • • o » ' . 9 0 8 o 0 " - o o e o » " KEY' o 0 o o 0° - 0 i D I S T R I C T S W I T H SoFT W A T C R . AMD H I & H R A T E S O P H i - A R T D l S E A S ^ 1^ ( i C D I 1 HOo-Hk-i) ^ DISTRICTS WITH H-ARO WATER MD Low RATES OF HCART J>ISE/\S£ K\AP 10: , 5 C M O O L D I S T R I C T S , N ec W H I C H , F O * . B O T H M . L C S A H F ^ L " ' ' M V S H , & H R A T E S O F : D I S E A S E - A^D S O F T W ^ O P - L O W H A r e s O F H E A R T ^ 5 C f t 5 E A H Cl H A R D W A T E ^ PIS; KiCT-S W I T H SoFT WM ftND 'riitH RATES OF HE-A it" " • o i Dl-SYR.VC.TS W I T H 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&lt R E G I O N S Or BK\T1S H CoL-Ur1£>)A 19 B. PATHOLOGY OF HEART DISEASE L e t us now c o n s i d e r w h e t h e r t h e r o l e o f c a l c i u m and magnesium i o n s i n h e a r t d i s e a s e m o r t a l i t y i s b i o l o g i c a l l y p l a u s i b l e . H e a r t d i s e a s e d e v e l o p s a s c h o l e s t e r o l , c a l c i u m a n d c o n n e c t i v e t i s s u e t h i c k e n t h e l i n i n g o f t h o s e a r t e r i e s w h i c h n o u r i s h t h e h e a r t m u s c l e . 1 C o r o n a r y a t h e r o s c l e r o s i s , a s p e c i a l t y p e o f t h i c k e n i n g a n d h a r d e n i n g o f t h e m e d i u m - s i z e d a n d l a r g e a r t e r i e s , a c c o u n t s f o r a l a r g e p r o p o r t i o n o f h e a r t a t t a c k s a n d c a s e s o f h e a r t d i s e a s e . T h i c k e n i n g o f t h e a r t e r i e s i n v o l v e s t h e a c c u m u l a t i o n o f f a t t y d e p o s i t c a l l e d p l a q u e on t h e a r t e r i a l w a l l s . T h e s e d e v e l o p m e n t s a r e i l l u s t r a t e d i n F i g u r e s 1-3, w h i c h a r e t a k e n f r o m B r a u n w a l d . The m a j o r c o m p o n e n t s o f t h e a t h e r o s c l e r o t i c p l a q u e a r e c e l l s a n d l i p i d . T h e l i p i d i s r e p r e s e n t e d by a s o f t , necrotic c o r e w h i c h i s r i c h i n c h o l e s t e r o l e s t e r s . P l a q u e s a r e c h a r a c t e r i z e d by r o u g h e d g e s w h i c h i r r i t a t e t h e smooth l i n i n g o f t h e a r t e r i e s . I n h e a r t d i s e a s e d e v e l o p m e n t , s c a r t i s s u e f o r m s on t h e a r t e r i a l l i n i n g , a r t e r i e s become h a r d a n d n a r r o w , a n d t h e f l o w o f b l o o d t h r o u g h t h e a r t e r i e s d e c r e a s e s . The t r a n s f o r m a t i o n o f t h e e l a s t i c a r t e r y w a l l s i n t o r i g i d a r t e r y w a l l s c a u s e s t h e h e a r t t o pump a l l b l o o d w i t h o u t a r t e r i a l a s s i s t a n c e . E f f e c t s o f a t h e r o s c l e r o s i s r e s u l t m a i n l y f r o m t h e l a c k o f b l o o d i n body p a r t s s u p p l i e d by t h e d i s e a s e d a r t e r i e s . I n p l a q u e s o f t h e m e d i u m - s i z e d a r t e r i e s , stenosis o f t e n r e s u l t s i n an o b s t r u c t i n g thrombus w h i c h f o r m s on t h e w a l l o f t h e ' B r a u n w a l d 1980:1221 2£ Fl&UR£ 1 : SiTES OF P R E D I C T I O N ! FOP. ATHE:w>scL.Eft.osis_> iM U S U A L R.A.MK. Q P J 5 E R -FIGURE 2.' DIAGRAM OF AN ATHEROSCLEROTIC PLAQUE r v - 0 - 7 7~» ° \ .«> / / a FIBROUS CAP DJUUI£SQU& BECAUSE OF — S I Z E , TENDENCY TO FRACTURE AND ULCERATE NECROTIC CORE HAHGEfiOUS BECAUSE OF — S I Z E , CONSISTENCY AND THROMBOFXASTIC SUBSTANCES T H E COMPONENTS C P T H E A V D V A N I C E Q (C.L I N I C A L L . V IM P 1 K T A N T ) A T H £ i e o r c LFUDTIC PLAOUS. C H A R A C T E R I S T I C S OF T H - E A D V A M C F B P U O U E A M D fTS C.L1MIC .AL. E F F E C T S I N / I M E D I U M ->Si2.ETO L J H U S C U L A R . ) A R T E T R I E S F I G U R E : 3 : PRINCIPLES OF THE PATHOGENESIS OF ATHEROSCLEROSIS • M Y O C A R D I A L I N F A R C T C E R E B R A L I N F A R C T G A N G R E N E O F E X T R E M I T I E S A B D O M I N A L A O R T I C A N E U R Y S M [ C L I N I C A L H O R I 2 ^ 0 N j CALCIFICATION C O M P L I C A T E D L E S I O N -H E M O R R H A G E , U L C E R A T I O N , T H R O M B O S I S FIBROUS PLAQUE FATTY STREAK t I T H E " N A T u R A . i _ H I S T D R V O F ATU.ERj)SCLEH.asis , P L A & U E T S L 1 5 U A L L I I ' . D E V E L O P S L O W L Y A J \ I . D i N s m u o n i L Y O V E R . M A M Y yEPJL-s) A M O T H E * ' « E I \ / £ R A I _ L . Y PRo.sft .E5s F R O M A . F A T T V J i T d E A K T a A F l S i e c u S P L A Q U E A l \ / D T K £ N I TO A C _ o M P U L C A T £ " D P L A G U E : T H A T / = L I K E L V T O £ £ A B T O C L I A I / H A L . effects* 23 b l o o d v e s s e l . Thrombus i n a c o r o n a r y a r t e r y c a n l e a d t o su d d e n coronary o c c l u s i o n a n d m y o c a r d i a l i n f a r c t i o n . A l a c k o f b l o o d i n t h e b r a i n may c a u s e a stroke. P a r t i a l o b s t r u c t i o n o f t h e c o r o n a r y a r t e r i e s ' b l o o d s u p p l y t o t h e h e a r t m u s c l e may c a u s e angina pectoris. I n p l a q u e s o f t h e a o r t a , t h e m a j o r e f f e c t s o f a t h e r o s c l e r o s i s a r e more l i k e l y c a u s e d by t h i n n i n g o f t h e m e d i a b e t w e e n t h e p l a q u e s , w e a k e n i n g o f t h e a r t e r i a l w a l l , aneurysm formation, a n d r u p t u r e . 1 T h e o r i e s o f p a t h o g e n e s i s o f a t h e r o s c l e r o s i s s u g g e s t t h a t p l a q u e d e v e l o p m e n t b e g i n s e a r l y i n l i f e , w i t h t h e p r o c e s s c o n t i n u i n g o v e r many y e a r s . I t h a s been s u g g e s t e d t h a t e x c e s s c h o l e s t e r o l i n t h e b l o o d , p r i m a r i l y c a u s e d by a d i e t h i g h i n a n i m a l f a t s a n d d a i r y p r o d u c t s may p r o m o t e a t h e r o s c l e r o s i s . 2 C h o l e s t e r o l i s i n s o l u b l e ; i t must be c a r r i e d t h r o u g h t h e b l o o d s t r e a m i n p a c k e t s o f f a t a n d p r o t e i n known a s lipoproteins. I n a p o p u l a r m o d el o f a t h e r o s c l e r o s i s , h i g h - d e n s i t y l i p o p r o t e i n c h o l e s t e r o l c a r r i e r s (HDL) may h e l p remove c h o l e s t e r o l f r o m b l o o d c i r c u l a t i o n ; l o w l e v e l s o f l o w - d e n s i t y l i p o p r o t e i n c a r r i e r s (LDL) have been l i n k e d t o a t h e r o s c l e r o s i s . 3 N o r m a l l y , t h e LDL b i n d t o a n d remove p a r t i c l e s c a r r y i n g c h o l e s t e r o l . The p r o d u c t i o n by t h e l i v e r o f b e n e f i c i a l LDL i s hampered by h i g h c h o l e s t e r o l d i e t s . " W h i l e t h e e x a c t p r o c e s s by w h i c h a t h e r o s c l e r o s i s o c c u r s i s n o t w e l l u n d e r s t o o d , t h e r e i s no 1 B r a u n w a l d 1980:1221 2 K a n n e l , C a s t e l l i , a n d G o r d o n 1979 3 I b i d "Huyghe 1985:34 d o u b t t h a t w i t h o u t c h o l e s t e r o l i t d o e s n o t o c c u r . 1 I b i d : 3 4 25 a. THE SPECIFIC ROLE OF CALCIUM IN HEART DISEASE Calcium, i n a d d i t i o n to i t s r o l e as an e s s e n t i a l element f o r s k e l e t a l i n t e g r i t y and r e g u l a t o r y f u n c t i o n of s k e l e t a l muscle c o n t r a c t i o n and r e l a x a t i o n , p l a y s a r o l e i n t i s s u e processes that r e g u l a t e c a r d i o v a s c u l a r p h y s i o l o g y and blood p r e s s u r e . 1 E p i d e m i o l o g i c evidence supports an hypothesized l i n k between l e v e l of c a l c i u m i n t a k e and blood pressure r e g u l a t i o n . 2 An animal study by McCarron supports the theory that d e f i c i e n t d i e t a r y c a l c i u m i s a c o n t r i b u t i n g f a c t o r i n the genesis of h y p e r t e n s i o n . 3 The most widely s t u d i e d g e n e t i c model of hy p e r t e n s i o n , the spontaneously h y p e r t e n s i v e r a t (SHR), manifests human-like a b n o r m a l i t i e s of c a l c i u m metabolism. In the SHR experiments i t was shown that r a t hyp e r t e n s i o n c o u l d be a m e l i o r a t e d by supplementing the d i e t of the SHR with c a l c i u m . Calcium supplementation i n the normotensive c o n t r o l f o r the SHR s t r a i n a l s o c o n t r o l l e d blood pressure l e v e l s . S t u d i e s which have assessed the e f f e c t s of c a l c i u m supplementation on blood pressure r e g u l a t i o n i n normotensive and h y p e r t e n s i v e humans i n d i c a t e t h at d i e t a r y c a l c i u m supplementation may be an e f f e c t i v e means of reducing blood pressure i n h y p e r t e n s i v e s , or p r e v e n t i n g blood pressure i n c r e a s e s i n those at r i s k f o r dev e l o p i n g h y p e r t e n s i o n . " 1 P a r r o t t - G a r c i a , McCarron 1984 2Schroeder l 9 6 0 a ; S t i t t et a l 1973; M a s i r o n i , Shaper 1981 3McCarron 1983 "Calabrese et a l 1980 26 Recent evidence has f u r t h e r proposed a connection between c a l c i u m and sodium metabolism in blood p r e s s u r e r e g u l a t i o n . 1 S e v e r a l s o c i e t i e s which have a low prevalence of h y p e r t e n s i o n a l s o consume d i e t s high i n sodium and c a l c i u m . 2 Animal evidence i n v o l v i n g the SHR supports the theory that sodium r e s t r i c t i o n may blunt the p o s i t i v e e f f e c t of high c a l c i u m i n t a k e or exacerbate blood p r e s s u r e i n both h y p e r t e n s i v e s and normotensives. 3 With respect to b i o l o g i c mechanisms, both animal and human s t u d i e s have supported the c l a i m that d e f i c i e n c i e s i n c a l c i u m can play a r o l e i n heart d i sease. 1Huyghe 1985 2 M a r i e r et a l 1979:57 3McCarron 1983 27 b. THE ROLE OF MAGNESIUM CONSIDERED E p i d e m i o l o g i c s t u d i e s s u g g e s t t h a t magnesium may be a f a c t o r w h i c h h e l p s p r e v e n t h e a r t a t t a c k . 1 M a g n e s i u m i o n s h e l p m a i n t a i n t h e f u n c t i o n a l a n d s t r u c t u r a l i n t e g r i t y o f t h e myocardium. M a g n e s i u m d e f i c i e n c y s e n s i t i z e s t h e m y o c a r d i u m t o t h e t o x i c e f f e c t s o f v a r i o u s d r u g s , w h i l e magnesium i s p r o t e c t i v e . 2 V a r i a t i o n s i n magnesium m i g h t be c r i t i c a l f o r h e a r t s t h a t a r e a l r e a d y damaged o r m a l f u n c t i o n i n g {arrythmia). H e g g t v e i t et al , i n 1969, r e p o r t e d t h a t i s c h e m i c , n o n - i n f a r c t e d h e a r t s t e n d t o be d e f i c i e n t i n magnesium, a f a c t o r t h a t c o u l d p r e d i s p o s e s u c h h e a r t s t o f a t a l arryt hmi as. 3 A n d e r s o n , i n 1973, s t a t e d t h a t magnesium d e f i c i e n c y c a n a l s o p r e d i s p o s e h e a r t s t o ventricular fibrillation. " The f i n d i n g s o f H e g g t v e i t a n d A n d e r s o n s u g g e s t t h a t magnesium's r o l e i n h e a r t d i s e a s e m o r t a l i t y i s i m p o r t a n t . 1 R e v i s et al 1980 2 S i n g h , S i n g h , Cameron 1981 3 M a r i e r e t a l 1979 " A n d e r s o n e t a l 1973 28 C. NUTRITIONAL CONSIDERATIONS The b e l i e f that water i s a s i g n i f i c a n t source of c a l c i u m and magnesium has been given s u p p o r t . 1 G e n e r a l l y , more than ten per cent of the human d a i l y need f o r waterborne elements ( p a r t i c u l a r l y c a l c i u m , magnesium, l i t h i u m , f l u o r i n e , copper, i r o n , and z i n c ) may be s u p p l i e d by tap water and may make the d i f f e r e n c e between poor and good h e a l t h . 2 Some r e s e a r c h e r s , however, have r a i s e d concerns about the p h y s i o l o g i c a l s i g n i f i c a n c e of water hardness, c a l c i u m , and magnesium. 3 These same r e s e a r c h e r s have c i t e d t h a t : (1) the amount of water people d r i n k d a i l y v a r i e s ; (2) the i n g e s t i o n of mi n e r a l s such as c a l c i u m and magnesium v a r i e s with one's s e l f - s e l e c t e d d i e t ; and (3) c a l c i u m and magnesium metabolism d i f f e r s among i n d i v i d u a l s . For e c o l o g i c a l a n a l yses of the type to be c a r r i e d out i n t h i s t h e s i s , i n d i v i d u a l d i f f e r e n c e s i n both water consumption and metabolism are not expected to be important. The s p e c i f i c amounts of c a l c i u m and magnesium which d r i n k i n g water can c o n t r i b u t e to one's d i e t w i l l now be examined. 1 M a r i e r et a l 1979 2 A l t u r a 1979 3Hammer, Heyden 1980:2400 29 a . GENERAL CONSIDERATIONS OF MINERAL INTAKE FROM WATER CALCIUM The d a i l y i n t a k e o f c a l c i u m f o r most w e s t e r n a d u l t p o p u l a t i o n s r a n g e s f r o m 360 t o 1,200 mg, d e p e n d i n g on age ( s e e t a b l e 2, w h i c h a p p e a r s i n D r i n k i n g W a t e r a nd  H e a l t h , 1 9 8 0 ) . D r i n k i n g w a t e r c o u l d c o n t r i b u t e an a v e r a g e o f 52 mg o f c a l c i u m p e r day a n d a maximum o f 290 mg o f c a l c i u m p e r day i f t h e a v e r a g e a d u l t d r i n k s two l i t e r s o f w a t e r w h i c h h a s a c a l c i u m c o n c e n t r a t i o n o f 26 mg/L o r a maximum o f 145 mg/L. 1 The Q u e s n e l s c h o o l d i s t r i c t h a s an a v e r a g e w a t e r b o r n e c a l c i u m v a l u e o f 51 mg p e r l i t e r ( s e e A p p e n d i x 3 ) ; i f t h e a v e r a g e p e r s o n i n Q u e s n e l d r i n k s two l i t e r s o f t h i s w a t e r p e r d a y , t h e n d r i n k i n g w a t e r i n t h i s d i s t r i c t c o u l d c o n t r i b u t e o v e r 100 mg o f c a l c i u m t o o n e ' s d a i l y i n t a k e . T h i s c o n t r i b u t i o n w o u l d r e p r e s e n t 8 t o 12 p e r c e n t o f t h e a d u l t recommended d a i l y a l l o w a n c e o f c a l c i u m . Where d i e t s a r e d e f i c i e n t i n c a l c i u m , t h e r e f o r e , w a t e r b o r n e c a l c i u m c o n t r i b u t i o n may be c r u c i a l . 1 W a l k e r 1972 30 b. MAGNESIUM The average d a i l y magnesium intake f o r most western a d u l t p o p u l a t i o n s ranges from 60 to 400 mg, depending on age (see t a b l e 2). D r i n k i n g water can provide n u t r i t i o n a l b e n e f i t f o r i n d i v i d u a l s consuming an otherwise magnesium-deficient d i e t . 1 In the d i e t of South A f r i c a n Bantu, the maize meal i s h i g h in magnesium, which has been c i t e d to e x p l a i n why c a r d i a c d i s e a s e i s seldom seen among the Bantu. 2 In Canada in 1975, N e r i and Johansen found that d r i n k i n g water with a high magnesium content may c o n t r i b u t e up to 20 per cent of the t o t a l d a i l y magnesium i n t a k e . Water data gathered for t h i s B r i t i s h Columbia study a l s o i n d i c a t e s that waterborne magnesium can, i n some d i s t r i c t s , c o n t r i b u t e almost 20 per cent of the t o t a l d a i l y magnesium i n t a k e . T h i s amount of magnesium may be important e s p e c i a l l y under circumstances where e l e v a t e d amounts might be needed by i n d i v i d u a l s undergoing s t r e s s f u l s i t u a t i o n s . 3 1 S a f e D r i n k i n g Water Committee 1980:275 2 M a s i r o n i , Shaper 1981 3 M a r i e r et a l 1979:94 3 1 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 5 H 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. I I . A. REVIEW OF THE LITERATURE Many s t u d i e s have r e v e a l e d an i n v e r s e r e l a t i o n s h i p between hard water and heart d i s e a s e m o r t a l i t y . The f i r s t evidence of a connection between human h e a l t h and water q u a l i t y was given i n Japan in 1957 by Kobayashi, who found a p a r a l l e l between the geographic d i s t r i b u t i o n of stroke and the a c i d i t y of r i v e r water. I t was not u n t i l 1960 i n the U n i t e d S t a t e s that Schroeder i d e n t i f i e d a s p e c i f i c c o nnection between water hardne'ss and heart d i s e a s e . 1 Schroeder reported a s t a t i s t i c a l l y - s i g n i f i c a n t i n v e r s e c o r r e l a t i o n (e.g. -0.29: p=<0.0l) between the t o t a l hardness of d r i n k i n g water and the death r a t e from heart d i s e a s e . Schroeder obtained no s i g n i f i c a n t c o r r e l a t i o n f o r n o n - c a r d i o v a s c u l a r causes of death. In t h i s same study, a h i g h l y s i g n i f i c a n t c o r r e l a t i o n c o e f f i c i e n t of -0.30 was obtained f o r waterborne magnesium, and -0.27 f o r c a l c i u m . I t i s i n t e r e s t i n g to note that i n another 1960 report by Schroeder, s e v e r a l m o r t a l i t y v a r i a b l e s other than water hardness were s t u d i e d i n r e l a t i o n to heart d i s e a s e m o r t a l i t y . 2 Schroeder r e p o r t e d s i g n i f i c a n t negative c o r r e l a t i o n s of water hardness with c a r d i o v a s c u l a r m o r t a l i t y , cancer m o r t a l i t y , c i r r h o s i s of the l i v e r , p o p u l a t i o n d e n s i t y , and per cent nonwhite p o p u l a t i o n . Conversely, Schroeder r e p o r t e d s i g n i f i c a n t p o s i t i v e 'Schroeder 1960b 2Schroeder 1960a 32 33 c o r r e l a t i o n s of water hardness with motor v e h i c l e a c c i d e n t s , other a c c i d e n t s , and c o n g e n i t a l malformations. I t was, however, Schroeder's i d e n t i f i c a t i o n of a negative c o r r e l a t i o n between water hardness and c a r d i o v a s c u l a r m o r t a l i t y which was to be f u r t h e r s t u d i e d by r e s e a r c h e r s i n other regions - many of whom subsequently r e p o r t e d a s i m i l a r c o r r e l a t i o n . In 1961, M o r r i s et al s t u d i e d 83 county boroughs i n England and Wales, and re p o r t e d i n v e r s e c o r r e l a t i o n s between v a r i o u s forms of c a r d i a c - r e l a t e d m o r t a l i t y and t o t a l hardness (-0.36 to -0.55), carbonate hardness (-0.40 to -0.54), and waterborne c a l c i u m (-0.45 to -0.65). 1 M o r r i s et al -- u n l i k e Schroeder -- d i d not o b t a i n a s t a t i s t i c a l l y - s i g n i f i c a n t c o r r e l a t i o n with waterborne magnesium. 2 In 1962 i n England and Wales again, Davies noted a f a c t t h a t was i n c o n t r a d i c t i o n to e a r l i e r B r i t i s h s t u d i e s which had found a r e l a t i o n s h i p between water hardness and heart d i s e a s e . 3 I t was found that Midland had hard water and low c a r d i o v a s c u l a r m o r t a l i t y (as B r i t i s h r e s e a r c h e r s such as M o r r i s might e x p e c t ) , but Birmingham had s o f t water and also low c a r d i o v a s c u l a r m o r t a l i t y . However, i t appears t h a t Davies d i d not c o n s i d e r the d i f f e r e n t socio-economic c o n d i t i o n s of Midland and Birmingham. 1 M o r r i s , Crawford, Heady, 1968 2 M a r i e r et a l 1979 3 D a v i e s 1962 34 I n 1962, S a u e r et al s t u d i e d 92 U n i t e d S t a t e s m e t r o p o l i t a n a r e a s . Among w h i t e s a g e s 45 t o 64 and 35 t o 74 y e a r s , t h e y f o u n d s i g n i f i c a n t l y n e g a t i v e a s s o c i a t i o n b e t w e e n h a r d n e s s and a l l c a r d i o v a s c u l a r - r e n a l c a u s e s c o m b i n e d a n d a l s o f o r c o r o n a r y h e a r t d i s e a s e . 1 I n a 1969 s t u d y o f 116 o f t h e 163 s t a n d a r d m e t r o p o l i t a n s t a t i s t i c a l a r e a s i n t h e U n i t e d S t a t e s , D u d l e y et al f o u n d a n e g a t i v e a s s o c i a t i o n b e t w e e n h a r d n e s s a n d c o r o n a r y h e a r t d i s e a s e i n w h i t e m a l e s a g e d 45 t o 65 y e a r s . 2 I n 1970, W i n t o n a n d McCabe, who s t u d i e d 135 c e n t r a l c o u n t i e s i n t h e U n i t e d S t a t e s , f o u n d a n e g a t i v e a s s o c i a t i o n b e t w e e n w a t e r h a r d n e s s and d i s e a s e s o f t h e h e a r t , b u t d i s a g r e e d w i t h S c h r o e d e r ( 1 9 6 0 b ) , who h a d r e p o r t e d a p o s i t i v e a s s o c i a t i o n betweem w a t e r h a r d n e s s a n d s t r o k e s . 3 A s t u d y by A n d e r s o n a n d L e R i c h e i n 1971 f o u n d a n e g a t i v e a s s o c i a t i o n b e t ween s u d d e n c a r d i a c d e a t h and w a t e r h a r d n e s s i n 34 m e d i u m - s i z e d c i t i e s a n d t o w n s i n O n t a r i o . " A n d e r s o n i n 1975 showed t h a t t h e h e a r t s o f c a r d i a c i s c h e m i a s u b j e c t s c o n t a i n e d 22 p e r c e n t l e s s magnesium t h a n was f o u n d i n h e a r t s o f n o n - c a r d i a c c a s e s , a n d t h a t t h e h e a r t s o f s o f t - w a t e r a r e a r e s i d e n t s c o n t a i n e d 6 t o 7 p e r c e n t l e s s magnesium t h a n f o u n d i n r e s i d e n t s o f h a r d - w a t e r l o c a l i t i e s . 5 'Sauer 1962 2 D u d l e y et al 1969 3 W i n t o n , McCabe 1970 " A n d e r s o n , L e R i c h e 1971 5 A n d e r s o n 1975 35 I n t h e N e t h e r l a n d s i n 1975, c e n t r a l w a t e r s o f t e n i n g was d i s c o u r a g e d by t h e p u b l i c h e a l t h c o u n c i l b e c a u s e o f t h e s t a t i s t i c a l l y - s i g n i f i c a n t n e g a t i v e a s s o c i a t i o n f o u n d by Z i e l h u i s a n d o t h e r s b e t w e e n t h e h a r d n e s s o f d r i n k i n g w a t e r and d e a t h r a t e f r o m h e a r t d i s e a s e o v e r t h e p e r i o d 1958 t o 1 9 7 0 . 1 I n a 1980 r e p o r t i n t h e U n i t e d S t a t e s , G r e a t h o u s e and O s b o r n e s t a t e d t h a t w a t e r h a r d n e s s a n d c a l c i u m a p p p e a r e d t o f o l l o w t h e t r e n d o f n e g a t i v e a s s o c i a t i o n s w i t h t h e m o r t a l i t y r a t e s f o r most g r o u p s o f c a r d i o v a s c u l a r d i s e a s e , w h i l e c o p p e r a n d l e a d i n w a t e r were p o s i t i v e l y a s s o c i a t e d . 2 I n 1980, H e w i t t and N e r i r e l a t e d w a t e r e x p o s u r e t o h e a r t d i s e a s e m o r t a l i t y o f i n d i v i d u a l s u b j e c t s ; m y o c a r d i a l t i s s u e o f r e s i d e n t s o f s o f t - w a t e r and h a r d - w a t e r a r e a s was c o m p a r e d , a n d t h i s c o m p a r i s o n c o n f i r m e d t h a t i n s u f f i c i e n t m agnesium i n t a k e i s a l i k e l y c a u s e o f h i g h e r h e a r t d i s e a s e m o r t a l i t y i n s o f t - w a t e r a r e a s . 3 M a s i r o n i , P i s a , and C l a y t o n i n 1980 s t u d i e d t h e r e l a t i o n b e t w e e n w a t e r h a r d n e s s a n d m y o c a r d i a l i n f a r c t i o n i n f i f t e e n E u r o p e a n c i t i e s . H i g h e r r a t e s o f m y o c a r d i a l i n f a r c t i o n were u s u a l l y f o u n d i n c i t i e s w i t h s o f t e r w a t e r . I n a 1981 s t u d y i n New G u i n e a , M a s i r o n i i n v e s t i g a t e d t h e r e l a t i o n s h i p b e t w e e n b l o o d p r e s s u r e i n v i l l a g e r s a l o n g t h e Wagupmeri R i v e r and t h e c a l c i u m c o n t e n t o f t h e d r i n k i n g w a t e r a t t h e s e v i l l a g e s . The c a l c i u m c o n t e n t o f t h e w a t e r 1 Z i e l h u i s , H a r i n g 1981 2 G r e a t h o u s e , O s b o r n e 1980 3 H e w i t t , N e r i 1980 36 d e c r e a s e d d o w n s t r e a m , y e t b l o o d p r e s s u r e o f t h e v i l l a g e r s was f o u n d t o i n c r e a s e . 1 I n 1981, M a s i r o n i f o u n d a n e g a t i v e r e l a t i o n s h i p b e t w e e n h a r d w a t e r and a r t e r i o s c l e r o t i c h e a r t d i s e a s e i n p o p u l a t i o n s l i v i n g a l o n g t h e C o l o r a d o , C o l u m b i a , and O h i o r i v e r s . 2 I n a s t u d y i n t h e U n i t e d K i n g d o m , P o c o c k et al had r e p o r t e d i n 1981 t h a t a s i g n i f i c a n t a s s o c i a t i o n e x i s t s b e t w e e n w a t e r h a r d n e s s and h e a r t d i s e a s e m o r t a l i t y ; towns w i t h s o f t w a t e r t e n d e d t o have h i g h e r d e a t h r a t e s t h a n towns w i t h h a r d w a t e r . 3 A l t h o u g h t h e r e l a t i o n s h i p was somewhat weakened a f t e r a l l o w i n g f o r c l i m a t i c and s o c i o - e c o n o m i c f a c t o r s , i t r e m a i n e d s t a t i s t i c a l l y - s i g n i f i c a n t f o r b o t h c o r o n a r y h e a r t d i s e a s e and s t r o k e . A f t e r a d j u s t m e n t o f o t h e r f a c t o r s , s o f t - w a t e r a r e a s h a d a 10 t o 15 p e r c e n t h i g h e r c a r d i o v a s c u l a r m o r t a l i t y t h a n a r e a s o f medium h a r d n e s s . " A s t u d y i n F i n l a n d by Luoma et al, p u b l i s h e d i n 1983, a s s e s s e d t h e r i s k o f m y o c a r d i a l i n f a r c t i o n i n two p o p u l a t i o n s d i s t i n g u i s h e d by d i f f e r e n t l e v e l s o f f l u o r i d e , m agnesium and c a l c i u m c o n c e n t r a t i o n i n d r i n k i n g w a t e r . The r e s u l t s o f t h i s c a s e - c o n t r o l s t u d y were c o n s i s t e n t w i t h t h e h y p o t h e s i s t h a t b o t h a low f l u o r i d e a nd a l o w magnesium i n t a k e a r e c o n d u c i v e t o a t h e r o s c l e r o s i s and a c u t e m y o c a r d i a l i n f a r c t i o n . W i t h t h e e x c e p t i o n o f t h e s t u d y o f D a v i e s , t h e p r e c e d i n g l i t e r a t u r e s u p p o r t s t h e h y p o t h e s i s t h a t s o f t 1 M a s i r o n i , S h a p e r 1981 2 M a s i r o n i , S h a p e r 1981 3 P o c o c k , S h a p e r , Packham 1981 " I b i d 1981:1 37 d r i n k i n g w a t e r c o n t r i b u t e s t o h e a r t d i s e a s e . Not a l l r e s e a r c h e r s , h o w e v e r , have had s i m i l a r s t a t i s t i c a l l y - s i g n i f i c a n t s t u d y r e s u l t s i n s u p p o r t of t h e h y p o t h e s i s . F o r e x a m p l e , M u l c a h y i n I r e l a n d c o u l d n o t f i n d a ny s i g n i f i c a n t c o r r e l a t i o n s between w a t e r h a r d n e s s a n d h e a r t d i s e a s e . 1 H o w e v e r , r e p o r t s p u b l i s h e d a f t e r M u l c a h y ' s s t u d y may be more r e l i a b l e b e c a u s e newer a n d more a c c u r a t e m e t h o d s o f m e a s u r i n g w a t e r c o n s t i t u e n t s h a v e been u s e d . The h y p o t h e s i s t h a t s o f t w a t e r may c o n t r i b u t e t o h e a r t d i s e a s e r e c e i v e d l e a s t s u p p o r t f r o m s t u d i e s done w i t h i n c i t i e s o r c o u n t i e s . F o r e x a m p l e , t h r e e c o m m u n i t i e s i n t h e L o s A n g e l e s a r e a were m a t c h e d f o r a g e , s e x , r a c e , i n c o m e , s o c i o e c o n o m i c s t a t u s a n d s t a b i l i t y by A l l w r i g h t et al . 2 No a s s o c i a t i o n c o u l d be f o u n d b e t w e e n w a t e r h a r d n e s s a n d h e a r t d i s e a s e . The a u t h o r s d i d p o i n t o u t t h a t t h e i r " s o f t " w a t e r c o m m u n i t i e s h a d w a t e r w h i c h w o u l d have b e e n c a l l e d " h a r d " by most B r i t i s h r e s e a r c h e r s . K l u s m a n a n d S a u e r f o u n d no s i g n i f i c a n t a s s o c i a t i o n b e t w e e n w a t e r h a r d n e s s i n a l l c o u n t i e s i n I n d i a n a , b u t t h e r a n g e o f h a r d n e s s i n t h e s e c o u n t i e s was s m a l l . 3 C o n n o r n o t e d i n 1970 t h a t t h e a r t e r i o s c l e r o t i c h e a r t d i s e a s e d e a t h r a t e among m a l e s was h i g h e r i n E d i n b u r g h w i t h i t s h a r d w a t e r , t h a n i n G l a s g o w , w h i c h h a s s o f t w a t e r . " T h i s d i s c r e p a n c y may be e x p l a i n e d by t h e f a c t t h a t b o t h t o w n s a c t u a l l y h a v e s o f t w a t e r a c c o r d i n g t o t h e c l a s s i f i c a t i o n s o f 1 M u l c a h y 1973 2 A l l w r i g h t et al. 1974 3 K l u s m a n , S a u e r 1975 "Conner 1970 38 w a t e r h a r d n e s s u s e d i n most r e p o r t s . F u r t h e r m o r e , t h e d i f f e r e n c e s i n d e a t h r a t e s i n E d i n b u r g h a n d G l a s g o w were s l i g h t . I n a c a s e - c o n t r o l s t u d y by C o m s t o c k i n 1971, p e r s o n s i n W a s h i n g t o n C o u n t y , M a r y l a n d , who had d i e d f r o m a r t e r i o s c l e r o t i c h e a r t d i s e a s e w e re c o m p a r e d w i t h c o n t r o l s d r a w n f r o m t h e same g e n e r a l p o p u l a t i o n . W a t e r h a r d n e s s v a l u e s were d e t e r m i n e d f r o m w a t e r s a m p l e s o b t a i n e d f r o m t h e home w a t e r t a p s o f c a s e s a n d c o n t r o l s . No s i g n i f i c a n t a s s o c i a t i o n o f a r t e r i o s c l e r o t i c a n d d e g e n e r a t i v e h e a r t d i s e a s e d e a t h s c o u l d be f o u n d w i t h w a t e r h a r d n e s s . The w a t e r s a m p l e s o b t a i n e d f r o m t h e home w a t e r t a p s o f s u b j e c t s were t a k e n a t t i m e o f d e a t h , a n d t h e w a t e r s u p p l i e s may have d i f f e r e d i n e a r l i e r l i f e . T h i s s t u d y was a b l e t o t a k e i n t o a c c o u n t t h e e f f e c t s o f i m p o r t a n t d e m o g r a p h i c , s o c i o - e c o n o m i c , a n d p e r s o n a l c h a r a c t e r i s t i c s w h i c h e c o l o g i c a l s t u d i e s a r e n o t o f t e n a b l e t o d o , b u t t h e f i n d i n g s o f t h i s s t u d y must be r e g a r d e d w i t h c a u t i o n b e c a u s e o n l y 412 c a s e s a n d c o n t r o l s were i n c l u d e d i n t h i s s t u d y . A c c o r d i n g t o M a r i e r et al . , much of t h e c o n f u s i o n w i t h r e g a r d t o w a t e r h a r d n e s s h a s r e s u l t e d f r o m i n a d e q u a t e e x p e r i m e n t a l d e s i g n s ; e . g . , s m a l l numbers o f s u b j e c t s were c o m p a r e d , t h e r a n g e o f w a t e r h a r d n e s s was t o o n a r r o w ( i . e . t o o n a r r o w a r a n g e w o u l d be one w h i c h e x t e n d s f r o m , s a y , 70 mg CaC03 p e r l i t r e t o 130 mg CaC03 p e r l i t r e ; t h i s r a n g e 39 w o u l d n o t p r o v i d e v a l u e s o f v e r y s o f t w a t e r o f v e r y h a r d w a t e r ) , a d e q u a t e c o n t r o l p o p u l a t i o n s were l a c k i n g , a n d m o r t a l i t y r a t e s were n o t s t a n d a r d i z e d . 1 Hammer a n d Heyden c i t e d " s p a t i a l a u t o c o r r e l a t i o n " t o e x p l a i n i n c o n s i s t e n c i e s i n s t u d y f i n d i n g s . S p a t i a l a u t o c o r r e l a t i o n i s t h e t e n d e n c y f o r n e i g h b o u r i n g g e o g r a p h i c a l u n i t s t o r e s e m b l e one a n o t h e r i n a l m o s t a n y a t t r i b u t e . O t h e r h e a r t d i s e a s e r i s k f a c t o r s w i l l now be c o n s i d e r e d . 1 M a r i e r e t a l 1979 I l l . A. OTHER HEART DISEASE RISK FACTORS Magnesium and c a l c i u m d e f i c i e n c i e s i n people's d i e t are the heart d i s e a s e r i s k f a c t o r s under i n v e s t i g a t i o n w i t h i n t h i s r e p o r t , but there are other heart d i s e a s e r i s k f a c t o r s which c o u l d be c o n s i d e r e d . The i n c i d e n c e of heart d i s e a s e v a r i e s g r e a t l y a c c o r d i n g to age, sex, and race. High serum c h o l e s t e r o l , high blood p r e s s u r e , gout, hyperglycemia, and smoking appear to i n c r e a s e the frequency of the d i s e a s e . These r e l a t i o n s h i p s are i l l u s t r a t e d in f i g u r e 4. Other r e s e a r c h e r s have i d e n t i f i e d 'Type A' p e r s o n a l i t y as a heart d i s e a s e r i s k f a c t o r . Lack of e x e r c i s e , poor n u t r i t i o n , s t r e s s f u l l i f e s t y l e s , extreme c l i m a t i c c o n d i t i o n s , a l c o h o l consumption, and hormonal and g e n e t i c d i f f e r e n c e s are a l s o suspected r i s k f a c t o r s of heart d i s e a s e . These f a c t o r s w i l l now be d i s c u s s e d . a. AGE Heart d i s e a s e m o r t a l i t y shows a r e l a t i o n s h i p to age. T h i s r e l a t i o n s h i p can be seen in f i g u r e 5. F i g u r e 5 i s an i l l u s t r a t i o n by Braunwald which shows the p r o b a b i l i t y of d e v e l o p i n g heart d i s e a s e i n 8 years a c c o r d i n g to age, sex, and r i s k category. We see that heart d i s e a s e i s r a r e among the young, e s p e c i a l l y women, but i n c r e a s e s with o l d e r age. Heart d i s e a s e becomes a major cause of death fo r men between the ages of 35 to 40 HI F l f r U K F H' P R O B A 8 I I _ \ T Y O F r j t rVFL-OPlMG- K E A R . T S X S i T A S C . w S ) / i£ARS A C C O R D I N G - T O A & E : S c X , M o M S K . cAT£-&-6 f=Ly . hooo FIG u Re 5 •• DEATHS t>oe TO DISeASeS OF THf He#KT IN eftCH SPf£.iri£t> A$E - GROUP, BRITISH COLUMBIA if BO. • 5ooo T O T A L D E A T H S DEATHS TJUC To D I S E A S E S or T H E H E A R T 3000 306O /oao: ! 231 1 rsmt ecmtis • If/9 4777 T»7AL U/TAT'frJi Term. Dk'AWi in o-xf 3o-39 /f?S\ 5t> S9 60-69 ItJliJiL D A T A FR.OK p B - Q V l ^ C e Off" fJl^C, MINISTRY O p HCALTH VlTP>L5TA"nSTlC_S. R.EPbftT'io<^ , H S Q 43 44 y e a r s . 1 By ages 55 to 64, approximately 40 per cent of a l l deaths among men are due to heart d i s e a s e . 2 b. SEX In Canada, the heart d i s e a s e r a t e f o r males i s two to three times higher than the heart d i s e a s e r a t e f o r females. 3 T h i s sex r a t i o e x i s t s i n a l l age c a t e g o r i e s (see t a b l e 3 and f i g u r e 6). In the United S t a t e s i n 1976, the white male m o r t a l i t y r a t e from heart d i s e a s e was 5.2 times g r e a t e r than the r a t e i n white females fo r the age group 35 to 44. T h i s sex d i f f e r e n c e i n m o r t a l i t y d e c l i n e d i n the age group 65 to 74. " In the United States in 1974, the male heart d i s e a s e m o r t a l i t y r a t e was 2.5 times g r e a t e r than the r a t e f o r females f o r the 34 to 44 age group and 1.5 times g r e a t e r f o r the 65 to 74 age group. The observed d i f f e r e n c e s between males and females become l e s s apparent with i n c r e a s i n g age. c. RACE White males and non-white females have the highest heart d i s e a s e m o r t a l i t y . 5 Since 1968, non-white males have shown an i n c r e a s i n g s u s c e p t i b i l i t y to heart d i sease. 6 'Province of B.C. 1983:36 2 P r o v i n c e of B.C. 1983:37 3 I b i d : 3 6 " H a v l i k , F e i n l e i b 1979 5 N a t i o n a l c e n t e r f o r h e a l t h s t a t i s t i c s of the United S t a t e s 6 H a v l i k , F e i n l e i b 1979 ( lu 5 £ <js r-v <s-s v>- sV- — r—ro. < o s I ~> •* s CO* 3 u. 0>: — f-O. Ml hi. > V -I v) o r 0° ro u; cs. 1-4 -6 : r. >- C-l oJ <vV sa 'S - sa 1— 3 - N \N o » > - s o ^1 m vo v& ; <i ro, tsV Vr>' Is- (i ^ — "v. i sjs -~ ro,' V , V 1 IT. ^ W A vo ro, 3-; s* r<~> ro, <S\ s^. vvl ^ ^ -3" cs ~~ -' vT> tvl • ^ ^ 5 " <sk a - ^ ^ - ^ i N r v . ^ ^ - t v i — - - j rv fv. r v f . ^ f i n v <s rv( r-O, >-I A s t ^ Qv. vt- — — t>. - O c v l ^ W go «N i ^ r s i a -3 -rA \v ^ | r - ~ » o , r - ~ C s l "3- 3- vO ml —• (-— Vr> rv *o —. m *vi I 00 tv o <vj ro. ro, ;r t j - V s cv\ c j ^ v v ^ o ^ ^ -3- or\ Cj r v sV ijs. ro. sj~ rs-, sj) <H fc> r s ( t v l s O ^ o ^ e s i - - . ^ v*— ! 0oo-~--^c>o >~ 2>- f-- ^ ° t< *0 iv • s t-so >0<i~ r s ; ( isj 3- st- v& r<^  s ^ ^ ^ 5 - W s ^  ^ ^ P I -S S u C C D Is. I Oo "5- oc I— rs\ r-~ !-— ro. rs( — r~~ *^*» sS — ^ rr» s^ — . e s t W rs Q rv| >o r - i - s i i v ^ , ^  w s r i - ^ V r , «v."^-rr \sS&s V) M > « v S O - 0 3 - Q ^v O ^ ~V- vO v . Ci rH SQ 3-sa ]j> 00 > sj iv d co s» ! r* ^ « J» 0^ 3- s -^rtv \a si si 1 uj ,s> =4 >-sS v, 5 5 "V 3 55 fcf. \ Vs >s 00 <» Vs 3: <vr <: " sv ^ > o <3 s . Q. 11 S ! ^ vl 3 v i N «\ T lO ^6 I s h V-> vtj r4 Ovi Ovi rs M5 F i GURE: IV< M A P S H O W I N G R E G I O N A L D I S T R I C T S . B R I T I S H C O L U M B I A R E G I O N A L D I S T R I C T S N o . N a m e N o . N a m e 1. A l b e r n i - C l a y o q u o t . l b . Greater Vancouver . 2. B u l k l e y - N e c h a k o . 17. K i t i m a t - S t i k i n e 3. C a p i t a l ( V i c t o r i a urea). 18. Koo tenay Boiin d a r y . 4. C a r i b o o . 19. M o u n t W a i l i l i n g t o n . 5. Cen t ra ! C o a s t . 20. Nana i rno . 6. C e n t r a l Fraser Va l l ey . 21 . N o r t h O k a n a g a n . 7. Cen t ra l Kootenay . 22 O k a n a g a n - S i m i l k a m e e n . 8. Cen t r a l O k a n a g a n . 23. Peace R i v e r - L i a r d . 9. C o l u m b i a - Shuswap . 24. P o w e l l River . 10. C o m o x - S t r a t h c o n a . 25. Skeena -Queen Char lo t t e 11. C o w i c h a n Va l l ey . 26 . S q t i a i n i s h - L i l l o o c t . 12. D e w d n e y - A l o u e t t e . 27. S! i k inc . 13. East Koo tenay . 28. Sunshine Coas t . 14. F r a s e r - C h e a m . 29 . T h o m p s o n - N i c o l a . 15. Fraser-Fl ir t G e o r g e . •SouR.ee; P R O V I N C E OF- fl.c_, M W I S T R . Y of H E A L T H ^ yiTftL S T A T I S T I C S (t£Pan.-r itrt | ^  So ^7 SU ?o SO IL> £j %> SD aj Qj 9_> --- — — 48 d. STRESS I n g e n e r a l , t h e c o u n t r i e s t h a t l e a d t h e w o r l d i n h e a r t d i s e a s e m o r t a l i t y a r e : 1. E n g l i s h - s p e a k i n g 2. I n d u s t r i a l i z e d , a n d 3. E u r o p e a n a n d N o r t h A m e r i c a n T h i s i s a p p a r e n t f r o m t h e r a n k i n g i n T a b l e 4. I t i s uncommon t o f i n d a h i g h r a t e o f h e a r t d i s e a s e m o r t a l i t y i n A s i a , t h e N e a r E a s t , A f r i c a , o r S o u t h a nd C e n t r a l A m e r i c a . Low h e a r t d i s e a s e r a t e s i n J a p a n , h o w e v e r , i n d i c a t e t h a t i n d u s t r i a l i z a t i o n n eed n o t a l w a y s be a s s o c i a t e d w i t h h i g h r a t e s o f h e a r t d i s e a s e . On t h e o t h e r h a n d , I s r a e l a n d U r u g u a y a r e two c o u n t r i e s o u t s i d e o f E u r o p e w i t h r a t h e r h i g h h e a r t d i s e a s e m o r t a l i t y r a t e s . M o r t a l i t y r a t e s f r o m h e a r t d i s e a s e c a n v a r y w i t h i n c o u n t r i e s a s w e l l a s b e t w e e n c o u n t r i e s . F o r e x a m p l e , i n t h e U n i t e d S t a t e s , h i g h m o r t a l i t y r a t e s o c c u r ( 1 ) i n c o u n t i e s a l o n g t h e s o u t h e a s t e r n A t l a n t i c C o a s t , (2) a c r o s s a s o u t h e r n b e l t t h r o u g h G e o r g i a a n d A l a b a m a , and (3) i n t h e i n d u s t r i a l i z e d s t a t e s o f t h e m i d w e s t and n o r t h e a s t . 1 Lower h e a r t d i s e a s e m o r t a l i t y r a t e s a r e f o u n d i n t h e G r e a t P l a i n s a n d m o u n t a i n s t a t e s . I t i s d i f f i c u l t t o e x p l a i n t h e s e r e g i o n a l d i f f e r e n c e s i n h e a r t d i s e a s e m o r t a l i t y r a t e s . 1Meade 1979 HI c TABLE: 4-AGE -STANDARDI ZED DEATH RATES FOR I SCHEMIC HEART D I S E A S E FOR SELECTED COUNTRIES COUNTRY RATE LATEST A V A I L A B L E 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 . New Zealand 160 .5 1983 8. Sweden 158 . 4 1984 9 . Maur111 us 158 . 2 1982 10. .Maita 157 .0 1982 1 1 . .U K.:Engl and and Wales 154 . 7 1982 12 . Denmark 153 .4 1982 13 .Hungary 151 .0 1984 14 .Iceland 148 .5 1983 15. .Austral 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 R E R L . T H S T A T I S T I C S ftWMOAL, 1185 50 e. CHOLESTEROL C h o l e s t e r o l may be the l e a d i n g r i s k f a c t o r i n heart d i s e a s e . 1 The d e t e r m i n a t i o n by p a t h o l o g i s t s that the main c o n s t i t u e n t of the a t h e r o s c l e r o t i c l e s i o n i n heart d i s e a s e i s c h o l e s t e r o l strengthened the concept that c h o l e s t e r o l i n the c i r c u l a t o r y blood i s d e p o s i t e d on the a r t e r i a l w a l l . The hypothesis has been s t r o n g l y supported by many s t u d i e s . 2 One study, f o r example, of Japanese men i n Hawaii and C a l i f o r n i a r e v e a l e d that men with lower c h o l e s t e r o l l e v e l s have lower heart a t t a c k r a t e s . 3 In i n d u s t r i a l i z e d c o u n t r i e s such as Japan, the i n c i d e n c e of c i g a r e t t e smoking and high blood pressure i s as high as the i n c i d e n c e i n the U n i t e d S t a t e s , but one sees an e i g h t h to a t e n t h as many heart a t t a c k s ; t h i s may be e x p l a i n e d by the f a c t that c h o l e s t e r o l l e v e l s of Japanese and Americans d i f f e r g r e a t l y . " f. SMOKING HABITS Most people are not aware that c i g a r e t t e smoking g r e a t l y a f f e c t s one's c a r d i o v a s c u l a r system as w e l l as one's l u n g s . 5 About h a l f of the 350,000 deaths a t t r i b u t a b l e to c i g a r e t t e smoking each year i n the U n i t e d S t a t e s r e s u l t from a heart a t t a c k . 6 Those who argue that smoking i s the most important r i s k f a c t o r i n \ 1Braunwald 1980 2Dawber 1980:121 3Marmot et al 1975 " I b i d 5Rogot 1974 6Huyghe 1985:84 51 heart d i s e a s e m o r t a l i t y p o i n t out that the 170,000 heart a t t a c k deaths in the United S t a t e s each year due to smoking account fo r 39 per cent of a l l deaths that are caused by coronary heart d i s e a s e . 1 S t u d i e s have shown that smokers have a 70 per cent g r e a t e r r i s k of dying from a heart a t t a c k than non-smokers, and the r i s k of dying doubles i n the heavy, or two-pack-a-day smokers. 2 C i g a r e t t e smoking i s known to i n c r e a s e the prevalence and extent of a t h e r o s c l e r o s i s i n coronary a r t e r i e s and a o r t a . 3 Carbon monoxide, n i c o t i n e , and other substances may i n j u r e the c e l l s of the blood v e s s e l s and cause an i n c r e a s e i n l i p i d d e p o s i t s which g r a d u a l l y narrow the a r t e r i e s over the y e a r s . Smoking a l s o i n c r e a s e s blood p l a t e l e t a ggregation which serves to t h i c k e n blood and f a c i l i t a t e c l o t t i n g . " Animal s t u d i e s have shown that c i g a r e t t e smoke can lower the t h r e s h o l d f o r v e n t r i c u l a r f i b r i l l a t i o n , an e l e c t r i c a l i n s t a b i l i t y of the heart muscle that may l e a d to sudden d e a t h . 5 1 I b i d 2 I b i d 3Rogot 1974 " I b i d 5Hugyhe 1985 52 The t r e n d f o r h e a r t d i s e a s e m o r t a l i t y i n Ca n a d a h a s been one o f i n c r e a s e b e t w e e n 1950 a n d 19 6 3 . 1 H o w e v e r , b e t w e e n 1963 a n d 1975, h e a r t d i s e a s e m o r t a l i t y h a s shown a s i g n i f i c a n t d e c l i n e ( s e e T a b l e 5 b e l o w ) . T A B L E 5 ; D^CLI^B ; N A G E - S P C C I F I C C.OR.OIS/A.R.Y' M c « . T A , L [ T V t IW1-T?7 5 A 6 E % 35-HM a 7 2. M'5 -5H 21M 55-feH 23-5 65-71 2 5 3 75-gM W l ^ i i r n y ol-- M t A L T K AND W i L F A R E C / V w ' A D ^ '*?7 C i g a r e t t e s m o k i n g h a s d e c l i n e d o v e r t h e l a s t 15 y e a r s , w h i c h may p a r t i a l l y e x p l a i n t h e d e c r e a s e i n h e a r t d i s e a s e m o r t a l i t y . Changes h a v e a l s o t a k e n p l a c e i n e a t i n g h a b i t s ; t h e r e has been a g e n e r a l d e c r e a s e i n t h e i n t a k e 1 M i n i s t e r o f H e a l t h a n d W e l f a r e C a n a d a 1978 53 o f s a t u r a t e d f a t a n d c h o l e s t e r o l i n t h e C a n a d i a n d i e t . 1 T h i s f a c t c o u l d a l s o e x p l a i n t h e d e c r e a s e i n h e a r t d i s e a s e m o r t a l i t y w h i c h was i n d i c a t e d i n t h e p r e v i o u s t a b l e . I n c r e a s e d p h y s i c a l a c t i v i t y among C a n a d i a n s may a l s o h e l p e x p l a i n t h i s d e c r e a s e . g. HYPERTENSION H y p e r t e n s i o n r e f e r s t o a b n o r m a l l y h i g h a r t e r i a l b l o o d p r e s s u r e a n d i s o f t e n c h a r a c t e r i z e d by a s t a t e o f h i g h e m o t i o n a l t e n s i o n . H y p e r t e n s i o n c o n t r i b u t e s t o many h e a r t a t t a c k s e a c h y e a r , a n d i s t h e p r i m a r y c a u s e o f stroke. S t r o k e , t h e c l i m a x o f cerebrovascular disease, i n v o l v e s b l o c k a g e o r r u p t u r e o f b l o o d v e s s e l s t h a t s u p p l y o x y g e n and n u t r i e n t s t o t h e b r a i n . 2 D i e t may be i m p o r t a n t i n t h e r o l e o f h y p e r t e n s i o n . 3 h. GOUT, HYPERGLYCEMIA, AND DIABETES G o u t , a d i s e a s e w h i c h o c c u r s p r e d o m i n a n t l y i n m a l e s , r e f e r s t o a m e t a b o l i c d i s t u r b a n c e a s s o c i a t e d w i t h an i n c r e a s e o f u r i c a c i d s i n b l o o d a n d body f l u i d s . I n t h e F r a m i n g h a m s t u d y , u r i c a c i d l e v e l s were p o s i t i v e l y a s s o c i a t e d w i t h s e r u m c h o l e s t e r o l . H i g h l e v e l s o f serum c h o l e s t e r o l , i n t u r n , h a v e shown a s t r o n g a s s o c i a t i o n w i t h h e a r t d i s e a s e . H y p e r g l y c e m i a , a c o n d i t i o n o f a b n o r m a l l y h i g h g l u c o s e c o n c e n t r a t i o n i n t h e b l o o d , h a s a l s o b een a s s o c i a t e d w i t h an i n c r e a s e d r i s k o f h e a r t 1 W a l k e r 1977 2 P r o v i n c e o f B r i t i s h C o l u m b i a 1983 3 K a n n e l e t a l 1979 54 d i s e a s e 1 Diabetes appears to be s t r o n g l y a s s o c i a t e d with heart d i s e a s e . A c c o r d i n g to Dawber, the average annual i n c i d e n c e r a t e of myocardial i n f a r c t i o n was approximately twice the ra t e i n d i a b e t i c men compared to those without t h i s d i s o r d e r . In d i a b e t i c women the rate was almost s i x times that i n the n o n - d i a b e t i c women.2 i . PHYSICAL ACTIVITY P h y s i c a l i n a c t i v i t y i s a l s o known to i n c r e a s e the in c i d e n c e of heart d i s e a s e , e s p e c i a l l y i n those who smoke and have a d i e t high i n c h o l e s t e r o l . 3 j . TYPE A PERSONALITY People with a Type A behaviour p a t t e r n have been thought to have a g r e a t e r r i s k of heart a t t a c k . " A person with a Type A behaviour p a t t e r n i s unusually impatient and e a s i l y roused to h o s t i l i t y . Friedman b e l i e v e s that a l l three major r i s k f a c t o r s - smoking, high blood p r e s s u r e , and high serum c h o l e s t e r o l l e v e l -are a consequence of Type A behaviour. 5 I t i s not known e x a c t l y how Type A behaviour might predispose one to a heart a t t a c k , though there are mechanisms to e x p l a i n why i t might happen. Type A's react to c h a l l e n g e s as i f they were f u l l - s c a l e emergencies. T h i s response leads to an excess s e c r e t i o n 1Braunwald 1980 2Dawber 1980:194 3Fox, Naughton 1972 "Friedman, Rosenman 1974 5 I b i d 55 of three hormones - n o r e p i n e p h r i n e , ACTH and t e s t o s t e r o n e . When s e c r e t e d to excess, at l e a s t two of these hormones are known to cause damage to a r t e r i e s . 1 The b e l i e f that Type A p e r s o n a l i t y i s a r i s k f a c t o r was r e j e c t e d u n t i l i t was r e p o r t e d by H a v l i k that men who m o d i f i e d t h e i r Type A behaviour a f t e r e x p e r i e n c i n g a heart a t t a c k s u f f e r e d o n e - t h i r d as many second heart a t t a c k s as men who had only c a r d i o l o g i c a l c o u n s e l l i n g . 2 k. EXTREME CLIMATIC CONDITIONS Seasonal v a r i a t i o n s i n heart d i s e a s e m o r t a l i t y are s a i d to demonstrate that c l i m a t e a f f e c t s d i s e a s e f r e q u e n c y . 3 Some s t u d i e s have f a i l e d to show that temperature and weather are c l e a r l y connected with the occurrence of myocardial i n f a r c t i o n . 4 Elwood et al found almost no a s s o c i a t i o n between ischemic h e a r t d i s e a s e and temperature. And i t has been noted by Crawford et al i n the U n i t e d Kingdom that there are l a r g e d i f f e r e n c e s in m o r t a l i t y from ischemic heart d i s e a s e , yet v a r i a t i o n i n c l i m a t e a c r o s s the Un i t e d Kingdom i s modest. M a s i r o n i found a r e l a t i o n s h i p between water hardness and l a t i t u d e . T h i s r e l a t i o n s h i p may have a r i s e n from temperature changes with l a t i t u d e , but M a s i r o n i claimed that t h i s r e l a t i o n s h i p has a r i s e n from " g e o l o g i c trends 1Huyghe 1985 2 H a v l i k 1979 3 M a s i r o n i et al 1980 "Elwood et al 1971; Crawford et al 1968 56 ( s i c ) across the c o n t i n e n t . " 1 World He a l t h O r g a n i z a t i o n data shows c l e a r l y that c o u n t r i e s with extreme c l i m a t e s do not n e c e s s a r i l y have higher m o r t a l i t y r a t e s from heart d i s e a s e . 1. ALCOHOL CONSUMPTION Ex c e s s i v e a l c o h o l consumption has a l s o been a s s o c i a t e d with an i n c r e a s e d r i s k of heart d i s e a s e . 2 T h i s a s s o c i a t i o n may be a t t r i b u t a b l e to the f a c t that a l c o h o l can d e p l e t e magnesium l e v e l s i n heavy d r i n k e r s by i n c r e a s i n g t h e i r r e n a l l o s s of magnesium. 3 E x c e s s i v e d r i n k i n g not only causes h e a r t s to beat f a s t e r , but i t a l s o causes a gen e r a l d e t e r i o r a t i o n of h e a l t h . m. HORMONAL AND GENETIC DIFFERENCES Some r e s e a r c h e r s b e l i e v e that hormones may help p r o t e c t females from heart d i s e a s e u n t i l menopause." Females tend to excrete l e s s magnesium, perhaps in response to hormonal f u n c t i o n s . I f females r e t a i n more magnesium, t h i s may he l p t o e x p l a i n the lower heart d i s e a s e m o r t a l i t y r a t e s among females. With res p e c t to ge n e t i c d i f f e r e n c e s , M i t c h e l l found an a s s o c i a t i o n between higher ischemic heart d i s e a s e m o r t a l i t y and the frequency of occurrence of blood group 0 i n the Un i t e d Kingdom. 5 Higher r a t e s of heart d i s e a s e M a s i r o n i et al 1980 2Yano et a l 1977 3 S a f e D r i n k i n g Water Committee 1980:272 "Dr. E l a i n e Eaker, U.S.National Heart, Lung and Blood I n s t i t u t e , Framingham Heart Study, Framingham, Massachusetts 5 M i t c h e l l 1977 57 m o r t a l i t y i n m a l e s a s c o m p a r e d t o f e m a l e s s u g g e s t t h a t p e r h a p s male body c h e m i s t r y i s i n f l u e n t i a l i n h e a r t d i s e a s e . 58 B. SUMMARY OF RISK FACTORS T h e r e a p p e a r t o be many r i s k f a c t o r s f o r h e a r t d i s e a s e . S o f t w a t e r may be among t h e s e r i s k f a c t o r s . I t i s d i f f i c u l t t o c o n t r o l f o r many o f t h e s u s p e c t e d r i s k f a c t o r s , b e c a u s e p e r s o n a l i n f o r m a t i o n on v a r i a b l e s s u c h a s s m o k i n g h a b i t s i s n o t e a s i l y o b t a i n a b l e . The c o m b i n e d e f f e c t o f s e v e r a l o f t h e s u s p e c t e d r i s k f a c t o r s may o u t w e i g h t h e s i n g l e f a c t o r o f s o f t w a t e r . F o r e x a m p l e , t h e r e s u l t o f i n s u f f i c i e n t p h y s i c a l a c t i v i t y c o m b i n e d w i t h o b e s i t y , s m o k i n g , e t c . , may l e a d t o h e a r t d i s e a s e m o r t a l i t y more q u i c k l y t h a n w o u l d d e f i c i e n t q u a n t i t i e s o f magnesium and c a l c i u m i n o n e ' s d i e t . ' O n t h e o t h e r h a n d , magnesium and c a l c i u m d e f i c i e n c y may be a s i m p o r t a n t i n c o n t r i b u t i n g t o h e a r t d i s e a s e m o r t a l i t y a s any o t h e r s i n g l e r i s k f a c t o r . IV. A. ASSUMPTIONS AND LIMITATIONS OF THE STUDY Some assumptions or l i m i t a t i o n s of t h i s study may have rendered d i f f i c u l t the d e t e c t i o n of an i n v e r s e r e l a t i o n s h i p between hard water and age-standardized heart d i s e a s e m o r t a l i t y r a t e s . The assumptions of t h i s study a r e : 1. There has been l i t t l e or no m i g r a t i o n of the study p o p u l a t i o n s . Larger communities have p o p u l a t i o n s which are more s t a b l e , 1 and although the r e s i d e n c y or l o c a t i o n of heart d i s e a s e cases may vary, by l o o k i n g at the l a r g e r communities with s t a b l e p o p u l a t i o n , d i f f e r e n c e s in r e s i d e n c y lengths should be reduced as a p o t e n t i a l confounder. 2. Per c a p i t a consumption of water does not vary i n B r i t i s h Columbia by school d i s t r i c t . 3. Heart d i s e a s e cases drank from the l o c a l water supply; they d i d not consume b o t t l e d water from another p l a c e . 4. D i e t a r y c a l c i u m and magnesium are absorbed and e x c r e t e d at s i m i l a r r a t e s by p o p u l a t i o n s i n each school d i s t r i c t i n B r i t i s h Columbia. 5. There i s no s i g n i f i c a n t d i f f e r e n c e i n q u a l i t y between tap water and water t e s t e d f o r hardness. Although i t i s r e c o g n i z e d that water i n g r e d i e n t s may a l t e r t h e i r c o n c e n t r a t i o n d u r i n g t r a n s p o r t a t i o n from the water works to consumers, I assume t h i s t o be an i n s i g n i f i c a n t 1 M a s i r o n i , Shaper 1981:386 59 60 c h a n g e . 6. W a t e r q u a l i t y h a s r e m a i n e d r e l a t i v e l y c o n s t a n t o v e r t i m e ; a n y s e a s o n a l a n d y e a r l y c h a n g e s s h o u l d be i n s i g n i f i c a n t . 7. Water CaC03 v a l u e s w h i c h a r e g r e a t e r t h a n 100 mg/L were c l a s s i f i e d a s h a r d , a n d CaC03 v a l u e s w h i c h a r e l e s s t h a n 100 mg/L were c l a s s i f i e d a s s o f t . F o r t u n a t e l y , few o f t h e w a t e r s a m p l e s o f t h i s s t u d y were on t h e b o r d e r b e t w e e n h a r d and s o f t ( e . g . n e a r 100 mg/L). 8. W a t e r m i n e r a l c o n s t i t u e n t s h a v e been m e a s u r e d a n d r e p o r t e d a c c u r a t e l y by t h e g o v e r n m e n t a l a g e n c i e s . 9. H e a r t d i s e a s e was r e p o r t e d r e l i a b l y and a c c u r a t e l y on d e a t h r e g i s t r a t i o n s . 10. The amount o f w a t e r s o f t e n i n g i n B r i t i s h C o l u m b i a w i l l be i n s i g n i f i c a n t i n t h i s a n a l y s i s . T h i s s t u d y has some d r a w b a c k s a s s o c i a t e d w i t h a l l s t u d i e s o f t h e e c o l o g i c a l d e s i g n ; h o w e v e r , l i k e t hem, i t h a s t h e a d v a n t a g e s o f b e i n g i n e x p e n s i v e , f a s t , a n d e f f i c i e n t , when t h e s t u d y r e g i o n a n d p o p u l a t i o n i s l a r g e . A l t h o u g h t h e c o r r e l a t i o n c o e f f i c i e n t o b t a i n e d f r o m e c o l o g i c a l s t u d i e s i s n o t s u f f i c i e n t t o c o n c l u d e c a u s a l a s s o c i a t i o n s , t h e e c o l o g i c a l s t u d i e s t h e m s e l v e s a r e o f t e n i m p o r t a n t i n g e n e r a t i n g a n d t e s t i n g h y p o t h e s i s . C o n s i s t e n t s t u d y r e s u l t s o f e c o l o g i c a l s t u d i e s s h o u l d p r o m p t r e s e a r c h e r s t o do f u r t h e r c a s e - c o n t r o l o r c o h o r t i n v e s t i g a t i o n s . 61 B. DATA SOURCES AND COLLECTION To t e s t whether any a s s o c i a t i o n c a n be d e t e c t e d between any of s e v e n c a t e g o r i e s o f h e a r t d i s e a s e and wa t e r h a r d n e s s , w a t e r b o r n e c a l c i u m , and w a t e r b o r n e magnesium, I g a t h e r e d : (a) Water q u a l i t y d a t a f o r 103 c i t i e s o f B r i t i s h C o l u m b i a and, (b) R e s i d e n c e d a t a on a l l B r i t i s h C o l u m b i a d e a t h s from h e a r t d i s e a s e f o r t h e p e r i o d 1956 t o 1 9 7 8 . 1 2 The r e c o r d s i n c l u d e a p p r o x i m a t e l y 108,859 males and 67,395 f e m a l e s . I f i r s t g e n e r a t e d a g e - s t a n d a r d i z e d m o r t a l i t y r a t e s from m o r t a l i t y d a t a by sex; t h e n , u s i n g t h e Spearman rank c o r r e l a t i o n method i n t h e SPSS.X s t a t i s t i c s p a c k a g e , I c o r r e l a t e d a g e - s t a n d a r d i z e d m o r t a l i t y r a t e s w i t h w ater h a r d n e s s , w a t e r b o r n e c a l c i u m , and w a t e r b o r n e magnesium. In a d d i t i o n , I r a n k e d w a t e r h a r d n e s s v a l u e s and h e a r t d i s e a s e m o r t a l i t y r a t e s f o r b o t h males and f e m a l e s ( s e e T a b l e s 6, 7, and 8 ) . a. Water Q u a l i t y I n f o r m a t i o n I o b t a i n e d w a t e r q u a l i t y i n f o r m a t i o n f r o m e a c h of t h e s i x government water management o f f i c e s w i t h i n B r i t i s h C o l u m b i a . D a t a was a v a i l a b l e f o r 95 o u t of t h e 103 c i t i e s under c o n s i d e r a t i o n . P o p u l a t i o n s o f t h e s e 95 c i t i e s r e p r e s e n t most o f t h e i n d i v i d u a l s i n t h e p r o v i n c e 1 C i t i e s w i l l i n c l u d e towns, v i l l a g e s , and d i s t r i c t - m u n i c i p a l i t i e s a s r e c o r d e d i n The 1981 Census of Canada: Populations in Descending Order; Populations Cat al ogue E-845. 2 M o r t a l i t y i n f o r m a t i o n was o b t a i n e d from t h e C a n c e r C o n t r o l Agency o f B r i t i s h C o l u m b i a by s p e c i a l a r r a n g e m e n t . T A B L E 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 ( 2 7 ) * 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 i n p a r e n t h e s i s r e f e r s t o the s c h o o l d i s t r i c t 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 .KITIMAT (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. .GOLDEN (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 . MISSION (75) 339 . 2 56. SOUTH OKANAGAN (14) 337 . 7 57. CRESTON-KASLO (86) 336 . 9 58 . CARIBOO-CHILCOTIN (27) 335. 1 59. LAKE COWICHAN (66) 330. 9 60. CENTRAL OKANAGAN (23) 330. 0 S1 . COQUITLAM (43) 329 . 7 62. NECHAKO (56) 329. 5 63. SAANICH (63) 325. 5 64 . HOWE SOUND (48) 319. 8 65 : KIMBERLY (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 . PRINCE 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 o f B r i t i s h C o l u m b i a , a n d a r e w e l l - d i s t r i b u t e d o v e r t h e p r o v i n c e ' s s c h o o l d i s t r i c t s , w h i c h i s t h e g e o g r a p h i c a l a r e a f o r w h i c h h e a r t d i s e a s e m o r t a l i t y d a t a was a v a i l a b l e ( s e e Maps 1A, 13, and T a b l e 9 ) . The w a t e r q u a l i t y d a t a o f t h e s e 95 c i t i e s was c o m p a r e d w i t h t h e m o r t a l i t y d a t a o f t h e 74 s c h o o l d i s t r i c t s , b e c a u s e t h e p l a c e of r e s i d e n c e o f a l l h e a r t d i s e a s e d e c e d e n t s was c o m p l e t e l y a v a l a b l e f o r s c h o o l d i s t r i c t s , a n d o n l y p a r t l y a v a i l a b l e f o r c i t i e s . O n l y e i g h t s c h o o l d i s t r i c t s l a c k e d w a t e r i n f o r m a t i o n . T h e s e e i g h t d i s t r i c t s , A r r o w L a k e s , G r a n d F o r k s , K e t t l e V a l l e y , N o r t h Thompson, C e n t r a l C o a s t , A g a s s i z - H a r r i s o n , S t i k i n e , and A r m s t r o n g - S p a l l u m c h e e n , were e x c l u d e d f r o m a l l a n a l y s e s i n t h i s r e p o r t . T h e r e s h o u l d be no d i s t o r t i o n o f i n f o r m a t i o n when w a t e r d a t a a n d h e a r t d i s e a s e i n f o r m a t i o n i s a n a l y s e d by s c h o o l d i s t r i c t b e c a u s e a m a j o r p r o p o r t i o n of e a c h s c h o o l d i s t r i c t ' s p o p u l a t i o n i s d r i n k i n g t h e w a t e r d e s c r i b e d a c c u r a t e l y by t h e d a t a s u p p l i e d by t h e d i s t r i c t s ' s m a j o r c i t y o r c i t i e s . F o r e x a m p l e , t h e F e r n i e s c h o o l d i s t r i c t h a s a p o p u l a t i o n o f a p p r o x i m a t e l y 10,000, and t h i s d i s t r i c t i s r e p r e s e n t e d by t h e c i t i e s , F e r n i e a n d S p a r w o o d , whose c o m b i n e d p o p u l a t i o n i s 9,601. I t i s a p p a r e n t t h a t F e r n i e a n d S p a r w o o d a c c o u n t f o r a s u b s t a n t i a l p r o p o r t i o n o f t h e F e r n i e s c h o o l d i s t r i c t ' s p o p u l a t i o n . I n d i s t r i c t s s u c h a s F e r n i e , ( w h i c h c o n t a i n two c i t i e s w i t h d i f f e r e n t w a t e r h a r d n e s s , c a l c i u m and (oQ> M A P I A : B R I T I S H C O L U M B I A S C H O O L D I S T R I C T S ? Ci'iiNi'MCJOi-: 3 K I fecn i .E f •< -iNOCf^er.t 7 NEC S C . 10 *nnuw L A K E S 11 T R A I L 13 K E I T U v*i i . f r i J :; (jc:i*i.-r,*H r.Niir.rrjK i ' f u - . - c t TON ?I *?IH*;I!'.(;:JC -'^Al.l.UHChf.CN 2^ vEriMCr; 23 CENIRAI. OKANAGAN ?G n THOMPSON CAniuoo -CH ILCO f * N 20 C U E S M E L >o u ri.i.oor.: |30 3 CAf'UlGrj HERRIII 3.? Hnpr 33 CuIlUrfACK 35 lANGLEY 3iJ ^L'f'C'EY 3 ' O E L T A 39 RICHMOND 3D VANCOUVER wcsiMiNsrrn 4 1 B"i.'lNAHY <i e m u : II.*M 44 N VANCOUVER <iS W VANCOUVER 'ii SI.'NCHINE COAST • !" >K>E SCUNO <!) CENTRAL COAST :*o OLTCN C M A R L O T I E 52 PRiMCE RijPE.'U 5-i SMI IhEfiS ' 5 BURN'S L A K E Su KEO'A<0 5; P R I N C E C£OMOC 59 PEACE R I V E ' CO P E A C E fllvEf Ol G R E A T E R V I C T O R I A 6 ? S OCKE 63 S A A N I C H G J GULP ISLANf E5 COwlCHAN £ 1 L A K E COWIC) 69 NiNAlMO O U A L I C U M 70 AI.OERNI '/! CClJRIENAT ^ CiMl'UEll R I V E R M I S S I O N 7G A G A S S U -H A R R I S O N ?7 SUHMERLANO 00 K I T I M A T e i r o n r N E L S O B-« VAH I S L WE B5 VAM I S L NO Oi] Cr.ESTOM-KA Q? SIIKINE 69 TEfiPACE R9 SHUSWAP 02 n1 SHGA T'ne VPJV I CoU\/fc:R. SCHOOL fioAftn O P P I C E (ol MAP!3; T H E I 0 3 L A R G E S T CITIES iH BRITISH COLUMfi/A } l ^ O , IWS1DE- S c h o o l DiSTRlor ftoUfJ D A R K T S \ , . T A B L E f, , • u T H E 103 L A R G E S T C I T I E S * I N B R I T I S H C O L U M B I A , 1980 /• VANCOUVER 4 1 4 , 2 8 1 2. SURREY 1 4 7 , 1 3 8 3- BURNABY 1 3 6 , 4 9 4 4- RICHMOND 9 6 , 1 6 4 %• D E L T A 7 4 , 6 9 2 £>• P R I N C E GEORGE 6 7 , 5 5 9 7. KAMLOOPS 6 4 , 0 4 8 C O Q U I T L A M 6 1 , 0 7 7 KELOWNA 5 9 , 1 9 6 /O. NANA I MO 4 7 , 0 6 9 //. C H I L L I W A C K 4 0 , 6 4 2 /2- NEW WESTMINSTER 3 8 , 5 5 0 /3- WEST VANCOUVER 3 5 , 7 2 8 /</• NORTH VANCOUVER 3 3 , 9 5 2 / t r - M A P L E RIDGE 3 2 , 2 3 2 }(,. V I C T O R I A 3 1 , 5 4 3 /7 PORT C O Q U I T L A M 2 7 , 5 3 5 / £ . P E N T I C T O N 2 3 , 1 8 1 /<?. M I S S I O N 2 0 , 0 5 6 20. VERNON 1 9 , 9 8 7 2/. PORT A L B E R N I 1 9 , 8 9 2 ^2 - P R I N C E RUPERT 1 6 , 1 9 7 25- CRANBROOK 1 5 , 9 1 5 2-4-CAMPBELL R I V E R 1 5 , 8 3 2 25-LANGLEY C I T Y 1 5 , 1 2 4 CITIES VJILU IM CLUDE 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. P I T T MEADOWS 6,209 tfg.MERRITT 6,110 L# MACKENZIE 5,890 54. REVEL STOKE 5,554 t ^ F E R N I E 5,444 5*. P A R K S V I L L E 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 M I L E 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 A L I C E 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 v a l u e s ) , t h e w a t e r q u a l i t y p a r a m e t e r s were w e i g h t e d a c c o r d i n g t o t h e c i t i e s ' p o p u l a t i o n s t o o b t a i n g r e a t e r a c c u r a c y i n e s t i m a t i n g t h e w a t e r h a r d n e s s , w a t e r b o r n e c a l c i u m , a n d w a t e r b o r n e magnesium v a l u e s f o r t h o s e s c h o o l d i s t r i c t s . The w e i g h t i n g t e c h n i q u e i s d e s c r i b e d i n A p p e n d i x 2, and t h e w a t e r - h a r d n e s s c l a s s i f i c a t i o n s o f t h e s c h o o l d i s t r i c t s a r e i n c l u d e d i n A p p e n d i x 3. b. H e a r t D i s e a s e M o r t a l i t y I n f o r m a t i o n I e x a m i n e d t h e g e o g r a p h i c d i s t r i b u t i o n o f d e a t h s f r o m h e a r t d i s e a s e i n B r i t i s h C o l u m b i a d u r i n g t h e t w e n t y - t h r e e y e a r s f r o m 1956 t o 1978. O n l y d e c e d e n t s o v e r t w e n t y - o n e y e a r s o f age were i n c l u d e d i n t h i s s t u d y ; t h o s e u n d e r t w e n t y - o n e were e x c l u d e d b e c a u s e t h e i r d e a t h s may be due t o c o n g e n i t a l h e a r t p r o b l e m s . The d a t a f o r h e a r t d i s e a s e d e c e d e n t s w h i c h was u s e d i n t h i s s t u d y i n c l u d e s y e a r o f d e a t h , s e x , a g e , s c h o o l d i s t r i c t o f r e s i d e n c e , a n d c a u s e o f d e a t h . The r e g i s t r a t i o n o f d e a t h s a n d o t h e r v i t a l e v e n t s i s t h e r e s p o n s i b i l i t y o f p r o v i n c i a l a n d t e r r i t o r i a l g o v e r n m e n t s u n d e r a p p r o p r i a t e V i t a l S t a t i s t i c s o r o t h e r A c t s . T h e s e A c t s r e q u i r e t h a t v i t a l e v e n t s be r e p o r t e d w i t h i n a p r e s c r i b e d t i m e and t h a t c a u s e o f d e a t h , r e s i d e n c e , s e x , and age o r b i r t h d a t e o f t h e d e c e d e n t be r e c o r d e d on d e a t h r e c o r d s . The c a u s e o f d e a t h i s r e c o r d e d by a m e d i c a l a t t e n d a n t on t h e r e g i s t r a t i o n f o r m a c c o r d i n g t o a f o r m a t p r e s c r i b e d by the" W o r l d H e a l t h 73 O r g a n i z a t i o n a n d s p e c i f i e d i n t h e r e l e v a n t r e v i s i o n o f t h e I n t e r n a t i o n a l C l a s s i f i c a t i o n o f D i s e a s e s (ICD). The r e c o r d e d s t a t e m e n t d e c l a r e s t h e u n d e r l y i n g c a u s e o f d e a t h , w h i c h i s d e f i n e d a s t h e d i s e a s e o r i n j u r y w h i c h i n i t i a t e d t h e s e q u e n c e o f e v e n t s w h i c h l e d t o d e a t h . The m u n i c i p a l i t y o r t o w n s h i p o f u s u a l r e s i d e n c e o f d e c e d e n t s i s a l s o c o d e d i n p r o v i n c i a l o f f i c e s . P o s s i b l e s o u r c e s o f e r r o r t h a t may a f f e c t m o r t a l i t y d a t a , and h e n c e t h e c o m p l e t e n e s s a n d r e l i a b i l i t y o f m o r t a l i t y r a t e s , i n c l u d e t h e f o l l o w i n g : 1. C o m p l e t e n e s s o f r e g i s t r a t i o n : I t i s t h o u g h t t h a t r e g i s t r a t i o n a p p r o a c h e s one h u n d r e d p e r c e n t . 2. R e c o r d i n g of d a t a : D e a t h r e g i s t r a t i o n f o r m s a r e l e g a l d o c u m e n t s a n d a r e c h e c k e d f o r c o n t e n t , b o t h a t t h e t i m e o f c o m p l e t i o n and a t t h e t i m e o f f i l i n g i n t h e p r o v i n c i a l o f f i c e s . I t i s l i k e l y t h a t t h e r e a r e e r r o r s i n c o m p l e t i o n o f c a u s e s o f d e a t h . However t h e p r o p o r t i o n of m i s c l a s s i f i c a t i o n s h o u l d n o t d i f f e r a g r e a t d e a l f r o m one s c h o o l d i s t r i c t t o a n o t h e r . The a c c u r a c y o f t h e c a u s e o f d e a t h i n f o r m a t i o n l a r g e l y d e p e n d s on t h e f a m i l i a r i t y o f t h e m e d i c a l a t t e n d a n t , who r e c o r d s t h e c a u s e o f d e a t h , w i t h t h e p a t i e n t . 3. C o d i n g a n d p r o c e s s i n g e r r o r s : E r r o r s a s s o c i a t e d w i t h c o d i n g o f age a n d s e x a r e i n s i g n i f i c a n t . E r r o r s i n c o d i n g r e s i d e n c y c a n be s i g n i f i c a n t , e s p e c i a l l y i n r u r a l a r e a s where p o s t a l a d d r e s s e s r a t h e r t h a n p l a c e o f r e s i d e n c e may be r e c o r d e d a n d a r e s u b s e q u e n t l y 74 c o d e d . I n t h i s s t u d y , I i n c l u d e d s e v e n c a t e g o r i e s o f h e a r t d i s e a s e t h a t a r e l i s t e d i n t h e I n t e r n a t i o n a l C l a s s i f i c a t i o n o f D i s e a s e s ( s e e A p p e n d i x 4 ) . T h e s e c a t e g o r i e s i n c l u d e : 1. R h e u m a t i c F e v e r 2. C h r o n i c R h e u m a t i c H e a r t D i s e a s e 3. A r t e r i o s c l e r o t i c a nd D e g e n e r a t i v e H e a r t D i s e a s e 4 . O t h e r D i s e a s e s o f t h e H e a r t 5. H y p e r t e n s i o n w i t h o r w i t h o u t H e a r t D i s e a s e 6. D i s e a s e s of t h e A r t e r i e s , V e i n s , and O t h e r D i s e a s e s o f t h e C i r c u l a t o r y S y s t e m 75 C. RESULTS AND ANALYSIS S e x - s p e c i f i c a g e - s t a n d a r d i z e d m o r t a l i t y r a t e s w e re c a l c u l a t e d a n d t h e s e r a t e s were c o m p a r e d w i t h v a l u e s o f w a t e r h a r d n e s s , w a t e r b o r n e c a l c i u m , a n d w a t e r b o r n e magnesium f o r e a c h s c h o o l d i s t r i c t i n B r i t i s h C o l u m b i a a s d e s c r i b e d a b o v e . The r e s u l t s o f t h e s t a t i s t i c a l a n a l y s i s a r e shown i n T a b l e s 10, 11, a nd 12. a. W a t e r H a r d n e s s : T a b l e 10 Wa t e r h a r d n e s s , by i t s e l f , was f o u n d t o e x p l a i n v e r y l i t t l e o f t h e o b s e r v e d v a r i a t i o n i n h e a r t d i s e a s e m o r t a l i t y i n B r i t i s h C o l u m b i a f r o m 1956 t o 1978. The a l p h a l e v e l f o r t h i s s t u d y was 0.05. As i n many o t h e r s t u d i e s o f t h e c o r r e l a t i o n b e t w e e n w a t e r h a r d n e s s a n d h e a r t d i s e a s e , a n e g a t i v e s t a t i s t i c a l c o r r e l a t i o n was o b t a i n e d f o r many h e a r t d i s e a s e c a t e g o r i e s . I n f a c t , i n t h i s s t u d y t h e c o r r e l a t i o n was n e g a t i v e f o r a l l m a l e h e a r t d i s e a s e c a t e g o r i e s e x c e p t f o r c a t e g o r y (4) Other Diseases of the Heart and (5) Hypertension with or. without Heart Disease. F o r f e m a l e s t h e c o r r e l a t i o n i s n e g a t i v e f o r e a c h c a t e g o r y e x c e p t f o r ( 5) Hypertension with or without Heart Disease. The o b s e r v e d c o r r e l a t i o n v a l u e s w e r e s m a l l a n d were n o t s t a t i s t i c a l l y - s i g n i f i c a n t f o r a ny h e a r t d i s e a s e c a t e g o r i e s . A c l o s e r a n a l y s i s o f T a b l e 10 w i l l h i g h l i g h t t h e i m p o r t a n c e o f t h e a s s o c i a t i o n b e t w e e n w a t e r h a r d n e s s a n d h e a r t d i s e a s e m o r t a l i t y . Column 1 o f T a b l e 10 l i s t s t h e c o r r e l a t i o n c o e f f i c i e n t s , w h i c h d e s c r i b e t h e a s s o c i a t i o n % CORRELATI COLUMN TABLE 10 ON BETWEN WATER HARDNESS AND AGE-STANDARDI ZED HEART DISEASE MORTALITY RATES CATEGORY 1.400-402 .410-416 .420-422 .430-434 .440-447 .450-468 .400-468 CATEGORY 1.400-402 .410-416 .420-422 .430-434 .440-447 .450-468 .400-468 KEY : 400-402 410-416 420-422 430-434 440-447 450-468 400-468 1 CORRELATION (MALES) -0.09158 -0.02455 -O.08529 O.18194 0.05122 -0.14101 -0.04872 (FEMALES) -0.06227 -0.06129 (R) 05352 06755 00839 10772 06956 R SQUARED 0.00839 0.00060 0.00727 0.03310 0.00262 0.01988 0.00237 0.00388 0.00376 .00286 .00456 .00007 .01160 .00484 0. 0. 0. 0. O. SIGNIFICANCE 0.46813 O.84486 0.49594 O.14372 0.68296 0.25876 0.69769 0.62219 0.62496 O.66955 0.58993 0.94667 O.38931 O.57888 RHEUMATIC FEVER CHRONIC RHEUMATIC HEART DISEASE ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE OTHER DISEASES OF THE HEART HYPERTENSION WITH OR WITHOUT HEART DISEASE DISEASES OF THE VEINS, ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM 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 d i s e a s e m o r t a l i t y r a t e s . For example, the f i r s t number i n Column 1, -0.09158, i s the c o r r e l a t i o n c o e f f i c i e n t which r e v e a l s t h a t a negative a s s o c i a t i o n e x i s t between water hardness and rheumatic heart d i s e a s e m o r t a l i t y r a t e s f o r males. The c o r r e l a t i o n c o e f f i c i e n t obtained c o u l d have occurred by chance, and, f o r t h i s reason, c o e f f i c i e n t s are t e s t e d to determine the l i k e l i h o o d that a r e a l a s s o c i a t i o n e x i s t s . In Column 2, the R squared values h i g h l i g h t the amount of m o r t a l i t y a t t r i b u t a b l e to water hardness. For example, the f i r s t number i n Column 2, 0.00839, i n d i c a t e s that 0.8 per cent of m o r t a l i t y due to t h i s cause can be e x p l a i n e d by water hardness. The f i r s t number i n Column 3 r e v e a l s that the c a l c u l a t e d c o r r e l a t i o n (R) of water hardness and rheumatic fever c o u l d occur by chance about 46.8 per cent of the time. A l s o i n Column 3 i t w i l l be observed that the str o n g e s t a s s o c i a t i o n occurs with Other Diseases of the Heart (males).'' However, the a s s o c i a t i o n i s a p o s i t i v e one, c o n t r a r y to what might be expected. Category (6), Diseases of the Arteries, Veins, and Other Diseases of the Circulatory System, showed the str o n g e s t negative r e l a t i o n s h i p with water hardness. T h i s category of heart d i s e a s e , which accounts f o r about e i g h t per cent of the heart d i s e a s e deaths in B r i t i s h Columbia, has not been 1Other Diseases of the Heart i n c l u d e e n d o c a r d i t i s , m y o c a r d i t i s , p e r i c a r d i t i s , and f u n c t i o n a l d i s e a s e of the hea r t , such as arr y t h m i a , heart block, and v e n t r i c u l a r f i b r i l l a t i o n . 80 shown by other r e s e a r c h e r s to vary with changes of water hardness. In t h i s study, the c o r r e l a t i o n c o e f f i c i e n t which measures the r e l a t i o n s h i p between water hardness and the death ra t e f o r a l l heart d i s e a s e c a t e g o r i e s combined i s -0.04872 f o r males and -0.06956 f o r females. The c o r r e l a t i o n c o e f f i c i e n t of t h i s same r e l a t i o n s h i p f o r both sexes in Schroeder's study was -0.29 (and t h i s was s t a t i s t i c a l l y - s i g n i f i c a n t ) . 1 The c o r r e l a t i o n c o e f f i c i e n t s obtained by M o r r i s et al were a l s o much higher than the c o e f f i c i e n t s obtained i n t h i s s t u d y . 2 In t h i s B r i t i s h Columbia study, the suggestion of a p o s i t i v e a s s o c i a t i o n between water hardness and hypertension i s i n d i r e c t c o n t r a d i c t i o n to the f i n d i n g r eported by M a s i r o n i . 3 I t might have been expected that the st r o n g e s t negative a s s o c i a t i o n s 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 c a t e g o r i e s of heart d i s e a s e were noted by many re s e a r c h e r s to vary with water hardness." Arteriosclerotic and degenerative heart disease i n c l u d e s aneurysm, myocardial i n f a r c t i o n or thrombosis, a r t e r i o s c l e r o s i s , coronary o c c l u s i o n , embolism, and 1Schroeder 1960b 2 M o r r i s , Crawford, Heady 1968 3 M a s i r o n i , Shaper 1981 "Ma s i r o n i , Shaper 1981; Winton, McCabe 1970; Luoma et al 1 983 81 i s c h e m i c h e a r t d i s e a s e . And other diseases of the heart i n c l u d e v e n t r i c u l a r a r r y t h m i a a n d f i b r i l l a t i o n . I t was p o s t u l a t e d p r e v i o u s l y i n t h i s p a p e r t h a t d e f i c i e n c i e s i n c a l c i u m a n d magnesium i o n s c o u l d p r e d i s p o s e i n d i v i d u a l s t o any o f t h e a b o v e - m e n t i o n e d o c c u r r e n c e s , s u c h a s a n e u r y s m o r m y o c a r d i a l i n f a r c t i o n . B o t h A n d e r s o n a n d H e g g v e i t s t a t e d t h a t a magnesium d e f i c i e n c y c a n t r i g g e r a r r y t h m i a . 1 M c C a r r o n p r e s e n t e d a n i m a l e v i d e n c e t o s u p p o r t t h e t h e o r y t h a t d e f i c i e n t d i e t a r y c a l c i u m i s a c o n t r i b u t i n g f a c t o r i n t h e d e v e l o p m e n t o f h y p e r t e n s i o n . 2 None o f t h e r e s u l t s o f T a b l e 10, h o w e v e r , i n d i c a t e t h a t s t r o n g e r n e g a t i v e a s s o c i a t i o n s e x i s t b e t w e e n w a t e r h a r d n e s s a n d c a t e g o r i e s 3, 4, o r 5. F u r t h e r m o r e , T a b l e 10 s u g g e s t s t h a t w a t e r h a r d n e s s d o e s n o t a p p e a r t o be a m a j o r f a c t o r i n any t y p e o f h e a r t d i s e a s e m o r t a l i t y . The m a j o r c o n s t i t u e n t s o f w a t e r h a r d n e s s - c a l c i u m and magnesium - were c o n s i d e r e d s e p a r a t e l y t o s e e w h e t h e r e i t h e r h a d an i n d e p e n d e n t i n f l u e n c e on m o r t a l i t y . b. W a t e r b o r n e C a l c i u m : T a b l e 11 I n g e n e r a l , t h e c o r r e l a t i o n b e t w e e n w a t e r b o r n e c a l c i u m a n d h e a r t d i s e a s e m o r t a l i t y i s n e g a t i v e , a l t h o u g h i t i s n o t s t a t i s t i c a l l y - s i g n i f i c a n t . The s t r o n g e s t i n v e r s e a s s o c i a t i o n a p p e a r s b e t w e e n c a l c i u m and t h e f e m a l e h e a r t d i s e a s e c a t e g o r y ( 6 ) , Diseases of 1 A n d e r s o n e t a l 1975 2 M c C a r r o n 1983 82 the Veins, Arteries and Other Diseases of the Circulatory System. I t i s n o t a s i g n i f i c a n t a s s o c i a t i o n ; f u r t h e r m o r e , i t i s s u r p r i s i n g b e c a u s e i t w o u l d be a n t i c i p a t e d t h a t t h e p r o t e c t i v e e f f e c t o f c a l c i u m w o u l d m a n i f e s t i t s e l f more s t r o n g l y i n C a t e g o r y ( 3 ) , Ar t er i os cler ot i c and Degenerative Heart Disease, where (1) t h e h e a r t m u s c l e i s more i n v o l v e d , a n d where (2) i t m i g h t be e x p e c t e d t h a t c a l c i u m p l a y e d a r o l e i n s t r e n g t h e n i n g t h e h e a r t m u s c l e t o p r e v e n t d i s e a s e . c. W a t e r b o r n e M a g n e s i u m : T a b l e 12 The r e s u l t s o f t h i s t a b l e a r e q u i t e i n t e r e s t i n g . The two s t r o n g e s t n e g a t i v e a s s o c i a t i o n s o c c u r r e d b e t w e e n w a t e r b o r n e magnesium a n d c a t e g o r y ( 3 ) , Ar t er i os cler ot i c and Degenerative Heart Disease f o r b o t h m a l e s a n d f e m a l e s . T h i s i n d e p e n d e n t c o n s i d e r a t i o n o f w a t e r b o r n e magnesium e n a b l e d u s t o see t h a t magnesium may p o s s i b l y be p r o t e c t i v e a g a i n s t a r t e r i o s c l e r o t i c a n d d e g e n e r a t i v e d i s e a s e . A l t h o u g h t h e a s s o c i a t i o n s a r e n o t s t a t i s t i c a l l y - s i g n i f i c a n t i n t h i s r e p o r t , t h e y a r e c o n s i s t e n t w i t h f i n d i n g s o f o t h e r r e s e a r c h e r s . 1 One f u r t h e r s t a t i s t i c a l a n a l y s i s w h i c h was done was a c o r r e l a t i o n o f w a t e r h a r d n e s s w i t h s t a n d a r d i z e d m o r t a l i t y r a t i o s . The r e s u l t s a r e shown i n T a b l e 13, a n d ca n be c o n t r a s t e d t o t h e r e s u l t s o f T a b l e 10, where t h e ' M a r i e r e t a l 1979 83 c o r r e l a t i o n was done u s i n g a g e - s t a n d a r d i z e d m o r t a l i t y r a t e s i n s t e a d o f r a t i o s . S t a n d a r d i z e d m o r t a l i t y r a t i o a n a l y s i s p r o d u c e s a c o m p a r i s o n o f v a l u e s f o r e a c h s c h o o l d i s t r i c t w i t h t h e mean o f a l l s c h o o l d i s t r i c t s c o m b i n e d . I n t h e t a b l e , w i t h v a l u e s a b o v e 100 a r e c o n s i d e r e d t o h a v e an e x c e s s o f m o r t a l i t y , a n d d i s t r i c t s w i t h v a l u e s b e l o w 100 a r e c o n s i d e r e d t o h a v e l e s s t h a n t h e e x p e c t e d number o f d e a t h s f o r a s p e c i f i e d c a t e g o r y . A g e - s t a n d a r d i z e d m o r t a l i t y r a t e s , w h i c h a r e o f t e n more i n f o r m a t i v e t h a n s t a n d a r d i z e d m o r t a l i t y r a t i o s , y i e l d e d s t r o n g e r n e g a t i v e c o r r e l a t i o n s i n more c a t e g o r i e s t h a n d i d t h e r a t i o s , a l t h o u g h a s e x p e c t e d , t h e same g e n e r a l t r e n d s i n t h e s t a t i s t i c a l r e s u l t s c a n be o b s e r v e d i n b o t h t a b l e s 10 a n d 13. The s c a t t e r g r a m s o f t h e c o r r e l a t i o n s w h i c h were done now f o l l o w . The s c a t t e r g r a m s show s c a t t e r w h i c h i s g e n e r a l l y i n d e p e n d e n t o f t h e v a r i a b l e a x e s . I f w a t e r h a r d n e s s , w a t e r b o r n e c a l c i u m , o r w a t e r b o r n e magnesium were n e g a t i v e l y a s s o c i a t e d w i t h s e x - s p e c i f i c , a g e - s t a n d a r d i z e d h e a r t d i s e a s e m o r t a l i t y r a t e s , t h e s c a t t e r g r a m s w o u l d h a v e l o o k e d more l i k e SH TABLE 13 CORRELATION BETWEN WATER HARDNESS AND AGE-STANDARDIZED HEART DISEASE MORTALITY RATIOS COLUMN CATEGORY 1 .400-402 2.410-416 3.420-422 4.430-434 5:440-447 6.450-468 7.400-468 CATEGORY 1.400-402 2.410-416 3.420-422 4.430-434 5.440-447 6.450-468 7.400-468 KEY : 400-402 410-416 420-422 430-434 440-447 450-468 400-468 1 CORRELATION (MALES) -0.13159 0.00363 0.13536 O.17844 0.08643 -0.24764 -O.11269 (FEMALES) -0.05568 -0.08274 -0.03326 -0.00397 0.03015 -0.02032 -0.03539 (R) R SQUARED 0.01732 0.00001 0.01832 0.03184 0.00747 0.06133 0.01270 00310 00685 001 1 1 00002 00091 00041 00125 SIGNIFICANCE . 29226 ,97690 .27851 .15173 49015 04499 . 36765 .65703 50895 7909 1 97475 81006 87135 77787 RHEUMATIC FEVER CHRONIC RHEUMATIC HEART DISEASE ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE OTHER DISEASES OF THE HEART HYPERTENSION WITH OR WITHOUT HEART DISEASE DISEASES OF THE VEINS, ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM ALL HEART DISEASE CATEGORIES COMBINED 85 t h i s : A N EXAMPLE" t>T M ASSOCIATION WiTH A C0fU<£LATlori C06FF lc rE l*T OP — O.HS ANP A R£&R£S5IM>I COEFPIC-tENT OF ~oa% I n t h i s s t u d y , t h e r e were no d i s t i n c t r e l a t i o n s h i p s shown by t h e s c a t t e r g r a m s . n e g a t i v e SCATTERS RAMS OF RESULTS C O R R E L A T I O N B E T W E E N WATEff> HARDriESS AMD S>£X~ S I C A&g-STAND ARPtZLE-D MORY^LITV fiVrVTE-S Pflft. SEVElvl CATE1QOK.IES OF HO\f t .T PlStTASE slftTE; T H f FiRST SEV.EVM 5 C A T T E ft A M.S A ' R . E F & K M A L E S J A N ! ? THE LATTER. STEVEN ScATT£"R.G.*sAM5 Age Fo.R. P E M A L E T S 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HKRDNSLSS AKID s e x . - S P e t l F i c ftfiC-STflNO MU>,z .£D M . R T A L i T y R A T E S 20:50:03 DOWN: WH 454 U n i v e r s i t y of B r i t i s h Columbia WATER HARDNESS /G»-Ce>3 ^/ t-) 2 6 ^ 10 14 ACROSS: 18 PoR. CHC-ONlC 2 rtETUM/YTic HEART DISEflse'^/nB'-fiS STANDARDIZED MORTALITY RATE (per [00,000*) 22 26 30 34 38 k + 409 409 354 274 229 49 * * 2 * * 2 * * * 2**3»2 * 319 184 139 94 12 20 28 32 40 OO DOWN: WH 409 184 94 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HftRDrJESS MVID sen.-SPEC I Fi c AGE -.STANTDARD IZ.EO MOK.rfli.iry K A T E 3 U n i v e r s i t y of B r i t i s h Columbia Foft RKSUMA-TIO PIEART D I S E A S E / M A L E ' S WATER HARDNESS (caCO >*j/l-) ACROSS: 1 3 5 7 9 STANDARDIZED MORTALITY RATE 11 13 15 1 f 19 409 CO !:«?aS6 5 n ^ ™ r ?r£lh*Z%TJ£iir1'' B E T W E E N W A T E R M * t o " M — C A « - « ™ ^ « Q M o ^ L i r y _ s WATER HARDNESS ACROSS: STANDARDIZED MORTALITY RATE 6 - / 0 ^ _l + _2_2_l +_ + 21S+ 3 0 7 335 363 391 4 19 447 } 454 " * * ^ ^ . . . . 20 DOWN 274 229 454 409 364 319 184 139 49 265 321 349 377 405 433 2 MAR 86 2 0 : 5 1 : 1 7 DOWN: WH A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HARDNESS Ma SEX-SPEC I F I c /\GEt-J.TMa AUDi iEO r ioRTALcrv RATES U n i v e r s i t y of B r i t i s h C o l u m b i a — WATER HARDNESS ( C*CO> ACROSS: 2 6 10 14 18 OTH-ER. D! 5 CASES CF T/+£~ R E f t f t r / M A L E ^ STANDARDIZED MORTALITY RATE (p^ttr 100,00a) 22 2G 30 34 38 409 229 139 94 49 454 409 3S4 319 274 229 184 139 94 2 MAR 86 20:51:43 DOWN: A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HACDWess Un ive rs i t y of B r i t i s h Columbia ftNfl SEX'SPea Pie A<ic-jSTAMDA*.Dii£-i:> r\iK.TAi_ir¥ R A T E S WATER HARDNESS ^Co .C0 3 ^ j / 1 - ) 3 9 15 ACROSS: 27 STANDARDIZED MORTALITY RATE (p*s- loejooo' ) 33 39 45 51 57 454 409 409 229 49 * * * * * * * * * * 2 * * 2*2 2** -12 18 24 30 36 42 48 54 60 364 319 274 274 184 184 139 94 94 31 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER rtneOrvltSS Ar<D 5EX.-5PCC/PIC A^E-STrtKOftRDlZE-D MoKTALlTV RrtTETS 2 0 : 5 2 : 1 3 U n i v e r s i t y o f B r i t i s h C o l u m b i a WH WATER HARDNESS (ccuC0 3 rng/L) 5 15 25 35 45 55 65 75 85 95 DOWN: FOR. D I S E A S E S . F T » f veiNjs Aft-rE/ues, A I J D ^ -HeR. rnsir/vs£VS o f T t t r cifttuLyv-rafiV s ACROSS: STANDARDIZED MORTALITY RATE (_pe.r- {00,000) 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 2 0 : 5 2 : 4 2 DOWN: A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER rfnK.Drt£SS AMD SEX-5PETC1FIC l\CF-SYm\tmR.DIJFD MoRrfli.ir» I W T E : U n i v e r s i t y of B r i t i s h Columbia ^ A u _ H 6 M r D i 5 e « f o ! n a i n ( f D / M ^ E S WATER HARDNESS (C«.C&-?> <^$/l~) ACROSS: STANDARDIZED MORTALITY RATE ('per l o o ^ o o ) 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 + * * * * + 4 9 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 8 6 2 0 : 5 3 : 1 5 D O W N : WH A P I L O T STUDY O F T H E R E L A T I O N S H I P B E T W E E N WATER ArtD S E X - S P E C I F I C A i . £ - S T * * I D f t R D . £ E D H ( * T « L I T V R A T E S U n i v e r s i t y o f B r i t i s h C o l u m b i a FoK. RttETu.rf'VTie KEft^-T" S I s e A S E /f&iA\-ES 2 7 4 2 2 9 1 8 4 4 9 W A T E R H A R D N E S S C^o-COj, >->q/l-) 1 3 5 7 A C R O S S : S T A N D A R D I Z E D M O R T A L I T Y R A T E £ f « r - l » o , o o o ) 11 13 15 17 19 4 0 9 2 7 4 2 2 9 184 1 3 9 4 9 35 2 MAR 8 6 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER UflrRD klcTSS ft*lD SEX •SPgci Fi C AaF-STfti*DftRDi2fI> rteRTTVLiTv 2 0 : 5 3 : 4 3 U n i v e r s i t y of B r i t i s h Columbia ( L H R ^ c H U E U M A T I C HETrtR.T D i s e W s ^ / F t e r i A t r S DOWN: WH WATER HARDNESS (CtJiOj, / O ACROSS 2 7 STANDARDIZED MORTALITY RATE £p£r |oo ,00£>^) 3 3 3 9 4 5 5 1 5 7 4 5 4 4 0 9 4 0 9 * * * * 3 6 4 3 1 9 2 7 4 2 7 4 9 4 9 4 * * * * * * * « * 2 * 2 * * * * * * 2 * 2 4 * » 4 9 12 1 8 2 4 3 6 5 4 6 0 35 2 MAR 86 20:54:08 DOWN: A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER WARDfJSSS AN/D S C A - S P C X I FtC ft«T-5Tft^DftROIZ£"D M oftTft UI TY fto-TTS University of Br i t ish Columbia prKxo^asca.£au>Tic AIMTJ DeG£TW£T<?A-n\J£f H-tTPrRT- Di5ffAS£/FenftLEjS WATER HARDNESS (_ CoXC^ n-vj / O ACROSS: . STANDARDIZED MORTALITY RATE (per l o o , C©6~) 159 217 275 333 391 449 507 565 623 6S 1 454 409 + + 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 + * * + 1 3 9 I * * I I * I 94 + * * * + 94 I * I I * * I j * * * I 49 + * * * * + 4 9 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 20:54:40 DOWN: WH 454 409 364 3 19 274 229 184 139 94 49 4 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER l4ft«0NE:s.'S A T J D ^cX-SffciFiC flcr-«Tfln/DflMin.Eo mRTftury R * T E T S University of B r i t i s h Columbia ._ / _ t -oR. D T » f ( L Pl«Se7VStT5 o p - T H E - H - E M . T / F f M A U T S STANDARDIZED MORTALITY RATE 1 0 0 , 0 0 0 . ^ WATER HARDNESS ( Cfl-COA "VJ / L^) ACROSS 15 27 39 57 454 409 364 319 «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<ifT-STANr>ftR.DixeT> rloR-muXY RATE-s 2 0 : 5 5 : 0 6 DOWN: WH U n i v e r s i t y o f B r i t i s h C o l u m b i a WATER HARDNESS 4 12 20 F6R. l - f Y P E T M ' F N S l o N l / F f M A L E 3 ACROSS: 36 STANDARDIZED MORTALITY RATE (r<-'~ ' • • • • s o ) 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 20:55:38 DOWN: A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HAHDNE5S AMD SOL^ SPETOFIC A6f-STrt^CA-fLD^FP MBRTA LI T Y RATES Univers i ty of B r i t i s h Columbia ^ B l s E ^ r s o P T l t r m r f R . e s Ve^sIS AUD . T I , ^ t » , 3 D , 5 e 3 o P T W d R u ^ m . i V SVST WATER HARDNESS £a.&>3 ^7/<-) ACROSS: STANDARDIZED MORTALITY RATE C p ^ l°°,«<*>) F£f1ficLE~5 a 4 o n o — ' 1 Q ji O E;Q 18 28 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 + * * + 1 3 9 9 4 + * * * + 94 j * I T * I I * * ^ J * * * I 4g + * * * * + 4 9 j * * I j * * * * I I * * * I I * * 2 * 2 * * * * * I 4 + * * 3 4 * * • * + 4 + + + + + + + + + + + + + + + + + + + + +. 3 13 23 33 43 53 63 73 83 9 3 103 100 2 MAR 86 20:56:07 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER rfftR0M£5S S £ X - 5 P E - C J F i c fV^c-s-r>viMi>ft«T>izED n o R r f t L i r v RATCJ5 U n i v e r s i t y of B r i t i s h Columbia p^P-. all. I t f A R r D I S E J U C c r t - T E - d j R I E S c » n O i > j E i > / F f M f l L E ^ WATER HARDNESS (CsJJS-*, I *-) ACROSS: STANDARDIZED MORTALITY RATE (per- l o o . o o o ) 214 290 366 442 518 594 670 746 822 898 454 409 364 364 319 319 274 274 229 229 184 94 49 139 4 +* . +-176 * 2 * * • 423 * 252 404 480 632 708 860 S C A T T E R S R A M S O F R E S U L T S C L ^ R R E L K T I O I N I BETTWEEtsl W A T E"RBofi^ET C A L H U M At\iD S E X - 5 P £ C j F l C  AG-E-STANDARD IZ-EJD MOR.-rAL.irV RArT&S F O R SEVElst CATGSQRlETS OF H E A R T DISEASE 101 2 MAR 86 20:43:12 81 73 65 57 49 33 25 17 A PILOT STUOY OF THE. RELATIONSHIP BETWEEN WATERBORNE CALCJUr-l AND .3 EX.-S PACIFIC A&E-STANDARDIZ.ED MORTALITY RflTCi Univers i ty of B r i t i s h Columbia fcf^ 1'«?tteu'n(=mc_ H"EBR.T TJ \se~f*SE /MfiiLES WATERBORNE CALCIUM 1 3 /o ^ l / L ) ACROSS: J 7 9 STANDARD IZEO MORTALITY RATE (ffer loo,Coo") 11 13 15 17 19 8 1 103 2 MAR 8G A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE <WD SCK-SPfC 1FIC A«-Sl>^Dft-R.Plz.eD rto^mu.ry R/yr§< 20:44:26 University of British Columbia p0f^  CK*oMiC Rfrg-wi/vnc H - C T B T DisEfKF /, M f t L f S DOWN: CA WATERBORNE CALCIUM .(r*3& ACROSS: STANDARDIZED MORTALITY RATE Cf^r l<">/c"">) 2 6 10 14 18 22 26 30 34 38 + + + + + + + + + + + + + + + + + + + + + . 81 + + 8 1 73 + + 7 3 65 + * + 6 5 57 + + 5 7 T * I T * * * I 49 + + 4 9 I * I I * I 4 1 + * * + 4 1 I * I 33 + + 3 3 I * I J * * * I 25 + c * * + 2 5 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 M A R 8 6 A P I L O T S T U D Y O F T H E R E L A T I O N S H I P B E T W E E N W A T E R B O R N E C^UCitiM A N D S E O C - S P f r a F - iC ftiiT-STANDARD ,-z.ef) MORTALITY* R A T E S 2 0 : 4 4 : 5 5 U n i v e r s i t y o f B r i t i s h C o l u m b i a r . _ . „ _ , „ / D O W N : C A W A T E R B O R N E C A L C I U M A j M A C R O S S : j . ; S T A N D A R D I Z E D M O R T A L I T Y R A T E (_pe.< l o o , o o o ) 1 9 5 2 2 3 2 5 1 " v 2 7 9 3 0 7 3 3 5 3 6 3 3 9 1 4 1 9 4 4 7 8 1 + + 8 1 I * I 7 3 + + 7 3 6 5 + * + 6 5 5 7 + + 5 7 I * I f I * * * I 4 9 + + 4 9 T * I I * I 4 1 + « * + 4 1 T * I I * I 3 3 + * * + 3 3 I 2 * I 2 5 + * * + 2 5 I * * I I * I 1 7 + * + 1 7 T * * * J J * * * J 9 + + 9 I * * * * * j I * * * * * * * * * j I * * * * * * * * + * * * * * * j 1 + » + 1 + 1 + + + + + + + + H h + ^ 1 -< + + + + +. 1 8 1 2 0 9 2 3 7 2 6 5 2 9 3 3 2 1 3 4 9 3 7 7 4 0 5 4 3 3 4 6 1 [05 DOWN: CA A PILOT STUDY OF THE 2 MAR 86 A r-iuu. B r 1 t 1 s n Columbia 20:45:24 U n i v e r s i t y of B r i t i s RELATIONSHIP BETWEEN WATERBORNE C A L c ^ M M o of: mf H-erASr I f t L C S 1 4 ACROSS. WATERBORNE CALCIUM \ J)' > , 8 22 26 S 10 STANDARDIZED MORTALITY R A T E ^ ^ r 30 38 Bt 8 1 65 57 33 17 3 * * 12 20 24 28 32 36 40 106 2 MAR 8S A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE C A L C i ltr"l A N D 5 f X - S P f T O F c c A&e-STiwonf> . D i z £ D M > R . T r t H T V RATETS 2 0 : 4 5 : 4 9 U n i v e r s i t y of B r i t i s h C o l u m b i a = r 0 R _ H - i -PEX-trw s 10 rvl C " A L t T ^ DOWN: CA WATERBORNE CALCIUM 3 9 ACROSS: 15 V 21 27 STANDARDIZED MORTALITY RATE (f*r loo.-ooo) 33 39 45 51 ' 57 73 G5 57 33 25 * * * * 2*2 *2* 18 24 36 2 MAR 86 20:46:27 DOWN: 107 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE C f l L U l i r t ArJT, 5ex-S PEOFIC AG ET-ST/vNDrtftDliEm MDft.ALiW IWIt-: University of British Columbia F o ( t MsirAsiTS OP ThC AscrETLi es, V!T> N S , f T C • / . r-lAi_£-S (C./^ ACROSS: STANDARDIZED MORTALITY RATE CPe' i°°.0Oo) J ' 35 45 55 65 75 85 95 WATERBORNE CALCIUM 5 15 25 81 73 49 33 25 17 •2* 2 4 2 57 49 25 0 10 20 30 40 50 60 70 80 90 100 W 2 MAR 86 20:46:58 CA A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE C A L C I U K ! AND S rX-SProF lc A£T- A(LDVi€T> MART* I irv /U=FT££ U n i v e r s i t y of B r i t i s h Columbia . r o f i , / U u D l S c f t S c - c A T r e u e i E S Ca-a.rtcD / . V i A u r s WATERBORNE CALCIUM (^ V1-) ACROSS: STANDARDIZED MORTALITY RATE loO;6o'o) 208 242 276 310 344 378 412 446 480 514 81 73 + + 7 3 65 + * + 6 5 57 I + 5 7 I * * * I 49 + + 4 9 j t * I 4 1 + * * + 4 1 T * I I * I 33 + * * + 3 3 T * I J * * * . 1 25 + * + 2 5 I * * 1 T * I 17 + * + 1 7 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 A i s l B SEX-SPECIFIC A G £T - -STANDARD I^ETD TOR.TW.ITY R A T E T S 2 0 : 3 7 : 3 3 U n i v e r s i t y o f B r i t i s h C o l u m b i a PoR. _ R t f - r U ^ A - r i c tr£WR1 D i 5 t ' . f l S E " / F £ M H i - £ S DOWN: MG WATERBORNE " " / L ) ACROSS: SMR 1 3 5 7 9 81 73 65 57 49 33 STANDARDIZED MORTALITY RATE IOO,OOOJ) 11 13 15 17 19 81 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE W u i u r t AND A S r i A ' s 2 0 . 3 8 : 0 5 U n i v e r s i t y of B r i t i s h C o l u m b i a PbR Ch-R.orJiC- Rtte-a^Arric HETAR.T DissASE-/FO-IALCS ACROSS: " STANDARDIZED MORTALITY RATE ^f^f_ 10o,OOo") 22 28 34 40 46 52 58 HA DOWN: MG 81 73 33 25 WATERBORNE CALCIUM 4 10 / / / 2 MAR 8 6 A P I L O T S T U D Y O F T H E R E L A T I O N S H I P B E T W E E N W A T E R B O R N E O v u c i u ^ i A M D A s r l f . 1 * 2 0 : 3 8 : 3 9 U n i v e r s i t y o f B r i t i s h C o l u m b i a F o r ^ A R . T o R . i o s c L e R e . r f t A N D D e & e r r J F R A - n v e - H - C T H ^ T D i s e r Y S t r -D O W N : MG W A T E R B O R N E CALCIUM ( ^ / L ) A C R O S S : S T A N D A R D I Z E D M O R T A L I T Y R A T E (per 100,006) 07?; 8 1 7 3 6 5 5 7 4 1 2 5 1 7 1 5 9 2 1 7 3 3 3 3 9 1 4 4 9 5 0 7 5 6 5 6 2 3 6 8 1 8 1 3 3 1 3 0 1 8 8 2 4 6 3 0 4 4 2 0 7 1 0 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^  o t h e r d i s e a s e ' s »FTH£ ft-E-ftRrr/FETiAUErs / ( Z) DOWN: MG WATERBORNE CALCIUM • (nfl/O ACROSS: 3 9 "15 J 21 27 STANDARDIZED MORTALITY RATE^ per 100,000*) 33 39 45 51 57 73 65 57 33 25 17 * * * * 2 •22 3* « 30 MAR 8S 39:4 1 M G A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE C A L t W " A r J 0 «Sn».\ U n i v e r s i t y of B r i t i s h Columbia E&K^ ^ yp f R - r p J s i o r-I / f E M A c f S WATERBORNE <LA1_C1U^ 4 12 20 28 ACROSS: 36 STANDARDIZED MORTALITY RATE / p e r ( O 0,oodf) 52 60 65 76 8 1 65 57 33 22" 15 24 32 40 48 56 64 72 80 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE C f t l X l u n AND Asr\R. S" 20:40:15 U n i v e r s i t y of B r i t i s h Columbia p^R. D i s o v s e r s oF T H E fR-reTye^, TONS, e"-ro / FE>~<P<<~£rs DOWN: MG 73 65 49 33 25 WATERBORNE .CALX! U K 8 18 28 (T^J/lJ) ACROSS: 38 48 STANDARDIZED MORTALITY RATE Cper <00,00o) 58 68 78 88 98 IIH 2 MAR 86 20:40:48 DOWN: MG \\5 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE C A L C I U M /Wt> A - S M * ' S U n i v e r s i t y of B r i t i s h Columbia Pop, A L L . H E - A R T S l t r f t s c C A T e-G-ay. vers aortoxJe-D/FEWAce-S . (T^M ACROSS: 442 518 WATERBORNE C ^ i - C I U ^ 214 290 366 STANDARDIZED MORTALITY RATE ^ P-c <»«,ooo\ 594 670 746 822 898 _ + + + -73 65 57 33 25 * 2 2 * * * * * « * * *424 176 252 328 404 480 556 632 708 784 860 936 S C A T T E R G R A M S O F R E S U L T S C O R R E L A T I O N ! B E T W f e e N W A T E R 6 D P . M E M A G N E S I U M A N D S^-SPFC\FIC £\G~£-- S T A N D A R D \ UE D M & R T A L I T V R A T E - S F O R . S EV/CKJ C / . T E & f l R .1 -ES OP r t e ^ f v r D I S E A S E R 8 6 A P I L O T S T U D Y OF T H E R E L A T I O N S H I P B E T W E E N W A T E R B O R N E M ( \ G M £ " S ( U M A N D specific AGe-.S77WOA<M>i:zED MORTALiTr RATES (ASM* : 1 1 University of B r i t i s h Columbia f0l< R H c ^ r . c . H E R R X w s o v s r / M A L E - . .('•jl1-) A C R O S S : S T A N D A R D I Z E D M O R T A L I T Y R A T E looj^oo^ W A T E R B O R N E l"]A-GrJ£:siUr\ 1 3 5 SO R 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE MiyJ-Jcsiun A N D A5<n<^'s :42 U n i v e r s i t y of B r i t i s h Columbia F O R cvifox-fic i^euMflnc K-£-*<vr D I S E T A S E " " / n < « - f 5 MG WATERBORNE MAGNESIUM .(r^jl^ ACROSS: STANDARDIZED MORTALITY RATE (pur I O a O O C > ) 2 6 10 14 18 22 26 30 34 38 + + + + + + + + + + + + + + + + + + + + + . 60 + + 6 0 54 + + 5 4 I * I 48 + + 4 8 42 + + 4 2 36 + + 3 6 30 + + 3 0 I * ^ 24 + + 2 4 I * I I * 1 18 + * * + 1 8 I 2 * * I 12 I + 1 2 T * * I I * * I j * * I g + * * * + 6 I * * * * I I * * I I 2 * I 1 * * 2 * * * * 2 2 2 I 0 + * * 3**422 2 + O + + + + + + + + + + + + + + + + + + + + + 0 4 8 12 16 20 24 28 32 36 40 R 8 6 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE M A & * l C S H A . r \ A M D /VI I - I« . X S : 2 2 U n i v e r s i t y of B r i t i s h Columbia F O R , 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 1 9 5 2 2 3 251 2 7 9 3 0 7 3 3 5 3 6 3 3 9 1 4 1 9 4 4 7 6 0 6 0 181 2 0 9 2 3 7 2 6 5 3 2 1 3 * » * 3 4 9 * * * * * 4 0 5 4 6 1 AR 8G A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE n f t f e T s m n fvrjp A s n « ' 3 0:51 U n i v e r s i t y of B r i t i s h Columbia P o p . o n t r K . p i s e n o r s df- "TH-er ftSVR.T / W A L E ' S MG WATERBORNE MAGNESIUM ' (^j/O ACROSS: STANDARDIZED MORTALITY RATE £per (00,000) 2 6 10 14 18 22 26 30 34 38 + + + + + + + + + + + + + + + + + + + + + . 60 + + 6 0 54 + + 5 4 I * I 48 + + 4 8 42 + + 4 2 36 + + 3 6 30 + + 3 0 I * I 24 + + 2 4 T * I T * I 18 + * * + 1 8 T * * * * I I * I 12 + * + 1 2 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 W S I E S . U M /"rSi-if^'s U n i v e r s i t y of B r i t i s h Columbia PoR- KVP^^TTEriMSio^i / MA-UETS WATERBORNE MAGNESIUM . 3 9 15 / " W O 21 ACROSS: 27 STANDARDIZED MORTALITY RATE (f"~ ico^oo) 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 M A < W E S ' a / - i AN IQ M M R ' S : :13 U n w e r s l t y of B r i t i s h Co lumbia p 0 R i SiSEVvseTS •»=- T H E " AArrtrR i es , v/r irJs, E T T C • //"><•> <-6"S WATERBORNE MAGNESIUM (-Wl-) ACROSS: STANDARDIZED MORTALITY RATE (per- too,ooo^ 5 15 25 35 45 . 55 65 75 85 95 MG 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 « « ^ r s i w M ArJD ASn«.S 2:57 U n i v e r s i t y of B r i t i s h Columbia fo- a ftu_ H-fflRT Pi5e"«se 60 WATERBORNE MAGNESIUM 208 242 276 ( ^ / O ACROSS: 310 344 STANDARDIZED MORTALITY RATE ^ p c W6,ooo) 378 412 446 480 514 60 * * * * * 191 225 259 327 * 2 2 2 * * * 2 * + - y + L 395 429 463 497 MAR 8G : 20:02 MG A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE H<W-I-MTSI«M « « D S£5I-5P«-IPI<I n < Z E - S - r w D t w » 2 £ D MORTALITY RATES U n i v e r s i t y of B r i t i s h Co lumbia pofk RHeunfYr iC- H-E-frR-T D ( 5 E > . s t _ / . . f e n f l u C S WATERBORNE MAGNESIUM 1 3 ACROSS: STANDARDIZED MORTALITY RATE (per l o o , o o 0 \ 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 U n i v e r s i t y of B r i t i s h Columbia F-oR. CfrRoUic RHEUMATIC HEART DisrASET / f f f n <M_£TS WATERBORNE MAGNESIUM (T^/1-) ACROSS: STANDARDIZED MORTALITY RATE ( p * r loo,ooo) 4 10 16 22 28 34 40 46 52 58 \l5 * * * * * * ** * * * * 2 22** *** 2 22**2 32 ** 2 60 48 30 12 13 25 31 37 49 55 2 MAR 86 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE MA6-fJe"s>u.M » « = «5n«'s o i K « e 20:21:29 U n i v e r s i t y of B r i t i s h Columbia DOWN: MG WATERBORNE MAGNESIUM f - j / O 159 217 275 333 IIS) ACROSS: 391 STANDARDIZED MORTALITY RATE (p*<- ( O o,ooo) 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 20:22:20 D O W N : MG 60 54 36 30 24 12 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE Mftl<Je5iu« U n i v e r s i t y of B r i t i s h Columbia WATERBORNE MAGNESIUM 3 9 15 ACROSS: 27 ! N E r i / t f j e r s i u f - ' /"+MT> f i i n n s , STANDARDIZED MORTALITY RATE (per 100,000) 33 39 45 5_1 57 IZ7 2 MAR 86 20:22:56 DOWN: MG A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE i-|PrC-*t «iui-l A N D ASMR s U n i v e r s i t y of B r i t i s h Columbia FOK KYPfTftT-tTNs.ori / F f n A L f S IZ8 60 54 48 42 36 30 24 18 WATERBORNE MAGNESIUM... 4 12 20 ACROSS: 36 STANDARDIZED MORTALITY RATE (pzr 1 0 0 , 0 0 0 ) 44 52 60 68 76 2 MAR 86 20:23:32 DOWN: 60 .30 18 \Z3 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE M A < W « > u M fl-rJn flS^K 5 U n i v e r s i t y of B r i t i s h Columbia FOR. P l^F^ s e ^ s of Tttfr A K T T T R I C S , VJTIMS, STANDARDIZED MORTALITY RATE CW " " V 0 0 0 ) 58 68 78 88 98 WATERBORNE MAGNESIUM 8 18 28 ACROSS: 48 2 MAR 86 20:26:40 DOWN: 130 A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE M W i J K i u n /vr>/D *SMR 5 U n i v e r s i t y of B r i t i s h Columbia F O R . / ^ C H E T B R - T " T>.Sfc-7*se- C A - T E . R . E " S c n R . ^ p / F m ^ S WATERBORNE MAGNESIUM . ("J /-) ACROSS: 214 290 366 442 518 STANDARDIZED MORTALITY RATE (per 1 0 0 , 0 0 0 ) 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 1 3 ] S C A T T E R . G - R A M S O F R E S U L T S CORRELATION! B E T W E E N ! WATE<^HAR>Dlsl£SS> AND SEX. "SPflCl F | C  A G - E - S T T X N D f t R - P I Z - E P HOPCTPKU )TV RATIOS F & R . S £ V £ l \ l C A T - E X S O R , i g S O F HEftRr D I S E A S E 22 OCT 8.5 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF D R I N K I N G W A T E R A N D HEART D15EASC 0 9 : 4 5 : 2 4 U n i v e r s i t y o f B r i t i s h C o l u m b i a 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. ( V r t E U M A T l C HETAB.T DISETfl-Se) FOR. THE ygAR,* IT5S-I178 364 319 + 2 2 2 3 + 4 * 4 3 9 + 6 1240 1736 1984 2232 S T A N D A R D H E ' D Mo;Vr7U-iTr R A T I O S 22 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF DRINKING- wftTER. AND HEPiR.r DISEASE "09:44:44 U n i v e r s i t y of B r i t i s h Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE --20 60 100 140 ACROSS: SMR STANDARDIZED MORTALITY RATIO 180 220 260 300 340 I33 454 409 t B A S E D ol4 MAXe D E A T H S D u e To I <-0 7 CATEGORIES HlO - Hit L'C.HAONIC RHCUr lATlC H r E f t f c T Dl S ^ f t S E ^ FOR r*tr ytTAR.* 1154.-197 8 409 49 364 319 274 274 229 229 £ 184 I" O i3g 184 139 4 + 2 *3 ** 3 * •* + + + + + + + + + + + + + + + + + + + + + +. 0 40 80 120 160 200 240 280 320 360 400 22 OCT 85 09:43:52 DOWN: DWHV A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS O F D R i h l K l N G W A T E R . AND HEART DISEASE U n i v e r s i t y of B r i t i s h Columbia 454 DRINKING WATER HARDNESS VALUE -- ACROSS: SMR 1 STANDARDIZED MORTALITY RATIO 104 210 31S 422 528 634 740 846 952 1058 454 409 + BASED ofi M A I X DEATHS C U E T o ItD 7 CATeG - 0« l£S H AO - H10. (^ ARTERiO S C L E R.OTK A^D vece^CM-kilB FOR. T H E yeARs l 9 5 t - / < ) 7 8 ') 409 3 19 3 19 274 274 229 229 < <n 184 O <-< 139 94 184 *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" 09:42:53 U n i v e r s i t y of B r i t i s h Columbia 135 DOWN: DWHV 454 409 DRINKING WATER HARDNESS VALUE --15 45 75 105 _ H i + H h -) H + -ACROSS: SMR 135 STANDARDIZED MORTALITY RATIO 165 195 225 255 285 +" BASED ON MALE DEATHS DUE T o ICD7 CATE&OR.ICS, H 3 0 - H 3 H [ OTHER DISEASES OF THEf rttTARi ") FoR THE y EARS 1156 -1478 454 409 274 274 94 229 O 184 139 184 49 49 30 * * 2* * *2 60 90 120 150 180 210 240 270 300 22 UCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF D R . I N K . I M 6 - W A T E R . AND HEART D I S E A S E '09:42:05 U n i v e r s i t y of B r i t i s h Columbia DOWN: DWHV 454 DRINKING WATER HARDNESS VALUE -- ACROSS: SMR"1" STANDARDIZED MORTALITY RATIO 15 45 75 105 135 165 195 225 255 285 + 454 409 + B A S E D O N MUZ. D E A T H S D U E : T O I C O 7 C A T E T S - O t i e r s , i < H o - 4 H 7 ^ H Y P E R T E V I S I O M ) F O R T H E y e A R S 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 2 2 OC'f 8 5 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF PRII-JK.IN&- WATER A N D HEART DISEASE; 0 9 : 4 1 : 0 8 U n i v e r s i t y of B r i t i s h Columbia 137 DOWN: OWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR1 STANDARDIZED MORTALITY RATIO 9 2 7 4 5 6 3 81 9 9 117 135 153 171 4 5 4 BASED OH f-IALET DEATHS DUE To ICQ 7 tATftf «RICS, HSo -M « (DISEASES o F TKST ARTERIES, iris , E r e ) P o * . T R E " ye"rtR.s /95i>-|<?79 4 5 4 4 0 9 2 7 4 229 3 6 4 3 19 3 1 9 ~~1 n o 1 8 4 1 3 9 184 139 + L. 18 5 4 9 0 108 126 162 1 8 0 3 0 OCT 8 5 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF D R I N K - I M G VJRTER. AMD HEAR.T D I S E A S E USlivffr 0 8 : 3 7 : 5 5 U n i v e r s i t y of B r i t i s h Columbia S T A N D A R D I Z E D M O R T A L , ™ J R A T U S DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR"*" STANDARDIZED MORTALITY RATIO 5 1 5 9 G 7 7 5 8 3 9 1 9 9 1 0 7 1 1 5 123 158 4 5 4 t B A S E D O M MALE: DETATrtS D U E To |CD T CATE &OR.IES, Hoo - % "3 (rtLL HEART U R E A S E S C O I - I O I N E D ) FoR. THE VKARS IISt-1178 4 5 4 4 0 9 3 6 4 2 7 4 2 2 9 184 * * 9 4 49 4 + . + -4 7 6 3 7 1 8 7 103 111 119 127 S T A N D A R D I S E D M O R T A L I T Y R A T I O S 22 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OP ORINKIM& WATER AND HEART DISEASE: USiMG-S T A I N / D A R D I I E D h a f t r d L i r v R A T I O S C9:40:21 U n i v e r s i t y of B r i t i s h Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE --172 51G 860 1204 ACROSS: 1548 SMR STANDARDIZED MORTALITY RATIO 1892 2236 2580 2924 454 409 + 8 A S E D Of-J FEMALE" DEATHS X>UE" To IC07 CATT»OK.IE;S , HOO - HOa. ( J J H E U M A T I C H - £ A R . T D I S E A S FOR THE ytARS H54>-l')78 364 319 274 n 184 O 12 12 + 4 12 14 13 19 +9 344 1032 1376 1720 2064 2408 5TArNDP.R.DlZE"D MORTALITY RATIOS 3096 3440 .IHO 22 0<"T 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF DRI^KlMG- W A T E R AMD H E A R T DISEASE 09:s5":01 U n i v e r s i t y of B r i t i s h 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 I ^ 0 f tS£O ON PEMAUT DEATHS Dus T o I C D 7 C A TETG-0 K.I E S , 4lO-4(fc> (j-!fROf'IC RtiEUMArit IrtART D l S O S c ) 4 0 g + FoR, T H ET yETARS I l 5 t - | l 7 8 + J09 364 + ' + 364 3 1 9 + + 3 19 I * I 274 + + 274 229 + + 229 -J I I If1 \ • - ! fl 184 * + 1 8 4 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- Dl s r f t S E T 09:38:09 U n i v e r s i t y of B r i t i s h Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE --53 7 1 89 107 ACROSS: 125 SMR STANDARDIZED MORTALITY RATIO 143 161 179 197 454 409 ^ B A S E D Or) FEr^ALST DEATHS 0\x£~ To , C D 7 <^Tir&<)/?JErS, 41o-flO. (n«.re P*WSCi£P-ST\C A.\lD P eCENFRA-, l MC) H E A R T - P I S E A S r Fo A. THC V6AR.S 11 5fo "111 409 364 319 229 229 184 O 184 139 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: 09:37:07 U n i v e r s i t y of B r i t i s h Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE -- ACROSS: SMR~^  STANDARDIZED MORTALITY RATIO 20 60 100 140 180 220 260 300 340 380 .4- + + + + + + + + + + + + + + + + + + + + . 454 + + I + B A S E D ON F E M f t i r DEATHS D U E T o , cD 7 H 3 o -H 3 4 ( ° T ^ D K r A S " °" " £ A R T ^ I F o a T H E " y ^ * * 5 l i s t -i<?71? + 364 319 274 r. 3 139 9 4 4 9 '2 * 40 80 2* 120 M2i 454 409 364 319 274 229 184 139 94 49 22-OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS O F DRINKING- WATER- AND HEAB-T D I S E A S E 09:35:43 U n i v e r s i t y of B r i t i s h Columbia 4 18 DOWN: DWHV DRINKING WATER HARDNESS VALUE --22 6G 110 154 ACROSS: SMR ' STANDARDIZED MORTALITY RATIO 198 242 28G 330 374 454 409 + SASETO ON F E M A L E D E A T H S D U E To | C P 1 C A T E « * l E S y HlO-^Hl Lj+YPiTRTeNS v6INl) FoP- THE ye:ARS \15<e -\17K 3G4 319 274 274 -4 229 O 184 O 139 184 139 * * 2 2 * * 88 132 264 308 352 22 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS OF- DRlNXlNtV WATER- A N O HEART D I S E A S E 00:13:01 U n i v e r s i t y of B r i t i s h Columbia DOWN: DWHV 454 409 DRINKING WATER HARDNESS VALUE -- ACROSS: SMR ' STANDARDIZED MORTALITY RATIO 5G 74 92 110 128 146 164 182 200 218 1"pAseO oN FCrlRLE BEATriS DUE T o I CD 7 C A T E 6 0 R 1 C.S , t S O -4-G ? LDlS E"A5 F/S OF THE" ARTERIES,VEt N?, ETt) FOR. T H E- yeA«-S l l S t o - I ^ S 274 o 4 + 47 65 83 3 4 • 101 2 2 137 209 227 -30 OCT 85 A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS 0 F DRINKING- WftreR AND H£Ae.r DlSfcftSE 08:39:19 U n i v e r s i t y of B r i t i s h Columbia DOWN: DWHV DRINKING WATER HARDNESS VALUE --75 91 • 107 123 ACROSS: SMR 139 + STANDARDIZED MORTALITY RATIO 155 171 187 203 409 3 A 3 E D ON FEMRUT DEATHS DUE: To I CD 7 t R T e « » R | E S , 4 0 O ~4 6 $ (jiLL H £ART~ D 13 EASE'S tun-lQjNrtO F»R THE y S T A R S IT 56> " I T 78 364 319 274 O 184 * * 94 4 + * 67 * * + •22*23 83 147 163 195 21 1 227 IH5 454 409 364 319 274 229 184 139 94 49 46 D. SUMMARY OF RESULTS The p a t t e r n of h e a r t d i s e a s e m o r t a l i t y i n B r i t i s h Columbia i s not a d e q u a t e l y e x p l a i n e d by the h y p o t h e s i s t h a t water hardness i s i n v e r s e l y a s s o c i a t e d w i t h h e a r t d i s e a s e m o r t a l i t y . There were, of c o u r s e , a number of l i m i t a t i o n s t o the data used i n t h i s s t u d y , and a number of assumptions were made i n o r d e r t o d e a l w i t h the a v a i l a b l e d a t a . These were d e t a i l e d p r e v i o u s l y i n P a r t IV, and i t may be t h a t s e v e r a l of the assumptions were not c o r r e c t . In a d d i t i o n , t h e r e a re s u s p e c t e d r i s k f a c t o r s f o r h e a r t d i s e a s e i n a d d i t i o n t o water ha r d n e s s . These o t h e r f a c t o r s may be more i m p o r t a n t . D i e t and l i f e s t y l e a r e noted h e a r t d i s e a s e r i s k f a c t o r s . Would d i f f e r e n c e s i n d i e t or l i f e s t y l e account f o r h e a r t d i s e a s e m o r t a l i t y v a r i a t i o n s i n B r i t i s h Columbia, or would these f a c t o r s be masking any r e l a t i o n s h i p between hard water and h e a r t d i s e a s e m o r t a l i t y ? Comstock's study, which was mentioned e a r l i e r i n t h i s t h e s i s , i n v o l v e d 412 cases and c o n t r o l s i n Ma r y l a n d who were matched f o r age, socioeconomic s t a t u s , m a r i t a l s t a t u s , and smoking h a b i t s . 1 T h i s i s one of the few s t u d i e s which t r i e d t o look a t s u b j e c t s s i m i l a r i n most r e s p e c t s , but who were exposed t o d i f f e r e n t l e v e l s of water h a r d n e s s . The water h y p o t h e s i s was not supported by Comstock's s t u d y ; A l l w r i g h t ' s e c o l o g i c a l study, a l s o mentioned i n the l i t e r a t u r e r e v i e w , matched p o p u l a t i o n s of t h r e e communities on socioeconomic s t a t u s (a way t o ensure comparable l i f e s t y l e s ) , and, a g a i n , the water h y p o t h e s i s was 'Cornstock 1971 1 4 7 n o t s u p p o r t e d . T h i s B r i t i s h C o l u m b i a s t u d y d i d n o t match p o p u l a t i o n s w i t h r e s p e c t t o l i f e s t y l e , and i t may be t h a t l i f e s t y l e f a c t o r s a r e more i m p o r t a n t i n d e t e r m i n i n g h e a r t d i s e a s e m o r t a l i t y i n B r i t i s h C o l u m b i a . To d e t e r m i n e w h e t h e r a s s o c i a t i o n s e x i s t b e t w e e n t h e s e o t h e r r i s k f a c t o r s and h e a r t d i s e a s e m o r t a l i t y , p r o v i n c i a l - w i d e i n f o r m a t i o n f o r l e v e l s o f p h y s i c a l a c t i v i t y , s m o k i n g , d r i n k i n g , a n d serum c h o l e s t e r o l l e v e l s o f s c h o o l d i s t r i c t p o p u l a t i o n s s h o u l d be g a t h e r e d . T h i s " " may h e l p t o e l u c i d a t e t h e s p e c i f i c c o n t r i b u t i o n s o f t h e v a r i o u s h e a r t d i s e a s e r i s k f a c t o r s t o h e a r t d i s e a s e m o r t a l i t y , a n d c l a r i f y t h e s i g n i f i c a n c e o f w a t e r h a r d n e s s i n h e a r t d i s e a s e m o r t a l i t y . Many s c h o o l d i s t r i c t s where m i n i n g and p u l p a n d p a p e r i n d u s t r i e s a r e i m p o r t a n t ( e . g . K i t i m a t , T r a i l , P o w e l l R i v e r , e t c . ) have h i g h h e a r t d i s e a s e m o r t a l i t y r a t e s . One c o u l d s p e c u l a t e t h a t p e r h a p s t h e r e a r e h i g h e r r a t e s o f s m o k i n g , d r i n k i n g , and c h o l e s t e r o l i n t a k e among t h e p o p u l a t i o n s o f t h e s e d i s t r i c t s . The w o r k i n g p o p u l a t i o n c o u l d be p r i m a r i l y men who have c h a r a c t e r i s t i c s and h a b i t s w h i c h p l a c e them i n a h i g h r i s k c a t e g o r y . More i n f o r m a t i o n on l i f e s t y l e s and d i e t a r y f a c t o r s w o u l d a l l o w f u r t h e r a n a l y s e s t o be made. A m a j o r a s s u m p t i o n o f t h i s s t u d y was t h a t t h e r e was no m i g r a t i o n o f t h e s t u d y p o p u l a t i o n s . I f t h e r e were h i g h e r r a t e s o f m i g r a t i o n t o o r f r o m s c h o o l d i s t r i c t s w h i c h do n o t r e v e a l t h e e x i s t e n c e o f an i n v e r s e a s s o c i a t i o n b e t w e e n w a t e r h a r d n e s s a n d h e a r t d i s e a s e , t h e n any a s s o c i a t i o n between w a t e r h a r d n e s s and h e a r t d i s e a s e m o r t a l i t y m i g h t h a v e been J 1 48 masked. The m o b i l i t y s t a t i s t i c s o f t h e p r o v i n c e do n o t s u g g e s t t h a t m i g r a t i o n i s a s i g n i f i c a n t f a c t o r . 1 The r a t i o o f movers t o non-movers i s s i m i l a r , f o r e x a m p l e , i n t h e s c h o o l d i s t r i c t s o f M i s s i o n , V a n c o u v e r I s l a n d N o r t h , P e a c e R i v e r , C e n t r a l O kanagan, and N e c h a k o . \ S t a t i s t i c s Canada 1981b ( v i d e b i b l i o g r a p h y ) 14<? D. CONCLUSION H e a r t d i s e a s e i s a m a j o r h e a l t h p r o b l e m i n t h e w o r l d t o d a y . H e a r t d i s e a s e i s t h e m a j o r e p i d e m i c o f modern t i m e s i n t h e t e c h n o l o g i c a l l y - a d v a n c e d c o u n t r i e s , where i t a c c o u n t s f o r r o u g h l y 50 p e r c e n t o f a l l c a u s e s o f d e a t h . 1 Owing t o t h e m u l t i f a c t o r i a l n a t u r e o f h e a r t d i s e a s e , i t i s d i f f i c u l t t o e s t i m a t e e x a c t l y t h e s p e c i f i c c o n t r i b u t i o n o f e a c h i n d i v i d u a l r i s k f a c t o r . F o r e x a m p l e , i t i s d i f f i c u l t t o c l a r i f y t h e a s s o c i a t i o n b e t w e e n d i e t a r y c h o l e s t e r o l and h e a r t d i s e a s e b e c a u s e o f t h e c o n c o m i t a n t r i s k f a c t o r s o f o b e s i t y , h y p e r g l y c e m i a , a n d h y p e r t e n s i o n . T h e r e a r e many s u s p e c t e d h e a r t d i s e a s e r i s k f a c t o r s a n d none a r e e a s y t o a s s e s s i n d i v i d u a l l y . I n t h i s s t u d y , no r e l a t i o n s h i p was f o u n d b e t w e e n w a t e r h a r d n e s s a n d h e a r t d i s e a s e m o r t a l i t y . I n f o r m a t i o n on p a t t e r n s o f s m o k i n g , d r i n k i n g , s t r e s s , p h y s i c a l a c t i v i t y , and d i e t a r y h a b i t s s h o u l d be s o u g h t t o compare w i t h t h e p a t t e r n o f h e a r t d i s e a s e m o r t a l i t y i n t h e d i s t r i c t s . The r e l a t i v e i m p o r t a n c e o f many h e a r t d i s e a s e r i s k f a c t o r s m i g h t t h e n be a s s e s s e d . From t h e r e s u l t s o f t h i s s t u d y one c a n c o n c l u d e t h a t : 1. T h e r e a p p e a r s t o be no r e l a t i o n s h i p b e t w e e n h e a r t d i s e a s e m o r t a l i t y a n d s o f t w a t e r , a t l e a s t a t t h e e c o l o g i c a l l e v e l o f a n a l y s i s i n B r i t i s h C o l u m b i a ; 2. O t h e r r i s k f a c t o r s may be more i m p o r t a n t t h a n w a t e r h a r d n e s s i n d e t e r m i n i n g h e a r t d i s e a s e m o r t a l i t y ; 1 W o r l d H e a l t h S t a t i s t i c s A n n u a l 1985 1 50 3. I f t h e r e i s any r e l a t i o n s h i p b e t w e e n h a r d w a t e r and h e a r t d i s e a s e m o r t a l i t y , more d e t a i l e d m ethods o f a n a l y s i s a r e n e c e s s a r y t o d e t e c t i t . BIBLIOGRAPHY A l d e r s o n , M . , International Mortality Statistics. F a c t s on F i l e , I n c . New Y o r k 1981 A l l w r i g h t , S . P . A . , C o u l s o n , A . , D e t e l s , R . , e t a l . , M o r t a l i t y a n d w a t e r - h a r d n e s s i n t h r e e m a t c h e d c o m m u n i t i e s i n L o s A n g e l e s . Lancet ( 2 ) , 1 9 7 4 :860-64 A l t u r a , B . M . , S u d d e n - d e a t h i s c h e m i c h e a r t d i s e a s e a n d d i e t a r y m a g nesium i n t a k e - - I s t h e t a r g e t - s i t e c o r o n a r y v a s c u l a r s m o o t h m u s c l e ? Medical Hypotheses. 1979:1-6 Anderson,T,W., The c h a n g i n g p a t t e r n o f i s c h e m i c h e a r t d i s e a s e . Can Med Assn J. ( 1 0 8 ) , 1973: 1500-04 Anderson,T.W., A new v i e w o f h e a r t d i s e a s e . New Scientist ( 9 ) , 1 9 7 8 : 3 7 4 - 7 6 Anderson,T.W., L e R i c h e , W . H . , Sudden d e a t h f r o m i s c h e m i c h e a r t d i s e a s e i n O n t a r i o a n d i t s c o r r e l a t i o n w i t h w a t e r h a r d n e s s a n d o t h e r f a c t o r s . Can Med Assn J ( 1 0 5 ) , 1971: 155-60 Anderson,T.W., Le Riche,W.H., M a c K a y , J . S . , Sudden d e a t h a n d i s c h e m i c h e a r t d i s e a s e c o r r e l a t i o n w i t h h a r d n e s s o f l o c a l w a t e r s u p p l y . 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J . , W a t e r H a r d n e s s a n d M o r t a l i t y i n t h e N e t h e r l a n d s , Sci Total Env,(]8), A p r i l 1 9 8 1 : 35-45 ABBREVIATIONS A c t a C a r d i o l : A c t a C a r d i o l o g i c a A c t a Med S c a n d : A c t a M e d i c a S c a n d i n a v i c a Am J C l i n N u t r : A m e r i c a n J o u r n a l o f C l i n i c a l N u t r i t i o n Am J E p i d : A m e r i c a n J o u r n a l o f E p i d e m i o l o g y Am J P u b l H e a l t h : A m e r i c a n J o u r n a l o f P u b l i c H e a l t h Ann I n t e r n Med: A n n a l s o f I n t e r n a l M e d i c i n e B r J P r e v Soc Med: B r i t i s h J o u r n a l o f P r e v e n t i v e S o c i a l M e d i c i n e Can Med A s s n J : C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l I n t J E p i d : I n t e r n a t i o n a l J o u r n a l o f E p i d e m i o l o g y JAMA: J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n J Amer D i e t A s s o c : J o u r n a l o f t h e A m e r i c a n D i e t e t i c A s s o c i a t i o n J Amer W a t e r Works A s s o c : J o u r n a l o f t h e A m e r i c a n W a t e r Works A s s o c i a t i o n J C h r o n D i s : J o u r n a l o f C h r o n i c D i s e a s e s J C l i n P h a r m a c o l : J o u r n a l o f C l i n i c a l P h a r m a c o l o g y J Env P a t h o l T o x i c o l : J o u r n a l o f E n v i r o n m e n t a l P a t h o l o g y a n d Tox i c o l o g y J Hyg: J o u r n a l o f H y g i e n e J N u t r : J o u r n a l o f N u t r i t i o n New Eng J Med: New E n g l a n d J o u r n a l o f M e d i c i n e N u t r M e t a b : N u t r i t i o n a n d M e t a b o l i s m 1 59-1 hO N u t r Rev: N u t r i t i o n R e v i e w s P r e v Med: P r e v e n t i v e M e d i c i n e P r o c Roy Soc Med: P r o c e e d i n g s o f t h e R o y a l S o c i e t y f o r M e d i c i n e S c i T o t a l E n v : S c i e n c e o f t h e T o t a l E n v i r o n m e n t Soc S c i Med: S o c i a l S c i e n c e a n d M e d i c i n e 16 1 APPENDIX 1: DEFINITIONS 1. ANEURYSM: a p a t h o l o g i c a l b l o o d - f i l l e d d i l a t a t i o n o f a b l o o d v e s s e l 2. ANGINA PECTORIS: p a i n i n t h e c h e s t r e g i o n due t o an i n a d e q u a t e b l o o d a n d o x y g e n s u p p l y t o t h e h e a r t 3. AORTA: t h e l a r g e v e s s e l a r i s i n g f r o m t h e l e f t v e n t r i c l e a n d d i s t r i b u t i n g a r t e r i a l b l o o d t o e v e r y p a r t o f t h e body 4. ARRYTHMIA: i r r e g u l a r b e a t i n g o f t h e h e a r t 5. ATHEROSCLEROSIS: a c h r o n i c d i s e a s e i n w h i c h t h i c k e n i n g and h a r d e n i n g o f a r t e r i a l w a l l s i n t e r f e r e s w i t h b l o o d c i r c u l a t i o n 6. ARTERIOSCLEROSIS: t h i c k e n i n g o f a r t e r i o l e s o r s m a l l e s t a r t e r i e s 7. CARDIOMYOPATHY: any d i s e a s e o f t h e m y o c a r d i u m 8. CARDIOVASCULAR DISEASE: d i s e a s e p e r t a i n i n g t o o r i n v o l v i n g t h e h e a r t and t h e b l o o d v e s s e l s o r c i r c u l a t o r y s y s t e m . I t i s d e f i n e d by t h e I n t e r n a t i o n a l C l a s s i f i c a t i o n o f D i s e a s e s c o d e s 3 3 0 - 3 3 4 , 410-468 ( 6 t h / 7 t h r e v i s i o n s ) and 393-458 ( 8 t h r e v i s i o n ) 9. CASE-CONTROL DESIGN: g r o u p s a r e s e l e c t e d a s t o w h e t h e r t h e y do ( c a s e s ) o r do n o t ( c o n t r o l s ) h a v e t h e d i s e a s e o f w h i c h t h e e t i o l o g y i s t o be s t u d i e d , a n d t h e g r o u p s a r e c o m p a r e d w i t h r e s p e c t t o e x i s t i n g o r p a s t c h a r a c t e r i s t i c s w h i c h a r e j u d g e d t o be o f r e l e v a n c e t o t h e e t i o l o g y o f t h e d i s e a s e 10. CEREBROVASCULAR DISEASE: p e r t a i n i n g t o d i s e a s e of t h e 1 63-b l o o d v e s s e l s o f t h e b r a i n 11. CONTROL: i n d i v i d u a l s who do n o t ha v e t h e d i s e a s e o f w h i c h t h e e t i o l o g y i s t o be s t u d i e d , b u t h a v e t h e p o t e n t i a l f o r b e i n g e x p o s e d t o t h e same p u t a t i v e c a u s a l f a c t o r s o f t h e d i s e a s e 12. CORONARY: o f o r p e r t a i n i n g t o v e s s e l s , n e r v e s , o r a t t a c h m e n t s t h a t e n c i r c l e a p a r t o r an o r g a n ; p e r t a i n i n g t o c o r o n a r y a r t e r i e s 13. CORONARY ARTERY DISEASE o r CORONARY HEART DISEASE: a c o n d i t i o n t h a t r e d u c e s t h e b l o o d f l o w t h r o u g h t h e c o r o n a r y a r t e r i e s t o t h e h e a r t m u s c l e 14. CORONARY ARTERIES: b l o o d v e s s e l s t h a t e n v e l o p a n d n o u r i s h t h e h e a r t m u s c l e 15. CORONARY THROMBOSIS: t h e o c c l u s i o n o f a c o r o n a r y a r t e r y by a b l o o d c l o t , o f t e n l e a d i n g t o d e s t r u c t i o n o f h e a r t m u s c l e 16. CORRELATION COEFFICIENT: a me a s u r e o f t h e i n t e r d e p e n d e n c e o f two random v a r i a b l e s t h a t r a n g e s i n v a l u e f r o m -1 t o +1, i n d i c a t i n g p e r f e c t n e g a t i v e c o r r e l a t i o n a t - 1 , a b s e n c e o f c o r r e l a t i o n a t 0, and p e r f e c t p o s i t i v e c o r r e l a t i o n a t +1. 17. D I A S TOLIC BLOOD PRESSURE: a r t e r i a l b l o o d p r e s s u r e d u r i n g e x p a n s i o n o f t h e c a v i t i e s o f t h e h e a r t 18. DISORDERED CALCIUM METABOLISM: n o r m a l c a l c i u m m e t a b o l i s m h a s b e e n c h a n g e d 19. ECOLOGICAL CORRELATION: a c o r r e l a t i o n i n w h i c h t h e u n i t s s t u d i e d a r e p o p u l a t i o n s r a t h e r t h a n i n d i v i d u a l s . 1&3 C o r r e l a t i o n s f o u n d i n t h i s manner may n o t h o l d t r u e f o r t h e i n d i v i d u a l members o f t h e s e p o p u l a t i o n s . 1 20. HARDNESS, WATER: an i n d e x o f t h e l a t h e r t h a t f o r m s i n l a u n d e r i n g , w a t e r b o r n e c a l c i u m a n d w a t e r b o r n e magnesium a c c o u n t f o r 95 p e r c e n t o f t h e h a r d n e s s o f w a t e r . The measurement o f h a r d n e s s i s g e n e r a l l y " m i l l i g r a m s o f c a l c i u m c a r b o n a t e p e r l i t e r " , o r mg CaC03 p e r l i t e r . 2 1 . HEART DISEASE: an a b n o r m a l o r g a n i c c o n d i t i o n o f t h e h e a r t o r o f t h e h e a r t a n d c i r c u l a t i o n 22. I C D : i n t e r n a t i o n a l c l a s s i f i c a t i o n o f d i s e a s e s 23. ISCHEMIC HEART DISEASE ( I H D ) : l o c a l a n e m i a c a u s e d by m e c h a n i c a l o b s t r u c t i o n o f t h e b l o o d s u p p l y a n d a b n o r m a l f u n c t i o n i n g o f t h e h e a r t T h e r e a r e t h r e e m a j o r f o r m s o f h e a r t d i s e a s e : one m a j o r f o r m i s a t h e r o s c l e r o s i s w h i c h i n v o l v e s t h e p r o g r e s s i v e h a r d e n i n g o f t h e a r t e r i e s , i n c l u d i n g t h e c o r o n a r y a r t e r i e s . A s e c o n d f o r m i s c a r d i o m y o p a t h y where t h e damage i s s p r e a d t h r o u g h o u t t h e h e a r t , a n d may l e a d t o m y o c a r d i a l i n f a r c t i o n , The t h i r d m a j o r f o r m i s c h a r a c t e r i s e d by damaged v a l v e s , c a u s e d by i n f e c t i o n o r a c o n g e n i t a l d e f e c t 24. L I POPROTEIN: any o f a c l a s s o f c o n j u g a t e d p r o t e i n s c o n s i s t i n g o f a p r o t e i n c o m b i n e d w i t h a l i p i d 25. MORTALITY RATE: t h e p r o p o r t i o n o f d e a t h s i n a g i v e n y e a r and a r e a t o t h e m i d - y e a r p o p u l a t i o n o f t h a t a r e a , u s u a l l y e x p r e s s e d a s t h e number o f d e a t h s p e r 1000 o f p o p u l a t i o n 1 L a s t 1983 16*t 26. MYOCARDIAL INFARCTION: a n e c r o t i c a r e a o f t i s s u e r e s u l t i n g f r o m f a i l u r e o f a l o c a l b l o o d s u p p l y 27. MYOCARDIUM: m u s c l e t i s s u e o f t h e h e a r t 28. NECROSIS: t h e d e a t h o f a l i v i n g t i s s u e i n a p l a n t o r a n i m a l 29. PATHOGENESIS: t h e d e v e l o p m e n t o f a d i s e a s e d c o n d i t i o n 30. REGRESSION FUNCTION: g i v e n two d e p e n d e n t random v a r i a b l e s , r e g r e s s i o n f u n c t i o n m e a s u r e s t h e mean e x p e c t a t i o n o f one r e l a t i v e t o a n o t h e r 3 1 . R ELATIVE R I S K : d e f i n e d a s t h e r a t i o o f t h e i n c i d e n c e r a t e o f d i s e a s e f o r p e r s o n s e x p o s e d t o a f a c t o r t o t h e i n c i d e n c e r a t e f o r t h o s e n o t e x p o s e d . The p r o b a b i l i t y o f a c q u i r i n g t h e d i s e a s e . 32. RETROSPECTIVE: t h a t w h i c h i s d i r e c t e d b a c k w a r d s o r t o t h e p a s t 33. STENOSIS: n a r r o w i n g o f c e l l w a l l s 34. STENOTIC-THROMBOTIC: a c o m b i n a t i o n o f s t e n o s i s and thombus 35. STROKE: s u d d e n l o s s o f m u s c u l a r c o n t r o l w i t h d i m u n a t i o n o f l o s s o f s e n s a t i o n a n d c o n s c i o u s n e s s r e s u l t i n g f r o m r u p t u r e o r b l o c k i n g o f b l o o d v e s s e l s i n t h e b r a i n 36. SURFACE WATER: t h a t w h i c h i s f o u n d on t h e l a n d s u r f a c e 37. SYSTOLIC BLOOD PRESSURE: a r t e r i a l b l o o d p r e s s u r e d u r i n g c o n t r a c t i o n o f t h e c a v i t i e s o f t h e h e a r t 38. THROMBUS: a b l o o d c l o t o c c l u d i n g a b l o o d v e s s e l o r f o r m e d i n a h e a r t c a v i t y 39. ULCERATION: t h e d e v e l o p m e n t o f an i n f l a m m a t o r y l e s i o n on t h e s k i n 40. UNCOMPLICATED ANGINA PECTORIS: a n g i n a w i t h o u t a p r e c e d i n g m y o c a r d i a l i n f a r c t i o n 4 1 . URBAN RESIDENCE: i n t h i s r e p o r t i t r e f e r s t o r e s i d e n c e i n a c o m m u n i t y w i t h a p o p u l a t i o n o f more t h a n 1000 p e r s o n s 42. VASOCONSTRICTORS: c a u s i n g c o n s t r i c t i o n o f t h e b l o o d v e s s e l s 4 3 . VENTRICULAR ARRYTHMIA OR F I B R I L L A T I O N : an e l e c t r i c a l i n s t a b i l i t y o r d i s t u r b a n c e o f t h e h e a r t m u s c l e t h a t may l e a d t o s u d d e n d e a t h 44. VULNERABLE MYOCARDIUM: m u s c l e t i s s u e o f t h e h e a r t s u s c e p t i b l e t o i n j u r y o f any k i n d 16.6 APPENDIX 2: DETERMINATION OF WEIGHTED WATER HARDNESS V A L U E S F o r s c h o o l d i s t r i c t s w i t h more t n a n one l a r g e c i t y w i t h i n , a w e i g h t , b a s e d on t h e p o p u l a t i o n o f t h e s e c i t i e s , w i l l be u s e d t o f i n d a v e r a g e w a t e r h a r d n e s s v a l u e s . TO C A L C U L A T E WEIGHTED V A L U E : ( p o p u l a t i o n o f c i t y A ) ( w a t e r h a r d n e s s v a l u e o f c i t y A ) + (pop B ) ( w a t e r v a l u e B) d i v i d e d by (pop A + p o p B) e . g . S c h o o l d i s t r i c t #1 ( F e r n i e ) w h i c h h a s two m a j o r c i t i e s w i t h i n i t : C i t y A : F e r n i e ( P o p u l a t i on = 5-1 44 ; w a t e r h a r d n e s s v a l u e = 1 4 2 . O m g / L ) C i t y B : S p a r w o o d ( P o p u l a t i o n = 4 1 5 7 ; w a t e r h a r d n e s s v a l u e = l 8 0 . 0 m g / L ) To c a l c u l a t e w e i g h t e d v a l u e : ( 5 4 4 4 ) ( 1 4 2 m g / L ) + ( 4 1 5 7 ) ( 1 8 0 m g / L ) d i v i d e d by (5444 + 4157) = 773048 + 748260 d i v i d e d by 5444 + 4 157 = 1521308 d i v i d e d by 9601 = 1 5 8 . 5 m g / L W e i g h t e d h a r d n e s s v a l u e s f o r t h e o t h e r s c h o o l d i s t r i c t s a r e l i s t e d i n A p p e n d i x 3: W a t e r C l a s s i f i c a t i o n o f S c h o o l D i s t r i c t s . APPENDIX -3/ ; WATETf^ CLASSIFICATION OF SCHOOL DISTRICT'S SCKoOL DISTRICT T£- MAMET W E T l C r H T E D WEICrHTED WClG-t+TED ^ LAA&EST CITY WATER. WATER WATERBORMC WATEWBORME VJiTHI*! D I S T R I C T H A R D I N I E S S KftRDr-l&S6, CALC|U;N\ MAGNCSIUM VALUE mj/u VALUE; ' VALUE r*)/l- VALUGT ^ L E T T E R . t r J P A R E r l X H E S l S R E F E R S T o T H E W A T E R . O L A - S S I f r CflTIOrJ-i OP TttG S C H O O L . P \ S T R | C T ^ H-- H-AR.D , S - S O F T , 6 L A I ^ K « E^ l feU-ReOr. -I, FEXNlE (H) A- FE-RrJiEr B. S P A R V J O O P )go- 0 ] 15?. 5 2.. CRflrJSRooK (rt) C R A M B R O O K <?7 0 ^7-0 3 , KIM3E:R.LV (S) KIH&EKLV H- WllslDERr-lERX (H) |MV,£R(V1ERE 7- NELSON (S) % C A S T L E G A R , (S) 10. ARR.OVAI L A K E S 11. TRAIL, £s) N E L S O N C A S T L E G A R /0. O 205-O I 0-0 55". o 10.0 55~.0 MAKUSP HoT AVAILABLE rJ/A T R A I L R&S5LAMD F R U I T V A U C . M o N T R O S E " 46.7 3.1 3S 3.5 13.-7 lo. <J C\3I a.I rvl.A. IZ GRftf^ D F O R K S C R A N D FORKS M.A. f^ -A-13 KETTLE VAL-LEY MIDWAY N / .A. ISJ.A. IH- SOUTH OKANA&AisI OLIVER. 133 O S o V O O S 3°° 231-7 N.A. 65.3 M.A tf.A. |6.o 15. PEMriCTot^J (s) PENTlcToM iO.H )lo, KEREMETOS (tf) KE-RfTMEOS 132. 10. H 132-3-M 0.71 7.5 A P P E N D I X 3 : coNfiwueo:- W/VTETR. C L A S S I F I C A T I O N O F S t f + o o L . D I S T R I C T S SCH-OOU PI S T R I C T j» , W E I G H T E D W E I G H T E D W £ | & H T E D Jff- MAME. ^ L A R G E S T C I T Y W A T E R W n W WfrT*X8.ft/S MET W*TTEK8oK.J!r W i T r t i H DISTRICT H*«J3.N«S f+AApNESS C A L C I U M M A & W C S t u n V ^ L U E VALUE: . ^ / L vTYLu.er I^A/U VALUE" "-3 A-17.. P^iNceTOrJ (H) P r V i M C E T o r J S^.H 7J . H [ iT.M 5-1 IS.. <XX_DErJ (H) f 53 153 30,M 1 g. 1 1% R E V E T U S T O K e 6s) R E V E L S T O K C HO .O HQ. 0 ) 3, <g SpAU-umCHEEM J L U M 0 Y 2.IO Coi_D5TR.Eflr-\ 23 OrMTRAt-OKANAG-AM ('u') KELOWMA: 117 3o. SouTH C/VRiSoo (H) CACHE" CR£EK. 3LJI ASHCROPT 37.5 174.3 WO.'? 1-7.7 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 H o u s e " HZ3 ^ ' jr-, . r H46.6 5z.?> 5-2.0 WILLIAMS UAKE" 452- ) 2-0". anersrtEL (v\) O U E S M E L /<g<) j <^ 5 1 15 Z<?. M L L O O E T £H) L I L L O O E T 2.13 2.13 3 3 ' " 7 1 ^ ' ^ I 5 2 . 0 3 4 . H l<»\ \(p3 APPENDIX 3 corJTlrJyEP •, WftTER c L.A SS I F I CAT 10 rJ OF SCrrOOL. P'-TST-RlOPS 31. nrRRi-rr (V) 31. Hope: (S) L A R G E S T C i r y WITH-lr* D I S T R I C T f l E R R l T T H O P E 42. 56 33. C W I L L I W A C K (h) C H I L U I W A C K mo 3H. A G B O T S F O R D (s") A B BOTSFORD -S? 35 L A M & L E Y (S) LAMGLEV CITY -36 S U R R E Y (s) 6uR.eev W H l T E B . O C < 37 D E L T A (s) T3EUTA 3?" R l C H M b M D (S) R l C t t M o M O 3*}. VAfslcouv.erR. (s) V A N C O U V E R . 5 5 5 5 5 8URMASY HI- B U R . M A G Y (s) Hi MAPLC RIDGE (s) t+AMey 5 ^ CO Q.Ut-TLA (s) COQUITLAM .5 PORT MootiV PORT D?(SUITLAH 5 PITT MEADOWS 5 ^ I H3L, 56 I Mo 5 5 5 5 Ho. MEW W E S T M > N S T E R ( S ) Nl. W t S T K I U S T E - R . -5" -5" 5 3" 5 2C- i 5o , i N.A -.2.0 3..0 1-0 .a.o W £ | & ( f T C I > s 3. H I o. 16 0,16 0,16 0,16 Q./6 0-16 O l 6 70 APPENDIX 3 C o M T i t v l U E D ', W A T C R . C L A S S I F I C A T I O N O F S C t r O O L . D I S T R I C T S S C H O O L D I S T R I C T " W E / G - H T E D . W&I&HTE. D 4fc WMng L A T E S T CITy ^ T E R W A T E R W A T E RB0»CN E WITI+IN DISTORT ITARDNESS h+ARoMESS CALDIUM V A L U E " ^ / L V / V L U C "j/l- V A U U E «H- M. VANCOUVER, fe) VANCoiWETR 5 5 ^.Q H5. VJ- VANCouv/eR^s) VI. V A N C O U V E R 5 % . SurJSrtiME COAS-TC 5 ) G-iBSoWS 2 ? . ? "-(7. P C I W E L L R J V E R . C S ) P G W U L L Riv/eR, 1 3 . O H?. HOWE SoutslD^s) 5QuAMi$H l ' ^ ' 4<^ . CENTRAL COAST HACEN'SE>©R& fV.A. 56. (SUEENl CHARLOTTE(5) MftSSerT 3o. 3 5 1 . P R I N C E : RuPE:R.-r( /S) PRirJcC RuPeRT ' $ 5H. 5MiT*+er<5 ( n ) S M I T H C R S h f O U S T O i - J GRAIN 1 S LET 55 B U R . M 5 L A K E C S ) B U R N ' S u A K E ia, o N . A . So. 2 5o. 3 5o. •? 56. N E C H A K O (ht) VANDJTRH-06F 3 d • F R A S E R . L A K E : 3<?. $ 57. PR INCET Cs€oK<bz(s) PR-irJcer G E O R G E 2.0M MACKEM2LIE" | 15 FOPT ST. JOHN 33? 5^ PETACrr SOUTH (H) DAWSOhJ CREEK. I £>2 -CH E T W Y M D . 2 2 ? , 1.63 Tsl. <°\ • 13.H 5 o , X 11.°} W E I U H T C D W A T t R & O R w e I - l A & K l E S I U f - l O.Ik M . 5 O. b l 0.13 rJ. A.. Kl.A. 0 . 3 1 15.8 /7 7- a GC.l 5, «} 71. / ^ P P E T N D i ; * 3 COMT.NUED: WATER C L A S S I F I C A T I O N OF SettoO L_ D I S T R I C T S S C H O O L - P I S T R I C T $ N A M E L A R 6 E - 3 T C I T V W A T E R . w e i s - H T e p WFIG-WTETJ W£ISHTED W A T E R . W i ^ T E R & O R r J E W A T E R S O R N C W iTH I r s I - Dl5TRi<^r , - > + A N > i J i 5 5 I + A R P K I E S 5 C A l - O M A G N E S I U M V A L U E - > ^ / L V ^ L U E (^/L. V A L U E **^/L- V A L U E : . r*y\-(oO. PLACET R:. KjORXH. (s) R>R-T ST-J&HNi ^ej. | U U P ^ N ' S H * P £ 3<J. 3 61. &R,£A-T£T< VICT£>.RiPt(s) VICTORIA U2. S o c - K e ^ £3, .SAAMICH ^5) SAAWICH S V D N I E V fetf. frULF I S L A N D S (5) G A N G - E S i»5. CowicHAM LS) DwsJCP,^ I t . o 34,5 Or. 5 66 L A K E - C^WlOUArN ( j 5 ) L A K ^ CoWlCHAtO <o% NAMAinO Cs) ~ N A N A I fAo L A D V S K I T H 37.1 11,5 6 ? l OuALiCun (H) QuA-uCun BEACH S?.3 P A R K S V . I L L E : 4^.3 7 0 . ALBERjvIl ("s) P O R T A L © E R I \ M 71 C&UR.TE-WAY (S) U C L U E L E T COURXEr^AV I'S.H 11. CAMPBELL. RjVER (s) C M M S E R L A M D I1-! C0, M O * ' ^ • ' ^ C A M P B E L L R I V E R - ^0.5 15 MiSS^Mi (S) MISSION to&.H 6 16.6 34,5 22.5 3 T . S 7 5.1 45.4 I7..W 2L6.5 M. A. 7 7-7 10. °) 5.7 1 . ? 5-9 rvi-A. 0.-7? o.G o,54 M, A. 0,7& .0.-73 /.O L-73L A*PPE"HDIX 8 coNTiMuep; WATER, CLASSIFICATION) of SCHOOL DiSTRt. C.T5 SCHOOL DISTRJCT NA M E C I T Y W I T H I N 0 I 5 T K . I C T WATC'S. VALUE P* rsf./V W C I C H T F . D W E I G H T E D v\l £" IG-HTE D W A T E R WATETSGoRlMET W / V T E R B 0 R . K i e HAR.DME"5-5 CAULIUJ-\ r - l A S M E S . / U f i ^/L- v ^ L u e V ^ - L - U C " ^ A - v/*i_uer ^ / N .A . . 77. S W r l M e R i A N l D (^S) SHMMerR.LA-rJD ^ ° £o K I T (MAT ( S ) K I T I M A T 9-5l $•-( V A N C O U V E R , I S L A N D VJ. G - O L D K . I V E « . 15 <25. vA^coiwex. ISLAND N1. PORT HARDY' I 3.2, CH) PORT n c N f i L poRT A u c e C R e S T o s I - K A S L 0(fs) C K f S T o i s ) 2.T 5 S7. SxiK-ine P E A S E " L A K E " N.a-"X-?- T E R R A C E T - K / S H & A C ' S) T E f t R A C e : 2% S H U S W A P ^ H ) STEWART 3*) 5ALM6NI A RM 1 3 3 -7 0 <?.5I Nfi A. 13, M 133.1 32. 3,17 10.1 M.A ^•3 3.^ 0.57 i .«gx M . A . 0."75 5.? APPENDIX T:INTERNATIONAL C L A S S I F I C A T I O N OF DISEASES,7TH REV VII. DISEASES OF T H E CIRCULATORY SYSTEM RHEUMATIC KEVEE (400—402) 400 Itlicuiiiulic fever without mention of heart involvement Arthritis, rheumatic, acute or subacute Meningitis, rheumatic (acute) Peritonitis, rheumatic (acute) Pleurisy, rheumatic (acute) Pneumonitis, rheumatic Rheumatic fever (activo) (acute) Rheumatism, articular, acute or subacute Tonsillitis, rheumatic (acute) 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. f o r 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 mitral, active or acute tricuspid, active or acute Rheumatic : endocarditis, active or acute 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 condition in 400 with endocarditis or valvular disease, subject to the limitations in the noto 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 \ t y p e c l ^ l f i a W e 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 * T r i c u s p i d ( v a l v e ) ( h e a r t ) ( r h e u m a t i c ) ( i n a c t i v e ) ( c h r o n i c ) : d i s e a s e r e g u r g i t a t i o n i n s u f f i c i e n c y s t e n o s i s o b s t r u c t i o n 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 * P u l m o n a r y v a l v e : i d i s e a s e / . « , • s p e w l i e u a s r h e u m a t i c i n s u f f i c i e n c y i 1 stenosis ' This title excludes diseases of pulmonary valve (421.3), unless specified as rheumatic. 414 Other endocarditis specified as rheumatic A n e u r y s m o f v a l v e o f h e a r t , r h e u m a t i c D e g e n e r a t i o n o f c a r d i a c v a l v e , r h e u m a t i c E h e u m a t i c : e n d o c a r d i t i s ( c h r o n i c ) v a l v u l i t i s ( c h r o n i c ) V a l v u l a r : j i n s u f f i c i e n c y > ( c h r o n i c ) ( i n a c t i v e ) s p e c i f i e d a s r h e u m a t i c s t e n o s i s \ This title excludes chronic endocarditis (421.4), unless specified as rheumatic. 415 Other myocarditis specified as rheumatic R h e u m a t i c d e g e n e r a t i o n , m y o c a r d i u m E h e u m a t i c m y o c a r d i t i s ( c h r o n i c ) 416 Other heart disease specified ns rheumatic A d h e r e n t p e r i c a r d i u m \ E h e u m a t i c : C h r o n i c : j N O S c a r d i t i s , c h r o n i c o r i n a c t i v e m e d i a s t i n o p e r i e a r - f or h e a r t d i s e a s e ( i n a c t i v e ) d i t i s i r h e u - ( c h r o n i c ) m y o p e r i c a r d i t i s l m a t i c p e r i c a r d i t i s / * When more than one valve is mentioned, priority in classification follows the order of listing in numbers 410-413; 17 k ARTERIOSCLEROTIC A N D 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- • t n n i r. • I any condition in 420.1 Cardiac angina \ J 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. ) u specified as rheumatic and without insufficiency } 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) ° X C l U ( 1 C S t l l C l i S t ° f l c o n < l i t i o n s w i t ' ' mention of any condition 422.1 With arteriosclerosis Cardiosclerosis Cardiovascular : arteriosclerosis degeneration disease Cardiovascular sclerosis Myocardial degeneration, with arteriosclerosis or syno-nym in 450 of heart or myocardium Heart disease : fibroid senile Myocardial : degeneration disease insufficiency sclerosis Myocarditis : NOS ch ro n i c (i n ters ti ti al) fibroid senile Myocardosis 422.2 Other Atheroma Atrophy Calcification Degeneration brown calcareous ischemic mural muscular pigmentary Glycogenic in-filtration 'Rupture Cardiac insufficiency Cardiac ossification This title excludes the listed conditions with mention of any condition in 450 (422.1). OTHER DISEASES OF HEART (430-434) 430 Acute and subacute endocarditis 430.0 Acute and subacute bacterial endocarditis Endocarditis : bacterial infective lent a malignant purulent septic ulcerative vegetative Mycotic aneurysm This title excludes acute endocarditis specified as rheumatic (401.1). (acute) (chronic) (subacute) 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 } . .^ m . „ rheumatic Toxic 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 . . 0 , , y . _ \ not specified 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 • . „ , , , r „ • , . > specified as non-rheumatic Myopencarditis, chronic ( r 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 ^ • i-t- - Ann • i i . u / • ( scribed as benign dition in 422, with hypertension 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 4 3 3 a n d 4 3 4 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) N O S 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 A n y 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 A n y condition in 594 with hypertension Bright's disease : \ N O S . r , . . / specified 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 h e n ? n ° / disease malignant This title excludes the listed conditious with mention of any condition in 594 (440). D ISEASES 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 » n R P < f f i e d site and of any specified Periphlebitis ' f\Q e x c e p f c \owc* ^ i m t y , por-n , / . , . , .. , i tai vein and intracranial venous Phlebitis (suppurative) \ mi, . I / . , . sinuses Thrombophlebitis j This title excludes phlebitis and thrombophlebitis : of intracranial "venous sinuses (341), of portal vein (582), of puerperal origin (645.1, 651, 682), and complicating pregnancy (648.3). 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 

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