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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  in THE  FACULTY OF GRADUATE  STUDIES  GEOGRAPHY  We a c c e p t to  THE  this  thesis  the required  as  conforming  standard  UNIVERSITY OF BRITISH COLUMBIA AUGUST 22, 1986  ©  MICHELE WIENS, 1986  In  presenting  degree  this  at the  thesis  in  University of  partial  fulfilment  of  of  department  this or  publication of  thesis for by  his  or  that the  her  representatives.  It  this thesis for financial gain shall not  <zr£~Q£ fy^RH Y  The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3  for  an advanced  Library shall make  it  agree that permission for extensive  scholarly purposes may be  permission.  Department of  requirements  British Columbia, I agree  freely available for reference and study. I further copying  the  is  granted  by the  understood  that  head of copying  my or  be allowed without my written  ABSTRACT  Several between due  s t u d i e s have  t h e h a r d n e s s o f community water  to heart  disease.  h a r d n e s s and h e a r t water h a r d n e s s the  i n d i c a t e d an i n v e r s e  disease  i n heart  hypothesis  mortality  In  that  The  calcium,  soft  heart  any  obvious  reviewed;  diets,  from  and o t h e r  ecological  the  the r o l e of and,  British  for of  103  cities  in  water h a r d n e s s ,  magnesium  with  mortality  waterborne  sex-specific rates  n o r does t h e g e o g r a p h i c a l  relationship.  effects  heart  water  data  The  effects  h a r d n e s s on human h e a r t - r e l a t e d m o r t a l i t y a r e separate  of  disease  disease  statistically-significant suggest  studies  water c o n t r i b u t e s t o h e a r t  waterborne  age-standardized  thesis,  are b r i e f l y  correlations  and  s u p p l i e s and d e a t h s  disease mortality i s assessed;  i s tested using  Columbia.  this  relationship  of  disease  correlation.  it  smoking,  risk  were n o t pattern of water  difficult  to  high-cholesterol  f a c t o r s a t the l e v e l  of  T a b l e 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  32  iJ.  A. REVIEW .OF THE LITERATURE  32  III  40 A. OTHER HEART DISEASE RISK FACTORS  40  B. SUMMARY OF RISK FACTORS  53  IV  5<? A. ASSUMPTIONS AND LIMITATIONS OF THE STUDY  59  B. DATA SOURCES AND COLLECTION  61  C. RESULTS AND ANALYSIS  75  D. SUMMARY OF RESULTS  146  E. CONCLUSION  149  BIBLIOGRAPHY  151  ABBREVIATIONS  159  APPENDIX 1 : D E F I N I T I O N S  161  APPENDIX  2:  DETERMINATION  OF  WEIGHTED WATER HARDNESS  VALUES  166  APPENDIX 3: WATER C L A S S I F I C A T I O N OF SCHOOL D I S T R I C T  167  APPENDIX 4:INTERNATIONAL REV  173  C L A S S I F I C A T I O N OF  Hi  DISEASES,7TH  L I S T OF TABLES Table  Page  WATER HARDNESS CLASSIFICATIONS RECOMMENDED DIETARY ALLOWANCES,  2 OR RDAs,  31  DEATHS DUE TO IHD LISTED BY SEX AND REGIONAL B.C. 1 980  DISTRICT, 44  AGE-STANDARDIZED DEATH RATES FOR ISCHEMIC HEART DISEASE FOR SELECTED COUNTRIES  49  A RANKING  OF WATER HARDNESS VALUES FOR B.C.SCHOOL  A RANKING  OF MORTALITY RATES FOR HEART  DISEASE,  A RANKING  OF MORTALITY RATES FOR HEART  DISEASE,FEMALES,B. C. 64  THE  103 LARGEST C I T I E S  DISTRICTS 62 MALES,B. c. 63  IN BRITISH COLUMBIA  RESULTS OF CORRELATION BETWEEN WATER HARDNESS AND DISEASE MORTALITY RATES, B.C  68 HEART 76  RESULTS OF CORRELATION BETWEEN WATERBORNE CALCIUM HEART DISEASE MORTALITY RATES, B.C  AND  RESULTS OF CORRELATION BETWEEN WATERBORNE MAGNESIUM HEART DISEASE MORTALITY RATES, B.C  AND  RESULTS OF CORRELATION BETWEEN DISEASE MORTALITY RATIOS  iv  WATER HARDNESS AND  77 78  HEART 84  L I S T OF  FIGURES  Figure  Page  B R I T I S H COLUMBIA WATER HARDNESS  SCHOOL D I S T R I C T S  7  I N B.C. BY SCHOOL D I S T R I C T  8  M A L E M O R T A L I T Y R A T E S FOR A L L HEART D I S E A S E S COMBINED SCHOOL D I S T R I C T , B.C. 1 9 5 6 - 1 9 7 7 F E M A L E M O R T A L I T Y R A T E S FOR A L L HEART D I S E A S E S BY SCHOOL D I S T R I C T , B.C. 1 9 5 6 - 1 9 7 7 G E N E R A L I Z E D MAP OF WATER HARDNESS BY SCHOOL D I S T R I C T  IN BRITISH  BY 9  COMBINED 1 0 COLUMBIA, 11  G E N E R A L I Z E D MAP OF MALE M O R T A L I T Y R A T E S FOR ALL HEART DISEASES COMBINED, BY SCHOOL D I S T R I C T , B . C . 1 9 5 6 - 1 9 7 7 12 G E N E R A L I Z E D MAP OF F E M A L E M O R T A L I T Y R A T E S FOR A L L D I S E A S E S C O M B I N E D , BY SCHOOL D I S T R I C T , B.C.  HEART 1956-1977 13  SCHOOL D I S T R I C T S I N B.C. WITH E I T H E R SOFT WATER AND HIGH RATES OF MALE HEART D I S E A S E M O R T A L I T Y , OR HARD WATER AND LOW R A T E S OF MALE HEART DISEASE MORTALITY, 1956-1977  14  SCHOOL D I S T R I C T S I N B.C. WITH E I T H E R SOFT WATER AND HIGH RATES OF F E M A L E HEART D I S E A S E M O R T A L I T Y , OR HARD WATER AND LOW R A T E S OF F E M A L E HEART DISEASE MORTALITY, 1956-1977  15  SCHOOL D I S T R I C T S I N B.C. WHICH, FOR BOTH MALES AND FEMALES, HAVE HIGH RATES OF HEART DISEASE M O R T A L I T Y AND SOFT WATER, OR LOW RATES OF HEART D I S E A S E M O R T A L I T Y AND HARD WATER  16  P H Y S I O G R A P H I C R E G I O N S OF B R I T I S H C O L U M B I A  17  G E O L O G I C D I V I S I O N S OF B R I T I S H C O L U M B I A  18  S I T E S OF P R E D I L E C T I O N FOR A T H E R O S C L E R O S I S  20  D I A G R A M OF AN A T H E R O S C L E R O T I C P L A Q U E  21  P R I N C I P L E S OF THE  22  P A T H O G E N E S I S OF A T H E R O S C L E R O S I S  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 DEATHS MAP  DUE TO D I S E A S E S OF THE HEART  SHOWING R E G I O N A L D I S T R I C T S ,  v  I N S P E C I F I E D AGE  B R I T I S H COLUMBIA  41 GROUPS 42 45  DEATHS DUE TO IHD BY REGIONAL DISTRICT,  B.C. 1980  46  BRITISH COLUMBIA SCHOOL DISTRICTS  66  A MAP OF THE 103 LARGEST C I T I E S IN BRITISH COLUMBIA  67  SCATTERGRAMS  OF RESULTS  .86  APPENDIX 3: WATER CLASSIFICATION OF SCHOOL DISTRICTS  VI'  167  ACKNOWLEDGEMENT For the  preparation  thesis and  a l l of t h e i r of  guidance, this  a d v i s o r s , Mr. R i c h a r d  Dr. Trevor  support,  paper, Copley,  Barnes.  vii  and kindness  I would  during  like  t o thank my  Mr. R i c h a r d  Gallagher,  I.  A.  STATEMENT OF There  in  THE  is  PROBLEM  evidence  Canada, E n g l a n d and that  inversely  associated  per  agreement can  be  the  calcium  cent  of  Wales, the  hardness  countries,  Waterborne  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  the  of  as  CaC03  per  or more can  study,  waters with  "soft,"  be 75  liter  are  considered  use  water  hardness  to Stocks  classifications It and  has  can  ions,  in heart  This  report  Map  2  (see is  a  may  seen  mg  as  waters with to  be  is  in Table  1.  al  result  in  mg  In  this  liter  are  more t h a n  100  "hard." that  in  mg  Many  (1975).  softer  95  liter  100  "hard". per  2  general  with  that d e f i c i e n c i e s  which  for  CaC03 p e r  classifications et  be  are  These  calcium  water,  are  disease mortality.  water h a r d n e s s and Columbia  be  There  CaC03  Neri  and  been h y p o t h e s i z e d  magnesium  factors  (1973)  and  mg  CaC03  similar  other  mortality.  waters  regarded  to  researchers  100  whereas  than  "soft,"  than  considered per  and  water  disease  water.  less  classified  be  drinking  heart  hardness  less  States,  w a t e r b o r n e magnesium a c c o u n t  t h a t a water w i t h  liter  of  1  with and  United  documents heart  maps  at  and  maps, f o r t h e  disease  m o r t a l i t y data  the  of  description  end of  this  water  first for  s e c t i o n , pp.  hardness  in  time, British 7-19). British  A11 words i n i t a l i c s i n t h i s t h e s i s a r e d e f i n e d i n a p p e n d i x 1, w h i c h i s a g l o s s a r y of terms H e w i t t , N e r i 1980; Pocock e t a l 1981; Z i e l h u i s , H a r i n g 1981 1  2  1  TABLEt  WATER.  HF\RDIN)ES5  CLASSIFICATIONS EHV  •STOCKS  WATER  P  R  O  I T  RON M E NT fME  C  T  I  O  N  CLASSIFICATION ( li75)  ULTRA  SOFT  VBR.Y  SOFT  SO  o- !4  0-50  FT  MoDEft.JATEL.-V  100-150  /oo-;M ? <  K/MtD  .2£>o-3oo  H A R D  VEfVY H A W )  NioTE '- £ A C H  0-15  50-100  SOFT  SLi G-HTL.Y HAR.D MODERATELY  30 " 5fi  >  3  0  O  > I So UNIT  of  (;ARi)NESs  IS E&aiiift  L t  7.S  loo  LbO  3oo  > 3oo  sir To I riCv CVtOj  PER.  LirR£  3  Columbia,  by  school  chloropleth  district,  mapping  technique.  age-standardized  heart  disease  Columbia.  5,  and  and 5,  Maps  heart 6,  disease  and  spatial  7,  we  6,  data  can  3  and  data  (2) h a r d  water and  7 show g e n e r a l i z e d w a t e r  hardness  Columbia. Comparing  geographical  9 show t h e  patterns  to  heart  school d i s t r i c t s  disease  school  water and  districts  low  see  the  disease have  and  the  heart  disease  w h i c h have e i t h e r  disease  r a t e s of h e a r t  Maps  which  mortality rates,  r a t e s of h e a r t low  show  British  w h i c h have h a r d  high  4  for  the  heart  r a t e s . The  water and  males  high  districts  mortality soft  Maps  five-category  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  water and  school  a  mortality  for B r i t i s h  use  m o r t a l i t y . Maps 8 and soft  using  disease  (1)  mortality ,  or  1  mortality  2  for  are:  1. Alberni 2. Burns Lake 3. Campbell R i v e r 4. Cariboo-Chilcotin 5. C e n t r a l Okanagan 6. Hope 7. Kamloops 8. Kitimat 9. Nechako 10. N e l s o n 11. P o w e l l R i v e r 12. P r i n c e R u p e r t 13. S o u t h Okanagan 14. T e r r a c e 15.  Trail  The rates  school  districts  of h e a r t  disease  with  either  m o r t a l i t y , or  (1)  soft  w a t e r and  high  (2) h a r d  w a t e r and  low  H i g h r a t e s of h e a r t d i s e a s e m o r t a l i t y a r e h e r e d e f i n e d a s g r e a t e r t h a n 401 d e a t h s per 100,000 Low r a t e s of h e a r t d i s e a s e m o r t a l i t y a r e h e r e d e f i n e d as l e s s t h a n 350 d e a t h s per 100,000 1  2  4  rates  of  heart  disease  mortality  1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.  Cariboo-Chilcotin C e n t r a l Okanagan Chilliwack Fernie Kitimat Lillooet Merritt Nechako Peace R i v e r N o r t h Peace R i v e r South P r i n c e George Powell River Quesnel S o u t h Okanagan Vancouver I s l a n d North Vernon  17.  Windermere  School of  districts  heart  of  disease  heart  are:  with  (1)  soft  water  and  high  rates  m o r t a l i t y , or  (2)  hard water  and  low  rates  disease  Central  indicated  mortality  population  lives  Looking water and males  i n these  high  rates  11, of  females,  Physiographic  5.7 7  we  all of  and  hard  water  mortality  are  all  located  the  Coastal  Mountain Region  ^ h e r e a r e o n l y 66 s c h o o l d i s t r i c t s due t o a l a c k of i n f o r m a t i o n .  districts  within  with  soft  for  both  the  Columbia,  rates  within  i s the  are  province's  mortality,  British  Geologic  Powell These  the  data  1  the  low  Nechako,  of  located  Region  The  cent  that  female  Okanagan.  disease  with  Region.  per  see  heart  are  South  districts.  districts  Physiographic  Kitimat,  and  About  a t Map  and  Mountain  10.  f o r b o t h male and  Hope,  Okanagan,  i n Map  are:  either  Cariboo-Chilcotin,  River,  for females  of  the  Coastal and  heart  disease  Intermontane  Region a s s o c i a t e d  Coast  Plutonic  because  the  8 were  with  Complex, excluded  5  which  i s composed m a i n l y  Geologic the  Region  a s s o c i a t e d with  unmetamorphosed s e d i m e n t a r y  Intermontane  Belt.  12.  suggest,  One  could  geology  is  disease lends  some  is  mortality,  B o t h Rogot conditions  may  study  disease  there  by  the h i g h e s t  r a t e s of  northern  school  to occur  province,  show  coastal  climatic  rates  in B r i t i s h  with  climate.  heart  districts i n the  climate  high  districts  and  1  not.  of  contradict  M a s i r o n i , Shaper 1981 R o g o t , P a d g e t t 1976; M a s i r o n i ,  climatic  Heart vary  disease would  southeast  and parts  the the  but  heart  2  not  i s o f t e n more m o d e r a t e .  rates  disease  between  do  in  water  mortality,  heart  in  were expect in  the  lower  of In  the  the fact,  climatically-moderate arguments  Masironi.  2  that  conditions.  Columbia,  heart  school  m o r t a l i t y to occur  in B r i t i s h  Map  Columbia  extreme  c o n d i t i o n s , one  disease  south  w h i c h do  Columbia If  of  heart'  relationship  extreme  in  some  disease  the  However,  hypothesis  is  region's  in B r i t i s h  that  to heart  any  a  pattern  with  stated  the  of  shown  that  are  some d i s t r i c t s  extreme c l i m a t i c  where t h e  relatively  associated  related  are  argument.  to the  be  aggravated  pattern  support  Masironi  c o n s i s t e n t way  did,  there  are  does not  regions  Masironi's  and  mortality  volcanic strata  regions,  lend  rock;  Intermontane Region  geographical  general  to  m o r t a l i t y and  disease  the  The  the  inversely  and  and  Masironi  to  support  which  hardness  rates  as  physiographic  districts  this  1  the  These g e o l o g i c  related  mortality.  single  any  of metamorphosed g r a n i t i c  Shaper  1981  of R o g o t  and  6  There a r e other dietary test  habit, l i f e s t y l e ,  whether a  Columbia I will  between h e a r t  a l s o t r y to  be  can  disease  detect  age-standardized I namely:  divided  (Part  1)  2) a r e v i e w  heart  disease; factors;  a  detected  separate  heart  in  British  hardness.  contributions  of  disease mortality.  disease  risk  factors,  study: m o r t a l i t y r a t e s w i l l  study  comment  on  into the  between h e a r t  of the l i t e r a t u r e  ( P a r t 3) a comment  four  be  heart  Columbia.  disease  main s e c t i o n s ,  plausibility  disease on  water;  heart  between  103  and  disease  of whether  relationship in  the  hardness  on s u s p e c t e d  mortality  of  and s o f t  water  and ( P a r t 4) an i n v e s t i g a t i o n  statistically-significant  h a r d n e s s and British  a  my  relationship  (Part  risk  in this  thesis I will  m o r t a l i t y and water  the  s u c h as  and s e x - s p e c i f i c .  have  suspected  be  and magnesium t o h e a r t  controlled  disease,  and s m o k i n g . In t h i s  and s e x , w h i c h a r e m a j o r  will  is  factors f o r heart  relationship  waterborne c a l c i u m Age  risk  there water  cities  in  Ii/\P I : BRITISH SCHOOL  COLUMBIA DISTRICTS  59  PEACE  P1vEf  32  HOPE  63  PEACE  R:VE1  33  CMRLIWACK  61  GREATER  3-1 iGDOTS^OnO  VICTORIA  35  UNCUT  36  SURREY  63  SAANICH  37  DCL'A  $4  &m_f  3a  PiCMnOttO  65  62  EG L * f t  40  60  HE"  4 1  4 2 MAPLE RIOCE.  7 1  <3  72  COQUITLAM  44 H VANCCLiVER *5 M <6  VANCOUVER  SUNSHINE  RIVER MISSIOH  76  AGASSIZ  ao^^n  77  SUMKEBLANO  PO  K I T I MA T FORT  50 DUEEN  NELSO  64  VAN  ISL  WE  CHARLOTTE  B5  VAN  ISL  NO  PRtHCc  65  RUPERT  CHESTQM-KA  54  SHI1HERS  B7  STIKINE  55  OURNS LAKE.  BO  TERRACE  N £ O U < 0  89  SHUSWAP  PRINCE  S2  NI5MGA  GEORGE  SCHOOL,  RIVER  Bi  57  VA>!£OU\/CR  -  HARRI50H  49 HOWE SOUND  56  ; THE:  COUHTENAY CAMPBELL  43 CCHT1UL COAST  52  5QUR.CC  ALDCRNI  75  COAST 4 7 POWELL  COHICl  rJANAlHO D U A L I CUM  70  8'JRNADY  ISl A N [  COWILHAN  39 VANCOUVER WESTMINSTER  j  SOCKE  c m c r  8 MAP 2X  V/rVTER.  HARDtvjESS  BY  MOTE:  WATLR.  &UM_ITY  D«.TA  W M  SCHOOL  o a T H i U h D  Ffto^  IH  BMTI5H  COLUMBIA  DISTRICT  n u W i c i P A i .  RLC<DR.DS  9 M A P 3 ' - AfrE-STANDARDIZED  M O R T f t L l T Y  D I S E A S E S  f l 1 S t - i n « )  8Y  STANDARD II MORTALITY  ^7.1  SCHOOL  ED  «.ftTETS  <. 3 0 O (per  l o  I S S S T t T S  fit ~T I  _iI MOTE;  > ° 45  DI5TMCT5 IK| IK|  T TH HIISS  MoT  H E A I T DISEASE FROM THE ft*  SPECIAL  INCLUDED  W J kJ N MM -f _ flSlt S S MOO-THLITY  CAtrtEt  INFORMATION  CCNTR.OL  A R R A N & E n C.MT*  ft&eMCY  WAS 00™,WHO OF B . C . ,  RATETS FOR  FOR  AU_ KCART  M f l L «  DISTRICT ,rJ  ,  B-C.  10  MAP  '•  A & E -  S T A N D A R D I Z E D  D I S E A S E ' S  M O R T A L  . T V  C O M ^ N f D ( 19 56 - I ?7«) QY  S C H O O L  D I S T R I C T  *GE-STANDARDIZED Pi0 RJT ALI T V fLATCS  ESij  30I-3SO  \ ^  351-Hoo  D I S T R I C T S ,ti  WoTE-  H E A R T F  K  O  BY  f  A  M O T  I N C L U D E D  A r / f t L . V 5 < S  T H I S  DlSE-ftSfc.  TrtB  .SPECIAL  O W C E *  M O R T A L C O NTH*.  A R R A W & E M ^ M T  1  TV  l H H « H M I o M  A M - M C V  R A T E S  Of  B 1  * A S ,  OBTA.NED  T O R  FoR. IN  A L U  H E A R T  F E M A L E S  3 . C .  11 MAPS-'  HoTe  &FNtRALiZ£D  ••  WATER.  au«irr  WATfH  P A T A  HftP-DAJh'SS  WAS  OBTAINIFO  flMTlSM  r«-<"i ,  COLUMBIA  HUW:C,P<M  (VI.(ARBS  NOTE:-  ut/ve-r oiser^ie  FRaM BV  M O K T A L I T /  T H E CAN1LER_  SPECIAL  conrttL  AWLAKjS-eHCrJT  INFORMATION! A-&£*)CY  OF  WAS  ac,  o&Tmtjea  13 MAP 7:GENERALIZED  AGE- STPSMDAR.DI2.ED D I S E A S E S  C O M B I N E D  8 V  ME-  S C H O O L  ('per  DISTRICTS W  T^is  HEART FROM BY  too,  MoT  If/CuuDED  AMALVSIS  DlSC^i*  T H E CANCER.  SPECIAL  o o o )  MOtTALiTV C«>ITR.OL  ARRAM&CMEWT  I NFdft M A T I  /s&eMcV  OP  (7  * "M;* 6l3T/\I^Ef>  B . C . ,  Fog.  R A T E S  F  D I S T R I C T  FU\TES  <( 3 5 0  NoT£  ( 19 5L-I <i")-?)  STANDAR-Dixeo  MORTALITY  •  M i U m L i r v  O  R  A  L  L  F E M A L E S ,  INI  B - C .  H E A R T  M A P  8- SCH-OOL.  Dl5rK.ic.TS  HUH  RATES  WATeK  ArJD  IN OP  L-OW KrM£5  KEY:  K§3  DI5TRICT5 MO  WiTH  SOFT  HIGH R A T E S  OF  W A T E R rt£ARrDlS£*S£  LICD 7l4oo- Hfctf) . ^ * o 3 DISTRICTS AMD  WITH HrARD WATER. A-ATES  OP  3-C  H-EAftT Q l S E A s C  w/T»f hHTKKT OF  EirHk'R.  SOFT  D'S£*S£  l*1r\i~t~~  tfCART  ^ r E «  l^oRTAuiTy £>/5£A5ET  AMD oR  /  HAfLD  t^[dR Jflui  ry,  15 MAP  ^ S C H O O L  IH B-C  DIST^ICIS  W.TER  ANJ>  LoU  E  WITtf  RArrS  OF  I THER  SOFT  F£M«UT  HEART  >', » o „  . 9  0 8 o  0 "  - o o e o  o  KEY'  -  DISTRICTS AMD  HI&H  WITH RATES  SoFT  WATCR.  O P Hi-ARTDlSEAS^  ( i C D I 1 HOo-Hk-i)  DISTRICTS MD  WITH  Low RATES  ^1  ^  H-ARO WATER OF HCART J>ISE/\S£  0  i  0 o o  0°  •  »"  • ? • o »'  ^ T f R  US**  flrJ  V  SET M. OR. T A L-iTV  )  K\AP  10: , 5 C M O O L F  ^  OP-  PIS; KiCT-S  " '  L  DISTRICTS '  M  V  LOW HAr e s  W I T H  SoFT  S  H  ,  &  O F  H  ,N R  A  WITH  AfJQ U>uJ R A T E ' S HO M A L IT Y  E  S  H E A R T  WM  ftND 'riitH RATES OF HE-A it" " • o i Dl-SYR.VC.TS  T  HARD O F ii £ A £ L T rMSE"A.SE.  ec  W H I C H ,  O F :  ^5Cft5E  F O * .  DISEASE A H Cl  -  BOTH  A^D  HARD  M.LCS  SOFT  W A T E ^  W  A H ^  MAP H  PKY5IO&RAPHIC. REGIONS  OF  BRITISH  COLUMBIA  MftP lj.  M/VTbR. G-EDLfi&lt  REGIONS  Or  BK\T1S  H CoL-Ur1£>)A  19 B.  PATHOLOGY OF H E A R T Let  DISEASE  u s now c o n s i d e r  whether  magnesium  ions  i n heart  plausible.  Heart  disease  and  connective  which a  tissue  medium-sized proportion Thickening fatty  of  and  large  heart  develops  muscle.  type  of  disease  thickening  called  involves  plaque  developments a r e i l l u s t r a t e d from  Braunwald.  The major  cases  calcium  of those  arteries  atherosclerosis, hardening  of the  for a  of heart  the accumulation  on t h e a r t e r i a l  i nFigures  walls.  1-3, w h i c h  i s represented  soft,  necrotic  core  i ncholesterol  scar hard  forms  plaques in  arterial  by  a  esters.  irritate  the  development,  arteries  through  theheart  become  the arteries artery  walls  t o pump a l l b l o o d  assistance.  of a t h e r o s c l e r o s i s result  i n body  parts  a n o b s t r u c t i n g thrombus  1980:1221  mainly  s u p p l i e d by t h e d i s e a s e d  o f t h emedium-sized  'Braunwald  disease  lining,  of blood  a r t e r y w a l l s causes  Effects blood  I n heart  on t h e a r t e r i a l and t h e flow  edges which  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  rigid  without  of  i srich  of t h ea r t e r i e s .  and narrow,  decreases. into  which  a r ec h a r a c t e r i z e d by rough  tissue  These  components o f t h e a t h e r o s c l e r o t i c  and lipid.The l i p i d  lining  of  a r e taken  a r ec e l l s  smooth  large  disease.  plaque  Plaques  and  i s biologically  accounts  and  calcium  cholesterol,  and  arteries,  of the arteries  deposit  as  Coronary  1  attacks  of  mortality  thicken thelining  nourish t h eheart  special  the role  arteries, which  stenosis  from  the lack  arteries. In often  f o r m s on t h e w a l l  results of the  2£  Fl&UR£  1:  SiTES iM  U S U A L  OF  P R E D I C T I O N !  R.A.MK.  QPJ5ER-  FOP.  ATHE:w>scL.Eft.osis_  >  FIGURE  2.'  DIAGRAM OF AN ATHEROSCLEROTIC PLAQUE  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  — r v - 0 - 7  7~» .«>  THE  COMPONENTS  CHARACTERISTICS >Si2.ETO  C P  T H E  AVDVANICEQ  OF T H - E A D V A M C F B  L J H U S C U L A R . )  ARTETRIES  (C.L  I  /  /  NIC A L L . V  PUOUE  IM P 1 K T A N T )  AMD  fTS  °\  a  ATH£ieorc  C.L1MIC.AL.  LFUDTIC  E F F E C T S  PLAOUS. IN/  IMEDIUM-  FIGURE:  PRINCIPLES OF THE PATHOGENESIS OF ATHEROSCLEROSIS  3 :  •MYOCARDIAL INFARCT  CEREBRAL  GANGRENE  INFARCT  EXTREMITIES  [ CLINICAL  H  OF  ABDOMINAL  AORTIC  ANEURYSM  ORI2^0Nj  CALCIFICATION COMPLICATED  LESION-  HEMORRHAGE,  ULCERATION,  THROMBOSIS  FIBROUS PLAQUE  FATTY STREAK t  THE"  NATuRA.i_  S L O W L Y FROM  I  AJ\I.D A.  P L A G U E :  H I S T D R V  FATTV  J i T d E A K  T H A T  /=  L I K E L V  ATU.ERj)SCLEH.asis  OF  iNsmuoniLY  O V E R . Ta T O  A  M A M Y  FlSiecuS £ £ A B  T O  ,  yEPJL-s  PLA&UETS )  A M O  P L A Q U E CLIAI/HAL.  Al\/D  L15UALL I'  T H E * '  TK£NI  effects*  .DEVELOP  I  «EI\/£RAI_L.Y TO  A  PRo.sft.E5s  C_oMPULCAT£"D  23 blood  vessel.  Thrombus  in  sudden  coronary  occlusion  and myocardial  of  blood  in  obstruction  muscle  aorta,  t h e major by  weakening rupture.  may  of the  that  high  of  arterial  i n animal  through  protein  known  carriers  have  of  the as  and  likely  the  plaques,  formation,  and  atherosclerosis early I t  dairy i s  bloodstream  in has  insoluble;  In  high-density  lipoprotein  may  help  remove  suggested caused  may  promote  of  popular  cholesterol  by a  i t must  packets a  with the  been  products  in  suggest  life,  lipoproteins.  been  linked  to atherosclerosis.  by  the  cholesterol  liver  be  fat and  model  of  cholesterol from  blood  diets.  occurs  3  Normally, the  cholesterol.  The  o f b e n e f i c i a l LDL i s hampered by " While  i s not well  Braunwald 1980:1221 K a n n e l , C a s t e l l i , a n d G o r d o n 1979 Ibid "Huyghe 1985:34 3  a r e more  low l e v e l s of low-density l i p o p r o t e i n c a r r i e r s  atherosclerosis 1  ofthe  between  t o a n d remove p a r t i c l e s c a r r y i n g  production  2  to the  I n plaques  i n the blood, primarily  Cholesterol  2  (HDL)  circulation;  high  lack  Partial  supply  aneurysm  wall,  begins  fats  atherosclerosis,  bind  media  many y e a r s .  cholesterol  carried  LDL  stroke.  a  pectoris.  pathogenesis  development  atherosclerosis.  (LDL)  cause  a r t e r i e s ' blood  the  can lead t o  infarction. A  of atherosclerosis  of  c o n t i n u i n g over  excess  diet  may  artery  1  plaque  process  effects  coronary  angina  cause  thinning  Theories that  brain  of the coronary  heart  caused  the  a  the exact  process  understood,  there  by  which i s no  doubt  1  that  Ibid:34  without  cholesterol  i t does not  occur.  25 a.  THE S P E C I F I C ROLE OF CALCIUM IN HEART DISEASE Calcium,  element of role  in  for skeletal  skeletal  supports  integrity  processes  and  blood  and  that  McCarron  link  pressure  supports  is a 3  hypertension,  function  between  the theory factor  The most w i d e l y  control pressure  on and  calcium  means o f r e d u c i n g  for  blood  pressure  blood  pressure  developing  hypertension."  r a t (SHR),  of  by  calcium  the  supplementing supplementation SHR  strain  the e f f e c t s  pressure  supplementation  preventing  dietary  humans may in  of  calcium  regulation indicate be  an  i n c r e a s e s i n those  in that  effective  hypertensives,  or  at risk for  P a r r o t t - G a r c i a , M c C a r r o n 1984 Schroeder l 9 6 0 a ; S t i t t e t a l 1973; M a s i r o n i , Shaper M c C a r r o n 1983 " C a l a b r e s e e t a l 1980 3  in also  1  2  the  levels.  hypertensive  blood  the  study  i t was shown t h a t r a t  Calcium  S t u d i e s w h i c h have a s s e s s e d supplementation  in  hypertensive  c o u l d be a m e l i o r a t e d  blood  animal  abnormalities  calcium.  calcium  of  hypertension  normotensive  An  2  of  s t u d i e d g e n e t i c model  In t h e SHR e x p e r i m e n t s  the  level  evidence  of  metabolism.  o f t h e SHR w i t h  cardiovascular  genesis  the spontaneously  diet  plays a  that d e f i c i e n t  human-like  dietary  regulatory  Epidemiologic  1  manifests  normotensive  essential  regulation.  contributing  hypertension.  controlled  a s an  regulate  pressure.  an h y p o t h e s i z e d  i n t a k e and b l o o d  calcium  to i t s role  m u s c l e c o n t r a c t i o n and r e l a x a t i o n ,  in tissue  physiology  by  addition  1981  26 Recent  evidence  between c a l c i u m and 1  prevalence  of h y p e r t e n s i o n  sodium and  calcium.  the p o s i t i v e blood  Several  the  With and  deficiencies  3  which  pressure  have  diets  involving  a  low  high  in  the  SHR  sodium r e s t r i c t i o n  may  calcium  i n t a k e or  exacerbate  both  hypertensives  to b i o l o g i c  studies in  di sease.  1  in  in blood  a l s o consume evidence  connection  blunt  and  3  respect  human  that  of h i g h  pressure  normotensives.  societies  Animal  2  theory effect  f u r t h e r proposed a  sodium metabolism  regulation.  supports  2  has  Huyghe 1985 M a r i e r e t a l 1979:57 McCarron 1983  have  calcium  mechanisms, supported  can  play  both  the a  role  claim in  animal that heart  27 b.  THE R O L E OF M A G N E S I U M Epidemiologic  a  factor  ions  which  help  studies helps  integrity  of  the  myocardium.  sensitizes  the  myocardium  that  drugs, in  arealready  non-infarcted a arryt  factor hmi as.  deficiency  that  is  attack.  to  structural  Magnesium  deficiency  the  might  toxic  be c r i t i c a l  t o be d e f i c i e n t  predispose in  important.  R e v i s et al 1 9 8 0 S i n g h , S i n g h , C a m e r o n 1981 M a r i e r e t a l 1979 " A n d e r s o n e t a l 1973  {arrythmia).  role  that in  ischemic, magnesium,  such hearts  hearts  i n heart  2  f o r hearts  1973, s t a t e d t h a t  predispose  of  protective.  or malfunctioning  tend  magnesium's  effects  i s  to  " The f i n d i n g s o f H e g g t v e i t that  Magnesium  1  and  al , i n 1 9 6 9 , r e p o r t e d  could  can also  fibrillation. suggest  damaged  Anderson,  3  heart  magnesium  magnesium  hearts  t h a t m a g n e s i u m may b e  functional  while  et  Heggtveit  3  prevent  the  Variations  1  suggest  maintain  various  2  CONSIDERED  and  to fatal magnesium ventricular Anderson  disease mortality  28 C. NUTRITIONAL The calcium more  belief  that  than  lithium,  ten  per  fluorine,  health.  concerns  about  the  calcium,  have c i t e d  that:  (2)  the  For this  given the  iron,  1  3  support. human  physiological magnesium.  (1) t h e amount  ecological thesis,  specific  analyses  3  These  individual  to  same  and  raised of  water  researchers drink  diet;  among  be  differences  and m e t a b o l i s m a r e n o t e x p e c t e d  M a r i e r e t a l 1979 A l t u r a 1979 Hammer, Heyden 1980:2400  poor  daily  s u c h as c a l c i u m and  self-selected  amounts o f c a l c i u m  be s u p p l i e d  have  people  for  magnesium,  significance  of water  of the type  need  between  i n g e s t i o n of m i n e r a l s one's  daily  however,  of  Generally,  1  and z i n c ) may  researchers,  and  source  calcium,  make t h e d i f f e r e n c e  and  (3)  individuals.  carried in t o be  out  both  in  water  important.  and magnesium w h i c h d r i n k i n g  water can c o n t r i b u t e t o one's d i e t  2  significant  and magnesium m e t a b o l i s m d i f f e r s  consumption The  a  (particularly  magnesium v a r i e s w i t h calcium  is  of  copper,  Some  2  hardness,  varies;  cent  elements  t a p water and may  good  water  and magnesium has been  waterborne  by  CONSIDERATIONS  will  now  be e x a m i n e d .  29 a . G E N E R A L C O N S I D E R A T I O N S OF M I N E R A L I N T A K E FROM WATER CALCIUM  The  daily  populations age  ranges  (see table  of calcium from  2, w h i c h  f o r most w e s t e r n  3 6 0 t o 1,200 mg,  appears  average  o f 52 mg  of calcium  mg  calcium  per day i f t h e average  mg/L  of water or  district mg  a  100  mg  of  contribution adult  are  calcium  1972  in  waterborne  calcium would  this to  deficient  of t h i s  1  The Q u e s n e l value  water  one's  could  of  two 26  school of  51  person i n day,  then  contribute  over  intake.  This  t o 12 p e r c e n t  of the  daily 8  per  an  o f 290  drinks  concentration  calcium  district  allowance  i n calcium,  c o n t r i b u t i o n may  adult  on and  contribute  3 ) ; i f the average  represent daily  Water  p e r d a y a n d a maximum  145 mg/L.  two l i t e r s  recommended  diets  of  (see Appendix  water  could  has a calcium  has an a v e r a g e  drinks  drinking  Walker  maximum  per l i t e r  Quesnel  which  water  adult  depending  Drinking  1980).  of  Drinking  in  Health,  liters  1  intake  of  calcium.  therefore,  be c r u c i a l .  Where  waterborne  30 b. MAGNESIUM The adult age  average d a i l y  populations (see  table  nutritional  magnesium  ranges 2).  benefit  from  intake  Drinking for  water  an  the  diet  of  meal  is  high  in  to explain  why  maize  the  disease 1975,  i s seldom  Neri  cited  found that  the t o t a l  for  this  British  waterborne almost  1 2 3  daily  magnesium Columbia  2  In  drinking  h i g h magnesium c o n t e n t may c o n t r i b u t e of  In  1  seen among t h e B a n t u .  and J o h a n s e n  under  circumstances  needed  by  situations.  3  of  study  magnesium where  in  with a  up t o 20 p e r  also  indicates  daily  cent  elevated  amounts  undergoing  1980:275  that  contribute  magnesium  may be i m p o r t a n t  individuals  S a f e D r i n k i n g Water Committee M a s i r o n i , S h a p e r 1981 M a r i e r e t a l 1979:94  Canada  i n t a k e . Water d a t a g a t h e r e d  20 p e r c e n t o f t h e t o t a l amount  cardiac  water  magnesium c a n , i n some d i s t r i c t s ,  This  provide  consuming  South  magnesium, w h i c h h a s been  can  individuals diet.  Bantu,  western  60 t o 400 mg, d e p e n d i n g on  otherwise magnesium-deficient African  f o r most  intake.  especially might  be  stressful  31  T A B L E X-  Recommended Dietary Allowances (RDA's)  0  R D A , mg/day Weight, kg  Group  Age, yr  Calcium  Magnesium  Infants  0.0-0.5 0.5-1.0  6 9  360 540  60 70  1-3 4-6 7-10  13 20 30  800 800 800  11-14 15-18 19-22 23-50 5H  44 6) 67 70 70  11-18 19-50 51 +  44-54 58 58  Phosphorus  Iodine  Iron  240 400  0.035 0.045  10 15  3 5  150 200 250  800 800 800  0.060 0.080 0.110  15 10 10  10 10 10  1.200 1,200 800 800 800  350 400 350 350 350  1,200 1,200 800 800 800  0.130 0.150 0.140 0.130 0.110  18 •18 10 10 10  15 15 15 15 15  1,200 800 800  300 300 300  1,200 800 800  0.115 0.100 0.080  18 18 10  15 15 15  Females, pregnant  1,200  450  1,200  0.125  18+  Females, laclaling  1.200  450  1,200  0.150  18  Children  Males  Females, not pregnant  Zinc  6  20  25  " From National Academy of Sciences, 19S4. The allowances are intended to provide for individual variations among most normal persons as they live in the United States under usual environmental stresses. Diets should be based on a variety of common foods to provide other nutrients for which human requirements have been less well defined. 6  This increased requirement cannot be met by ordinary diets; therefore, the use of supplemental iron is recommended.  II.  A.  REVIEW OF Many  evidence  was  have  water and  of  parallel the  LITERATURE  studies  between h a r d  quality  THE  United  heart  a  connection  given  i n Japan  between  acidity  revealed  of  the  river  States  between  human h e a l t h and  by  I t was  not  Schroeder  reported  correlation  ( e . g . -0.29: p=<0.0l) between  of  drinking  Schroeder  water  the  no  death  causes  highly  correlation  obtained It by  Schroeder,  hardness  were  mortality.  2  mortality, population Conversely, 'Schroeder Schroeder  2  of  disease.  in  of cancer  In t h i s  -0.27  of  -0.30  for  hardness  density, Schroeder  and  per  1960  cent  32  was  report  than  heart  with  a  calcium.  significant  cirrhosis  reported  1960b 1960a  to  for  same s t u d y ,  i n another  relation  mortality,  inverse  correlation  coefficient  reported  water  1  disease.  several m o r t a l i t y v a r i a b l e s other studied  specific  heart  the  the  r a t e from h e a r t  death.  to note t h a t  Schroeder  correlations  a  and  hardness  f o r w a t e r b o r n e magnesium, and is interesting  in  a  total  significant  non-cardiovascular significant  and  stroke  statistically-significant  and  obtained  hardne'ss  water  found  1960  identified  between  first  who  of  until  connection  a  The  Kobayashi,  distribution  Schroeder  water  relationship  mortality.  i n 1957  water.  inverse  disease  geographic  that  an  water  disease negative  cardiovascular of  nonwhite significant  the  liver,  population. positive  33 correlations other  of water h a r d n e s s w i t h  accidents,  however,  congenital  Schroeder's  correlation mortality other  and  between  motor v e h i c l e malformations.  identification  water  hardness  w h i c h was t o be f u r t h e r  regions  accidents,  of and  studied  - many o f whom s u b s e q u e n t l y  It  a  was,  negative  cardiovascular  by r e s e a r c h e r s reported  in  a similar  correlation. In  et  1961, M o r r i s  al  studied  E n g l a n d a n d W a l e s , and r e p o r t e d various  forms  hardness  of  (-0.36  to  -0.55),  --  unlike  magnesium. In  mortality  --  had  found  a  was f o u n d  that Midland  cardiovascular  mortality  (as  might  did  conditions  1 2 3  expect),  cardiovascular  Davies  1  not with  total  (-0.40 t o Morris obtain  et a  waterborne  Davies noted a  British  studies  fact which  r e l a t i o n s h i p between w a t e r h a r d n e s s and h e a r t  It  low  in  2  was i n c o n t r a d i c t i o n t o e a r l i e r  Morris  hardness  did  correlation  that  3  and  (-0.45 t o - 0 . 6 5 ) .  1962 i n E n g l a n d and W a l e s a g a i n ,  disease.  boroughs  c o r r e l a t i o n s between  carbonate  Schroeder  statistically-significant  county  inverse  cardiac-related  -0.54), and waterborne c a l c i u m al  83  not  British  consider  However,  the  M o r r i s , C r a w f o r d , Heady, M a r i e r e t a l 1979 D a v i e s 1962  1968  i t  different  and B i r m i n g h a m .  w a t e r and low  researchers  b u t B i r m i n g h a m had s o f t mortality.  of Midland  had h a r d  such  w a t e r and appears  as also that  socio-economic  34 In  1962,  metropolitan years,  hardness also  areas.  they  found  and  a  1969  statistical negative disease In  1970,  counties  between water disagreed positive A  heart  116  i n the  study  by  i n 34  Anderson  males aged and  United  Anderson  1975  less  of  soft-water magnesium  localities.  than  5  'Sauer 1962 D u d l e y et al 1969 W i n t o n , McCabe 1970 "Anderson, LeRiche 1971 Anderson 1975 3  5  65 who  35  to  74  of  non-cardiac  found  who  135  a  heart  central  the  heart,  had  reported  and  in  towns  1971  hearts  cent  less  residents  3  found and  a  a  water  in Ontario."  the  cases,  but  strokes.  of  cardiac  magnesium and  residents contained in  found  coronary  cardiac death  and  per  al  a negative association  LeRiche  that  area  et  2  hardness  sudden  22  and  metropolitan  studied  found  and  and  years.  (1960b),  showed  in hearts  of  and  standard  diseases  Schroeder  was  2  to  States,  subjects contained  found  64  States  a s s o c i a t i o n between  hardness  45  and  163  medium-sized c i t i e s in  to  S t a t e s , Dudley  McCabe,  ischemia  cent  the  United  a s s o c i a t i o n between  hardness  45  United  1  a s s o c i a t i o n betweem w a t e r  negative  hearts  of  between  hardness  with  ages  negative  disease.  of  Winton  i n the  92  c a r d i o v a s c u l a r - r e n a l causes combined  association i n white  studied  Among w h i t e s  study  areas  al  significantly  a l l  for coronary In  et  Sauer  of  than  that 6 to  the 7  per  hard-water  35  In  the  Netherlands  discouraged  by  the  in  1975,  public  statistically-significant and  others  and  rate  from  1980  report  stated  that  water  of  negative  1970.  a  Osborne follow  the  trend  rates  for  most  copper  and  In  lead  1980,  between  heart  disease  tissue  of  i n the  and  of  of  the  was  of  the  found  drinking  period  this  by water  1958  to  in soft-water  Masironi, relation fifteen  In  water  European  infarction a  likely  and  1981  study  at  these  River  and  with  water  that  to  myocardial areas  was  insufficient  heart  and  1980  disease  studied  myocardial rates with  pressure  in  the  calcium  content  villages.  The  calcium  content  the  infarction of  water.  investigated  villagers of of  in  myocardial  softer  Guinea, Masironi  and  Zielhuis, Haring 1981 Greathouse, Osborne 1980 Hewitt, Neri 1980  2  exposure  subjects;  in  in cities  blood  while  3  Higher  i n New  to  mortality  disease,  higher  Clayton  found  the  hard-water  of  and  apppeared  associated.  confirmed  cause  cities.  r e l a t i o n s h i p between Wagupmeri  related  hardness  were u s u a l l y  calcium  individual  areas.  Pisa,  between  of  Greathouse  cardiovascular  comparison  is a  States,  associations  soft-water  mortality  3  over  h a r d n e s s and  Neri  mortality  intake  1  hardness  were p o s i t i v e l y  and  magnesium  2  because  association  United  of  i n water  residents  compared,  water  the  disease  groups  Hewitt  heart  the  council  softening  1  In  the  health  negative  Zielhuis death  c e n t r a l water  the  along  drinking  the  water  36  decreased  downstream, yet  was  to  found In  hard  1981,  water  living  a  i n the  hard  water.  3  remained  coronary  heart  disease  soft-water  cardiovascular study  assessed  for  and  climatic  risk  had  than  rates than  and  was  socio-economic  of  a  other  low  cent  published  myocardial  c a s e - c o n t r o l study  per  of  medium h a r d n e s s .  different  15  both  of  this  both  adjustment  for  areas  al,  towns  somewhat  to  et  had  towns  10  Luoma  d i s t i n g u i s h e d by  conducive  al  a  results  are  death  stroke. After  areas  2  mortality;  relationship  calcium concentration  intake  et  statistically-significant  i n F i n l a n d by  that  rivers.  association exists  disease  the  between  populations  Pocock  significant heart  in  Ohio  Kingdom,  and  hypothesis  villagers  relationship  and  magnesium of  the  disease  t o have h i g h e r  mortality  the  populations  a  allowing  i t  heart  Columbia,  Although  factors,  A  a negative  United  that  tended  weakened a f t e r  factors,  found  h a r d n e s s and  water  of  1  Colorado,  1981  water  soft  with  the  in  pressure  arteriosclerotic  study  reported between  Masironi  and  along  In  with  increase.  blood  in  infarction levels  of  higher  1983, in  were c o n s i s t e n t w i t h and  t o a t h e r o s c l e r o s i s and  a  low  acute  two  fluoride,  i n d r i n k i n g water.  fluoride  "  The the  magnesium myocardial  infarct ion. With preceding  the  exception  literature  of  supports  M a s i r o n i , Shaper 1981 M a s i r o n i , Shaper 1981 P o c o c k , S h a p e r , Packham " I b i d 1981:1 1  2  3  1981  the the  study  of  Davies,  hypothesis  that  the soft  37 drinking  water  contributes  researchers,  however,  any  For  heart  disease.  study  may  However,  1  be  disease  received  cities  or  Los  water that  least  counties.  s t a t u s and could  disease.  authors d i d point  The  communities  had  most B r i t i s h Klusman between range  water  disease  death  and  Sauer  hardness  actually  have  rate  found  that have  no  that  accurate  used. to  done  heart within  communities race,  in the income,  al .  h a r d n e s s and  their been  "soft"  called  No  2  heart water  "hard"  explained  water  1974 1975  significant  by  was  association  in Indiana, small.  but  higher  which by  according  the  has  in Edinburgh soft  fact  the  3  the a r t e r i o s c l e r o t i c  was  i n Glasgow,  be  soft  1970  among m a l e s  than  may  Mulcahy 1973 A l l w r i g h t et al. Klusman, Sauer "Conner 1970 3  would  water  in a l lcounties  in  1  2  out  i n these counties  noted  hard water,  discrepancy  which  more  been  sex,  and  researchers.  of hardness Connor  its  water  and  b y A l l w r i g h t et  between  find  Mulcahy's  contribute  three  the  hardness  studies  f o r age,  stability  found  may  not  after  newer  from  example,  association  similar  water  published  water  support For  be  between  a l l  i n s u p p o r t of  c o n s t i t u e n t s have  A n g e l e s a r e a were matched  socioeconomic  had  because  soft  Not  in Ireland could  reports  more r e l i a b l e  hypothesis  disease.  results  Mulcahy  correlations  methods of measuring The  study  example,  significant  heart  have  statistically-significant hypothesis.  to  water."  that  both  heart with This towns  to the c l a s s i f i c a t i o n s  of  38 water  hardness  differences  used  in  in  death  most  rates  reports.  Furthermore,  the  i n Edinburgh and Glasgow  were  slight. In  a case-control  Washington  County,  arteriosclerotic drawn  from  values  disease  same  taps  had  differed  in  account  could  be f o u n d  earlier  life.  and  of this  regard  to  experimental compared,  t o M a r i e r et  designs;  t h e range  narrow  hardness  a range  mg C a C 0 3 p e r l i t r e  would  No  significant  hardness.  heart  The water  taps of subjects  water  supplies  were  may  have  T h i s s t u d y was a b l e t o t a k e important  often  able  to  be r e g a r d e d w i t h were  included  into  demographic,  characteristics do,  which but the  caution  in this  because  study.  al . ,  much o f t h e c o n f u s i o n w i t h  has  resulted  e.g., small  of water  hardness  degenerative  water  the  not  s t u d y must  water  with  of  412 c a s e s a n d c o n t r o l s  According  and  personal  are  from controls  Water  controls.  t h e home w a t e r  effects  studies  died  samples o b t a i n e d from the  and  of death, and  socio-economic,  findings  from water  cases  from  the  ecological  population.  arteriosclerotic  obtained  a t time  who  d i s e a s e were compared w i t h general  of  of  deaths  samples  too  Maryland,  were d e t e r m i n e d  association  only  i n 1971, persons i n  heart  the  home w a t e r  taken  s t u d y by Comstock  inadequate  numbers o f s u b j e c t s  hardness  be one w h i c h  t o 130 mg C a C 0 3  from  was t o o extends  per  litre;  narrow from, this  were  (i.e. s a y , 70 range  39 would  not p r o v i d e  water),  adequate  mortality cited in  in  now  Marier  soft  Spatial  populations 1  of  were Hammer  considered.  e t a l 1979  autocorrelation i s  geographical  any a t t r i b u t e . be  water  very  hard  lacking, and  and  Heyden  autocorrelation" to explain inconsistencies  neighbouring  will  1  control  findings.  almost  of very  r a t e s were n o t s t a n d a r d i z e d .  "spatial  study  for  values  Other  the  tendency  u n i t s t o r e s e m b l e one  another  heart  factors  disease  risk  Ill.  A.  OTHER HEART DISEASE RISK FACTORS Magnesium and  the  heart  this  r e p o r t , but  calcium  disease  risk  there  be  could  varies  greatly according  to  increase  disease  have  risk  stressful  consumption, suspected now  and  risk  the  discussed.  a.  AGE Heart  of  h o r m o n a l and  This  relationship  can  is  an  illustration  by  according heart but  to  disease increases  sex,  major c a u s e of d e a t h  in  seen  heart  f o r men  40  High  the  serum  poor  4.  Other  a  heart  nutrition, alcohol  d i f f e r e n c e s are  a  will  relationship 5.  which  shows in  8  5  the years  see  young, e s p e c i a l l y disease  to  Figure  c a t e g o r y . We  between t h e  also  factors  in figure  Heart  and  disease.  figure  disease  risk  o l d e r age.  disease  conditions,  Braunwald  and  within factors  p e r s o n a l i t y as  shows  i s r a r e among t h e with  of  d i s e a s e . These  developing age,  race.  are  gout, h y p e r g l y c e m i a ,  genetic  be  risk  of h e a r t  exercise,  mortality  age.  of  and  extreme c l i m a t i c  disease  probability  sex,  frequency  f a c t o r s of h e a r t  be  investigation  incidence  'Type A'  Lack  in people's diet  disease  illustrated  identified  lifestyles,  The  pressure,  are  factor.  heart  t o age,  blood  relationships  researchers  other  considered.  high  smoking a p p e a r These  f a c t o r s under  are  which  cholesterol,  deficiencies  that  women,  becomes a  a g e s of  35  to  HI  F l f r U K F H'  PROBA8II_\TY ACCORDING-  OF TO  rjtrVFL-OPlMGA&E:  ScX,  M o  KEAR.T MSK.  SXSiTASC. cAT£-&-6f=Ly .  w  S)/i£ARS  FIG  hooo  u Re  5 ••  DEATHS IN  t>oe  eftCH  BRITISH  •  TOTAL  TO DISeASeS  SPf£.iri£t> COLUMBIA  OF THf  He#KT  Term.  Dk'AWi  A$E - GROUP, if BO.  DEATHS  DEATHS TJUC To  5ooo  or T H E H E A R T  DISEASES  4777 T»7AL U/TAT'frJi  3000  306O • If/9  /f?S\  /oao: ! 1  231  rsmt ecmtis  in o-xf  DATA  FR.OK  pB-QVl^Ce  3o-39  ItJliJiL 5t> S9  60-69  Off" fJl^C, MINISTRY O p HCALTH V l T P > L 5 T A " n S T l C _ S . R.EPbftT'io<^ , H S Q  43 44  years.  cent  of  all  disease. b.  By  1  a g e s 55 deaths  t o 64,  among  men  are  due  40  per  to  heart  2  SEX In Canada,  to  three  females. (see  the h e a r t  times This  3  the  sex  5.2  times  the  age  g r o u p 35  States was  t o 44  74  age  figure  the  heart  exists  6).  times age  than  t o 44.  the  i n 1974,  34  ratio  greater  in  2.5  than  r a t e f o r males  In  disease  i n a l l age  the  United  is  age  the  This  rate  sex  group  categories States  greater  g r o u p and  g r o u p . The  than 1.5  observed  t o 74.  disease  females for  " In t h e  disease  the  in  difference in mortality  65  t h e male h e a r t  i n white  two  rate for  w h i t e male m o r t a l i t y r a t e from h e a r t  was  declined  disease  higher  t a b l e 3 and  1976,  United  mortality  r a t e for females  rate  for  the  65  to  d i f f e r e n c e s between m a l e s  and  times  f e m a l e s become l e s s a p p a r e n t  c.  approximately  greater  with  f o r the  increasing  age.  RACE W h i t e m a l e s and  heart  disease  have  shown  d i sease.  non-white  mortality. an  5  Since  increasing  f e m a l e s have t h e 1968,  highest  non-white  susceptibility  to  males heart  6  ' P r o v i n c e of B.C. 1983:36 P r o v i n c e o f B.C. 1983:37 Ibid:36 "Havlik, F e i n l e i b 1979 National center for health Havlik, Feinleib 1979 2 3  5 6  statistics  of  the  United  States  (  >-  m  C-l oJ  vo  v&  —  <i ro, tsV  1  <vV s a ' S - sa 1— ^ 3- N \N s^. vvl ^  r-v <s-s  ;  i sjs  "v.  -~  Vr>'  I-  (i  ro,'  V,  V  s  ^  tvl  IT.  W  vo ro, 3 - ; s* r<~> ro, <S\ ^ -3" cs ~~ -  A  ' vT>  lu <js  v>- sV- —  0>:  —  o»>-so  r—ro.  ^ 1• ^ ^ 5 "  <sk  a - ^ ^ - ^ i N r v . ^ ^ - t v i  —  --j  5£  <  I  o  s ~> •* s  CO* 3  rv  f-O.  Ml  fv.  ro  u.  u; cs.  hi.  1-4 -6 :  Qv. f in v <s I A s t ^ rv( r-O, >- O c v l ^ W  ^  > V rA  \v  *o "3—. 3m  r.  ^  vO *vi  mlI 0—• 0  s ^ ^  I  (-— Vr> rv tv <vj ro.  o  5-Ws^  ^  vtgo  3 -  — t>. i^rsia-  —  «N  cv\ c j ^ v v ^ o ^ ^ <Hfc>r s ( t v l v*—  -3- or\ Cj r v s V i j s . s O ^ o ^ e s i - - . ^ !  ~V- vO  0oo-~--^c>o >~ 2>- f-- ^° t< *0 i v •st-so  >0<i~rs;  (  v. Ci rH SQ  s t - v&  i s j 3-  r<^  — r~~ ^**» s S rr» s ^ — . e s t  3-  r-i-si iv ^ ,^ w s r i - ^ V r , «v."^-rr\sS&s V) M > «v SO-03Q ^v O ^  sa  Oo  ^  ^  rv|  >o  "5- o c I— rs\ r-~ !-— r o . rs(  —^  Is.  v) o  r  ro, ; r t j - V s ~ C s l ro. sj~ rs-, sj)  |r-~»o,r-  rvf.  0°  W  I  ]j> 00 > s»  sj  iv  rs  Q  d  co ^  ! r*  «  J»  3- s^rtv \a  ^0  PISS  u  >-  si si  <vr  3 00  CCD sS  1  ,s>  =4  N  «\ T  lO  ^6  <»  <:  "  sv  S! ^  3  vl vi  \  Vs Vs  v,  uj  11  >s  "V  5 5  55 fcf.  3:  ^<3 > o. s. Q  Is  V-> v t j  r4  h  O vi rs Ovi  M5  F i GURE: IV<  M A P S H O W I N G R E G I O N A L DISTRICTS. BRITISH  REGIONAL  PROVINCE  OF-  fl.c_,  MWISTR.Y  DISTRICTS Name No. l b . Greater Vancouver. 17. K i t i m a t - S t i k i n e 18. K o o t e n a y B o i i n d a r y . 19. M o u n t W a i l i l i n g t o n . 20. Nanairno. 21. N o r t h O k a n a g a n . 22 O k a n a g a n - S i m i l k a m e e n . 23. Peace R i v e r - L i a r d .  Name No. 1. A l b e r n i - C l a y o q u o t . 2. B u l k l e y - N e c h a k o . 3. C a p i t a l ( V i c t o r i a urea). 4. C a r i b o o . 5. C e n t r a ! C o a s t . 6. C e n t r a l F r a s e r V a l l e y . 7. C e n t r a l K o o t e n a y . 8. C e n t r a l O k a n a g a n . 9. C o l u m b i a - S h u s w a p . 10. C o m o x - S t r a t h c o n a . 11. C o w i c h a n V a l l e y . 12. D e w d n e y - A l o u e t t e . 13. East K o o t e n a y . 14. F r a s e r - C h e a m . 15. F r a s e r - F l i r t G e o r g e .  •SouR.ee;  COLUMBIA  24. 25. 26.  Powell River. Skeena-Queen  Charlotte  Sqtiainish-Lillooct. 2 7 . S! i k i n c . 28. Sunshine Coast. 29. T h o m p s o n - N i c o l a .  of  HEALTH^  yiTftL  STATISTICS  (t£Pan.-r itrt | ^ So  ^7  SU ?o SO IL> £j %> SD  aj  Qj  9_> ---  —  —  48 d.  STRESS In  heart  general,  disease  the countries that  English-speaking  2.  Industrialized,  3.  European  in  from  to find  Asia,  the Near  America.  Low  indicate  that  other  Israel  Europe  a high  in  East, Africa, disease  high  with  Table  rate of heart or  rates  of  and Uruguay rather  4.  disease  South  rates  industrialization  with  of  in  American the ranking  heart  associated hand,  world  and  and North  i s apparent  uncommon  the  mortality are:  1.  This  lead  I t  mortality  and  Central  i n Japan,  however,  need  not  always  heart  d i s e a s e . On t h e  a r e two c o u n t r i e s  high  i s  heart  disease  be  outside  mortality  rates. Mortality countries the  across (3)  as w e l l  United  counties  high  belt  heart  i n the Great  Plains  difficult disease  1979  to e x p l a i n these  mortality  rates.  can vary  within  c o u n t r i e s . F o r example, mortality  through  Lower  1  disease  southeastern  i n the i n d u s t r i a l i z e d  found  Meade  the  a southern  from heart  as between  States,  along  northeast.  1  rates  Atlantic  Georgia  states disease and  r a t e s occur  of  (1) i n  Coast,  (2)  and Alabama, and the  midwest  mortality  mountain  in  and  rates are  states.  I t  i s  regional differences in heart  HI  c T A B L E : 4A G E - S T A N D A R D I ZED DEATH RATES COUNTRY  1. U.K.:Northern Ireland 2 .U.K. :Scot land 3 . S1ngapore 4 . Czechoslovakia 5 . Ireland 6. F1nland 7 .New Zealand 8. Sweden 9 . Maur111 us 10..Maita 11 .U.K.:Engl . and and Wales 12 . Denmark 13 .Hungary 14 .Iceland 15..Austral 1a 16 .Canada 17 .United States 18 ..Cuba 19 .Norway 20 .Bulgaria 21 .Israe1 22 .Romania 23 .Austr1 a 24 .Nether 1ands 25 .Germany, Federal Repub. 26 .Kuwa1t 27 .Venezuela 28 .Costa Rica 29 .Belgium 30 .Italy 31 .Puerto Rico 32 . Panama 33 .Po1 and 34 .Sw1tzer1 and 35 .Yugos1avia 36 .Portugal 37 . France 38 Dominican Republic 39 .Hong Kong  P/kTA  Wo«.i_B  FOR I S C H E M I C HEART D I S E A S E FOR S E L E C T E D RATE L A T E S T A V A I L A B L E YEAR  (per 100,000) 209 .9 187 .9 186 . 3 179 . 7 176 . 7 167 .2 160.5 158 . 4 158 . 2 157 .0 154 . 7 153 .4 151 .0 148 .5 146 . 3 145. 1 144 . 4 134 . 6 126 .4 124 . 2 1 19.0 1 10.0 104 .0 103 . 4 102 . 5 99.9 87 .7 84 .6 81 .4 79 .6 75 .1 75 .0 70.8 69 .8 56 .2 50. 8 47 .3 42 .5 39 .6  RERL.TH  STATISTICS  1981 1984 1981 1983 1981 1983 1983 1984 1982 1982 1982 1982 1984 1983 1983 1982 1982 1981 1983 1983 1983 1983 1983 1983 1984 1982 1980 1980 1982 1980 1982 1983 1984 1984 1982 1982 1981 1982 1984  ftWMOAL,  1185  COUNTRIES  50 e.  CHOLESTEROL Cholesterol  disease.  The  1  may  is  the  the  i n the  arterial  wall.  supported  by  circulatory The  i n H a w a i i and  with  lower  cholesterol  rates.  3  incidence is  as  one  s e e s an  this levels f.  levels  as  the  eighth be  explained  of J a p a n e s e and  by  on  f o r example,  s u c h as  that  many  the  fact  Americans d i f f e r  greatly one's  people  affects lungs.  United argue  States that  are  not  attack  to  half  cigarette result  smoking  pressure  States,  heart  5  6  but  attacks;  that c h o l e s t e r o l greatly."  of  i s the  the  smoking  from most  system as  a heart  well  350,000 each  year  attack.  important  risk  6  as  deaths in  the  Those  who  factor  in  \  Braunwald 1980 Dawber 1980:121 Marmot et al 1975 "Ibid Rogot 1974 H u y g h e 1985:84 3  the  aware t h a t c i g a r e t t e s m o k i n g  one's c a r d i o v a s c u l a r About  5  attributable  2  of  SMOKING HABITS Most  1  the  men  Japan,  blood  United  as  that  strongly  revealed  high  i n the  to a tenth  been  the  heart  concept  have l o w e r h e a r t  countries  incidence  in  i s deposited  study,  c i g a r e t t e s m o k i n g and  high  may  One  2  the  has  California  industrialized  of  blood  hypothesis  many s t u d i e s .  heart  pathologists that  strengthened  J a p a n e s e men  In  by  factor in  atherosclerotic lesion  cholesterol  cholesterol  leading risk  determination  main c o n s t i t u e n t of disease  be  51 heart  disease  attack  mortality point  deaths  in  smoking a c c o u n t caused that  by  a  dying  coronary  heart  prevalence  other  and  also  and  3  5  for of  arteries  heart  170,000 h e a r t  each year  a l l deaths 1  Studies  greater  to  of the  risk  of  the  of  the  years. which  clotting." can  fibrillation,  m u s c l e t h a t may  coronary  blood  deposits  aggregation  c i g a r e t t e smoke  the  n i c o t i n e , and  in l i p i d  facilitate  dying  increase  cells  over  are  two-pack-a-day  monoxide, the  to  have shown  risk  or  due  that  a t h e r o s c l e r o s i s in  platelet  and  of  known  increase  ventricular the  is  injure  have shown t h a t  instability  Ibid Ibid Rogot 1974 "Ibid Hugyhe 1985  blood  States  heavy,  Carbon  blood  the  n o n - s m o k e r s , and  of  an  narrow t h e  threshold  5  may  cause  thicken  death.  cent  than  3  that  disease.  the  aorta.  increases  studies  per  extent  substances  gradually  1  heart  in  and  vessels  cent  C i g a r e t t e smoking  2  arteries  United per  attack  doubles  smokers.  2  f o r 39  smokers have a 70  from  to  the  out  an  which  Smoking serves Animal  lower  the  electrical  lead to  sudden  52  The  trend  one  o f i n c r e a s e between  1963  f o rheart  a n d 1975,  significant  disease  heart  decline  T A B L E  5  C.OR.OIS/A.R.Y'  1950 a n d 1 9 6 3 . disease  ;  5  h a s been  However,  1  has  between shown  a  below).  A G E - S P C C I F I C  N  Mc«.TA,L[TV  i n Canada  mortality  (see Table  D^CLI^B  ;  mortality  t  IW1-T?7 5  A 6 E  % 35-HM  a 7 2.  M'5 -5H 55-feH 65-71  21M 23-5 253  75-gM  Wl^iirny  ol--  MtALTK  AND  WiLFARE  C/Vw'AD^  '*?7  Cigarette smoking  has d e c l i n e d over  partially  explain  mortality. habits;  1  Minister  Changes  there  of Health  thel a s t  the have  h a s been  15 y e a r s ,  decrease also  taken  a general  andWelfare  which  i n heart place  decrease  C a n a d a 1978  in  may  disease eating  i nthe intake  53 of  saturated  diet.  1  heart  This  f a t and  fact  disease  previous  could  also  mortality  table.  blood high  pressure  Stroke,  involves  blockage  oxygen  refers  i n the  physical  activity  among  to  decrease.  abnormally  high  arterial  or  cause  o f cerebrovascular  rupture  of  of  c o n t r i b u t e s t o many  and i s the primary  theclimax  of hypertension.  of  disease,  blood  and n u t r i e n t s t o t h e b r a i n .  i n the role  vessels Diet  2  that  may  be  3  GOUT, H Y P E R G L Y C E M I A , AND D I A B E T E S Gout,  males,  a  refers  disease  Framingham  associated  with  cholesterol, with  heart  abnormally also  which  to a metabolic  increase of uric  the  3  i n  indicated  tension. Hypertension  stroke.  important  1  t h e decrease  was  explain this  a t t a c k s each year,  supply  2  Canadian  and i so f t e n c h a r a c t e r i z e d by a s t a t e  emotional  heart  an  the  HYPERTENSION Hypertension  h.  i n  explain  which  Increased  C a n a d i a n s may a l s o h e l p g.  cholesterol  acids  study,  i n blood  uric  turn,  disease.  acid  have  W a l k e r 1977 Province of British K a n n e l e t a l 1979  C o l u m b i a 1983  with  fluids.  levels  were  High  levels  In  positively of  serum  shown a s t r o n g a s s o c i a t i o n  concentration  been a s s o c i a t e d w i t h an  in  associated  a n d body  Hyperglycemia,  glucose  predominantly  disturbance  serum c h o l e s t e r o l .  in  high  occurs  increased  a  condition  of  i n the blood, has risk  of  heart  54 disease  1  Diabetes  heart  disease.  incidence  a p p e a r s t o be s t r o n g l y a s s o c i a t e d According  rate  of  approximately  twice  those  this  without  was a l m o s t i.  that  inactivity  of  thought person  to with  impatient believes high  heart  i n the non-diabetic  i s a l s o known  disease, high  to  rate  women.  increase  especially  in cholesterol.  a  Type A b e h a v i o u r  have  a  greater  a Type  A  risk  behaviour  easily  roused  t h a t a l l t h r e e major  2  the  i n those  who  3  pressure,  and h i g h  i s n o t known one  to  pattern to  risk  to  a  heart  challenges  emergencies. This  response  B r a u n w a l d 1980 Dawber 1980:194 F o x , Naughton 1972 " F r i e d m a n , Rosenman 1974 Ibid  attack." A  is  unusually  hostility.  Friedman  factors  smoking,  -  serum c h o l e s t e r o l l e v e l 5  e x a c t l y how Type A b e h a v i o u r  mechanisms t o e x p l a i n why react  p a t t e r n have been  of h e a r t  a c o n s e q u e n c e o f Type A b e h a v i o u r .  predispose  5  i n d i a b e t i c men compared t o  with  and  blood  It  3  was  TYPE A PERSONALITY People  1  infarction  d i s o r d e r . I n d i a b e t i c women t h e  smoke a n d have a d i e t  2  annual  PHYSICAL A C T I V I T Y  incidence  are  myocardial  the rate  s i x times  Physical  j.  t o Dawber, t h e a v e r a g e  with  attack,  i t might as  i f they  leads  though happen. were  t o an e x c e s s  might  there are Type  A's  full-scale secretion  55 of  three  hormones  testosterone. these  When  -  norepinephrine,  secreted t o excess,  belief  i t was r e p o r t e d  who m o d i f i e d  their  Type A b e h a v i o u r  heart  suffered one-third  attack  attacks  as  counselling.  men  Seasonal said  to  frequency.  occurrence  and  temperature.  studies  climate  across  found  a  this  men  heart  cardiological  disease  have  infarction.  there  ischemic the United  heart  relationship This  changes w i t h  relationship  latitude,  1  2  3  et  al  heart  disease,  may  1968  show  et  is  that  al  found  d i s e a s e and al  in  differences  in  by C r a w f o r d  et  yet variation in modest.  Masironi  water  hardness  have  arisen  but M a s i r o n i  has a r i s e n from  Huyghe 1985 H a v l i k 1979 M a s i r o n i et al 1980 "Elwood et al 1971; C r a w f o r d  Elwood  are large  between  relationship  4  to  disease  connected with the  ischemic  Kingdom  mortality are  affects  failed  And i t has been n o t e d  from  temperature  second  only  weather a r e c l e a r l y  Kingdom t h a t  latitude.  that  experiencing a  many  climate  no a s s o c i a t i o n between  mortality  as  had  that  of m y o c a r d i a l  United  after  v a r i a t i o n s i n heart  Some  3  Havlik  factor  CONDITIONS  demonstrate  temperature  almost  who  by  1  2  EXTREME CLIMATIC  that  two o f  t h a t Type A p e r s o n a l i t y i s a r i s k  was r e j e c t e d u n t i l  the  at least  and  hormones a r e known t o c a u s e damage t o a r t e r i e s . The  k.  ACTH  "geologic  and from  claimed trends  56 (sic) across data do  shows c l e a r l y  World Health  1  that c o u n t r i e s with  not n e c e s s a r i l y  heart 1.  the c o n t i n e n t . "  have  higher  Organization  extreme  mortality  climates  rates  from  also  been  disease.  ALCOHOL CONSUMPTION Excessive  associated This  with  an  can  increased  deplete  increasing their  drinking also  consumption risk  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  alcohol by  alcohol  not o n l y  magnesium renal loss  of heart to  levels  the  disease. fact  i n heavy  o f magnesium.  causes hearts  causes a general  has  t o beat  3  2  that  drinkers Excessive  faster,  but i t  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 protect  researchers  females  Females  from h e a r t  tend  disease  may  help  to  to genetic  Kingdom.  5  help  menopause."  retain  more  e x p l a i n t h e lower  heart  females. differences, Mitchell  higher  and t h e frequency  i n the U n i t e d  until  f u n c t i o n s . I f females  a s s o c i a t i o n between  mortality 0  respect  hormones may  l e s s magnesium, p e r h a p s i n  m o r t a l i t y r a t e s among  With an  this  that  disease  to excrete  response t o hormonal magnesium,  believe  ischemic  of occurrence Higher  heart  disease  of b l o o d  r a t e s of heart  found  group  disease  M a s i r o n i et al 1980 Y a n o e t a l 1977 S a f e D r i n k i n g Water Committee 1980:272 "Dr. E l a i n e E a k e r , U . S . N a t i o n a l H e a r t , Lung a n d B l o o d I n s t i t u t e , Framingham H e a r t S t u d y , Framingham, M a s s a c h u s e t t s M i t c h e l l 1977 2 3  5  57 mortality  in  perhaps male disease.  males as compared  body  chemistry  is  to females  suggest  influential  in  that heart  58 B. SUMMARY OF R I S K There Soft to  appear  water  control  personal not  may  FACTORS t o b e many  be among t h e s e  information  suspected  heart  risk  water.  activity  other  may  mortality  of  and  risk  factor.  factors,  than  and calcium  to heart  habits i s  of several  the single  smoking,  calcium  because  etc., would  of the  f a c t o r of  of i n s u f f i c i e n t  more q u i c k l y  in contributing  single  effect  outweigh  obesity,  magnesium  hand, magnesium  risk  disease.  It i s difficult  such as smoking  the result  with  f o r heart  factors.  The c o m b i n e d  factors  combined  disease  important  risk  on v a r i a b l e s  For example,  quantities other  factors  f o r many o f t h e s u s p e c t e d  easily obtainable.  soft  risk  physical  may  lead  to  deficient  i n one's d i e t . ' O n the  deficiency disease  may  mortality  be  as  as any  IV.  A.  ASSUMPTIONS AND  Some  LIMITATIONS OF  assumptions  rendered  difficult  limitations  the  d e t e c t i o n of an  hard  mortality  r a t e s . The  T h e r e has  water  been  populations.  heart  larger in  and  little  or  Larger  disease  of  no  although  cases  communities with  residency  this  study  inverse  this  lengths  stable should  study  disease  are: of  residency  vary,  by  the  study  or  which  location  l o o k i n g at  population, be  have  relationship  have p o p u l a t i o n s  the  may  may  heart  migration  communities  and  1  of  age-standardized  assumptions  a r e more s t a b l e , of  STUDY  or  between  1.  THE  reduced  the  differences  as  a  potential  confounder. 2.  Per  c a p i t a consumption  Columbia 3.  Heart they  4.  school  disease d i d not  in  similar British  There tap  i s no  and  r a t e s by  from  magnesium a r e populations  significant water  that  to consumers, I  Masironi,  vary  in  British  the  local  water  supply;  from a n o t h e r a b s o r b e d and  i n each  place. excreted  school  district  quality  between  Columbia.  Shaper  difference  in  t e s t e d for hardness. Although  water  concentration during  1  drank  consume b o t t l e d w a t e r  w a t e r and  recognized  water d o e s not  district.  cases  Dietary calcium at  5.  by  of  ingredients  may  alter  t r a n s p o r t a t i o n from t h e  assume  this  1981:386 59  to  be  an  water  i t is their works  insignificant  60 change. 6.  Water  quality  time;  any  has  remained  seasonal  and  relatively  yearly  constant  over  should  be  changes  insignificant. 7.  8.  Water  CaC03 v a l u e s  classified  as  100  mg/L  were  the  water  9.  Water  mineral  Heart  The be  disease  of  the  advantages study  as  soft.  this  study  (e.g.  near  the  reported  water  than  which are  have  on  were  less  than  the  of  border  mg/L). been  governmental reliably  mg/L  F o r t u n a t e l y , few  were 100  100  measured  and  agencies.  and  accurately  ecological generating  has  some  ecological of  on  r e g i o n and  to  ecological  drawbacks  studies  c a s e - c o n t r o l or  associated  however,  inexpensive, population  obtained  conclude  testing  Columbia  will  analysis.  design;  being  studies and  softening in British  in this  coefficient  sufficient  further  was  of  study  correlation  of  CaC03 v a l u e s  constituents  insignificant  when t h e  not  soft  greater  registrations.  This  the  and  of  a c c u r a t e l y by  amount  studies  and  are  classified  samples  hard  death 10.  hard,  between  reported  which  like  fast,  is large.  are  hypothesis.  Consistent  cohort  and  prompt  i t  often  Although  the  studies i s  important study  researchers  investigations.  has  efficient,  associations,  themselves  should  them,  from e c o l o g i c a l  causal  with a l l  the in  results to  do  61  B.  DATA  S O U R C E S AND  To any  test  (a)  whether  of seven  waterborne Water  COLLECTION any a s s o c i a t i o n  categories of heart calcium,  quality  and  data  c a n be d e t e c t e d  disease  waterborne  and water  magnesium,  f o r 103 c i t i e s  of  between hardness,  I  gathered:  British  Columbia  and, (b)  Residence  disease  data  on a l l B r i t i s h  f o rthe period  approximately  1956 t o 1 9 7 8 .  108,859  males  generated  age-standardized  data  sex;  by  method  in  then,  the  waterborne ranked rates  a.  Water I  the  and females  Quality  obtained  water  Columbia.  cities  cities  under  represent  include  females.  I  from rank  package, with  heart  records  rates  first  mortality correlation  I  correlated  water  magnesium.  and heart  from  hardness,  In a d d i t i o n ,  I  disease mortality  ( s e eTables  6, 7, a n d 8 ) .  Information  s i x government  British 103  males  values  The  Spearman  rates  and waterborne  1 2  deaths  67,395  statistics  hardness  f o rboth  the  mortality  calcium,  water  and  mortality  using  SPSS.X  age-standardized  Columbia  Data  quality water  information management  was a v a i l a b l e  from offices  f o r 95 o u t  consideration. Populations most  of the individuals  each  of  within of  of these  the 95  i n the province  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. 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 f r o m t h e C a n c e r C o n t r o l A g e n c y 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 . 1  2  TABLE  6  :  A RANKING FROM HARD TO SOFT OF: WATER HARDNESS I N B R I T I S H COLUMBIA BY SCHOOL DISTRICT SCHOOL D I S T R I C T WATER HARDNESS (mg C a C 0 3 / L ) 1. CARIBOO-CHILCOTIN ( 2 7 ) * 446.6 FORT NELSON ( 8 1 ) 2. 282 .0 3. SOUTH OKANAGAN ( 1 4 ) 231 . 7 4 . LILLOOET ( 2 9 ) 213.0 5 . WINDERMERE ( 4 ) 205.0 6 . PRINCE GEORGE ( 5 7 ) 201 . 9 7 . NECHAKO ( 5 6 ) 196.8 8 . OUESNEL ( 2 8 ) 189 .0 9. PEACE RIVER SOUTH ( 5 9 ) 179. 2 10. VERNON ( 2 2 ) 174 . 3 1 1 . FERNIE ( 1 ) 158 . 5 12. GOLDEN ( 1 8 ) 153.0 13 . SOUTH CARIBOO ( 3 0 ) 152 .0 14 . MERRITT ( 3 1 ) 142 .0 15. CHILLIWACK ( 3 3 ) 140.0 16 . SHUSWAP ( 8 9 ) 133 . 1 17 . KEREMEOS ( 1 6 ) 132 .0 18 . CENTRAL OKANAGAN ( 2 3 ) 115.3 19. CRANBROOK ( 2 ) 97 .O 20. SMITHERS ( 5 4 ) 96.6 21 . VANCOUVER ISLAND NORTH ( 8 5 ) 91.4 22 . PRINCETON ( 1 7 ) 89.4 2 3 . QUALICUM ( 6 9 ) 75.4 24 . SUMMERLAND ( 7 7 ) 70.0 24 . PEACE RIVER NORTH ( 6 0 ) 66.4 25 . HOPE ( 3 2 ) 56.0 26 . ABBOTSFORD ( 3 4 ) 55 .0 27 . CASTLEGAR ( 9 ) 55 .0 28 . BURNS LAKE ( 5 5 ) 50. 8 29. QUEEN CHARLOTTE ISLANDS ( 5 0 ) 50. 8 30. T R A I L ( 1 1 ) 47 . 9 31 . ALBERNI ( 7 0 ) 45.6 32 . REVELSTOKE ( 1 9 ) 40.0 33 . KAMLOOPS ( 2 4 ) 36 . 2 34 . NANAIMO ( 6 8 ) 34 . 8 35 . GULF ISLANDS ( 6 4 ) 34 . 5 36 . SUNSHINE COAST ( 4 6 ) 29.9 37 . CRESTON-KASLO ( 8 6 ) 29.5 38 . COWICHAN ( 6 5 ) 22 . 5 39 . CAMPBELL RIVER ( 7 2 ) 20. 5 40. LAKE COWICHAN ( 6 6 ) 19.9 4 1 . COURTENAY ( 7 1 ) 17.4 42 . GREATER VICTORIA ( 6 1 ) 16.0 43. SOOKE ( 6 2 ) 16.0 44 . SAANICH ( 6 3 ) 16 .O 45. TERRACE-NISHGA ( 8 8 ) 13.4 46 . POWELL RIVER ( 4 8 ) 12.0 47 . VANCOUVER ISLAND WEST ( 8 4 ) 12.0 48 . PENTICTON ( 1 5 ) 10.4 49 . NELSON ( 7 ) 10.0 50. KIMBERLY ( 3 ) 10.0 51 . K I T I M A T ( 8 0 ) 9.51 52 . PRINCE RUPERT ( 5 2 ) 9. 18 53. M I S S I O N ( 7 5 ) 5.0 54 . LANGLEY ( 3 5 ) 5.0 55 . SURREY ( 3 6 ) 5.0 56 . DELTA ( 3 7 ) 5.0 57 . RICHMOND ( 3 8 ) 5.0 58. VANCOUVER ( 3 9 ) 5.0 59 . NEW WESTMINSTER ( 4 0 ) 5.0 60. BURNABY ( 4 1 ) 5.0 61 . MAPLE RIDGE ( 4 2 ) 5.0 62 . COQUITLAM ( 4 3 ) 5.0 63 . NORTH VANCOUVER ( 4 4 ) 5.0 64. WEST VANCOUVER ( 4 5 ) 5.0 6 5 . HOWE SOUND ( 4 8 ) 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 t h e 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 ( 1 9 5 6 - 1 9 7 7 ) FOR MALES, BY SCHOOL D I S T R I C T , B.C. SCHOOL D I S T R I C T MORTALITY RATE (PER 100,000) 519 .0 1. FERNIE ( 1 ) 2. CRANBROOK ( 2 ) 509 .0 494 . 2 3 . HOPE ( 3 2 ) 4 . PRINCE RUPERT ( 5 2 ) 477 . 3 5. KAMLOOPS ( 2 4 ) 452 .8 6 . VANCOUVER ( 3 9 ) 449 . 6 7 . QUESNEL ( 2 3 ) 444 . 7 8 . NEW WESTMINSTER ( 4 0 ) 442 .9 9 . NORTH VANCOUVER ( 4 4 ) 442 .6 439 . 7 10 . BURNS LAKE ( 5 5 ) 1 1.KITIMAT ( 3 0 ) 435 . 7 12 .RICHMOND ( 3 8 ) 426 . 1 13 .MAPLE RIDGE ( 4 2 ) 423 .0 14 .PEACE RIVER SOUTH ( 5 9 ) 422 .0 15 .TRAIL ( 1 1 ) 4 20 . 9 16 .CAMPBELL RIVER ( 7 2 ) 4 18 .6 17 .MERRITT ( 3 1 ) 414 .0 18 .PRINCE GEORGE ( 5 7 ) 412 . 9 19 .NELSON ( 7 ) 409 . 5 20 .TERRACE-NISHGA ( 8 8 ) 408 . 9 21 .ALBERNI ( 7 0 ) 408 . 7 22 .NANAIMO ( 6 8 ) 407 . 7 23 .LILLOOET ( 2 9 ) 407 .4 24 .BURNABY ( 4 1 ) 404 . 5 25 .POWELL RIVER ( 4 7 ) 404 . 5 26 . SURREY ( 3 6 ) 401 . 7 27 .LANGLEY ( 3 5 ) 401 . 3 28 .PRINCETON ( 1 7 ) 400 . 6 29 .WEST VANCOUVER ( 4 5 ) 393 . 9 30 .QUALICUM ( 6 9 ) 390 . 9 31 .OUEEN CHARLOTTE ISLANDS ( 5 0 ) 389 .4 32 .REVELSTOKE ( 1 9 ) 387 . 2 33 .VANCOUVER ISLAND NORTH ( 8 5 ) 386 . 3 34 .CASTLEGAR ( 9 ) 383 . 8 35 .KEREMEOS ( 1 6 ) 383 . 3 36 .GREATER VICTORIA (61 ) 382 .6 37 .COURTENAY (7 1) 381 . 1 38 .COWICHAN ( 6 5 ) 380 .9 39 .FORT NELSON (81 ) 380 .8 4 0 VERNON ( 2 2 ) 377 . 5 41 .SMITHERS ( 5 4 ) 377 . 1 42 .SUMMERLAND ( 7 7 ) 377 . 1 43 .PENTICTON ( 1 5 ) 376 .9 44 .SUNSHINE COAST ( 4 6 ) 372 .0 45..GOLDEN ( 1 8 ) 368 . 3 46 .SOUTH CARIBOO ( 3 0 ) 362 . 2 47 .CHILLIWACK ( 3 3 ) 359 . 7 48 .SHUSWAP ( 8 9 ) 359 . 7 49 .SOOKE ( 6 2 ) 357 . 7 50. WINDERMERE ( 4 ) 356 . 1 51 .DELTA ( 3 7 ) 354 .0 52 .GULF ISLANDS ( 6 4 ) 351 . 9 53 .ABBOTSFORD ( 3 4 ) 346.. 7 54 .PEACE RIVER NORTH ( 6 0 ) .0 346 . 55 .M I S S I O N ( 7 5 ) 339 .2 56. SOUTH OKANAGAN ( 1 4 ) 337 .7 57. CRESTON-KASLO ( 8 6 ) 336 .9 58 .CARIBOO-CHILCOTIN ( 2 7 ) 335. 1 5 9 . LAKE COWICHAN ( 6 6 ) 330. 9 60. CENTRAL OKANAGAN ( 2 3 ) 330. 0 S1 .COQUITLAM ( 4 3 ) 329 .7 6 2 . NECHAKO ( 5 6 ) 329. 5 6 3 . SAANICH ( 6 3 ) 325. 5 64 .HOWE SOUND ( 4 8 ) 319. 8 65 :KIMBERLY ( 3 ) 300. 0 6 6 . VANCOUVER ISLAND WEST ( 8 4 ) 191 .8  TABLE  8'  A RANKING FROM HIGH TO LOW OF: AGE-STANDARDI ZED MORTALITY RATES FOR ALL HEART DISEASES COMBINED ( 1 9 5 6 - 1 9 7 7 ) FOR FEMALES, BY SCHOOL D I S T R I C T , B.C. SCHOOL D I S T R I C T MORTALITY RATE (PER 100,000) 1. VANCOUVER ISLAND NORTH ( 8 5 ) 918 .0 2 . KITIMAT ( 8 0 ) 432 . 7 3. HOPE ( 3 2 ) 416 . 7 4 . PRINCETON ( 1 7 ) 401 . 7 5 . PEACE RIVER NORTH ( 6 0 ) 364 .0 6 . SOUTH CORIBOO ( 3 0 ) 363 . 7 7 . POWELL RIVER ( 4 7 ) 352 . 3 8 . NELSON ( 7 ) 339 . 5 9. QUEEN CHARLOTTE ISLANDS ( 5 0 ) 333 .6 10. CASTLEGAR 9 9 ) 323 . 4 1 1 .PRINCE RUPERT ( 5 2 ) 318 . 5 12. KEREMEOS ( 1 6 ) 318 . 3 13 . SOOKE ( 6 2 ) 308 . 3 14 . FERNIE ( 1 ) 297 .8 15. CRANBROOK ( 2 ) 293 . 2 16 . HOWE SOUND ( 4 8 ) 290 .0 17 . T R A I L ( 1 1 ) 289 .9 18 . CAMPBELL RIVER ( 7 2 ) 289 .8 19. NANA IMO ( 6 8 ) 287 . 7 20. TERRACE-NISHGA ( 8 8 ) 286 .8 21 . PEACE RIVER SOUTH ( 5 9 ) 280 .0 22 . DELTA ( 3 7 ) 275 . 9 23 . KIMBERLY ( 3 ) 275 . 1 24 . PENTICTON ( 1 5 ) 273 . 4 25 . NORTH VANCOUVER ( 4 4 ) 272 . 9 26 . VANCOUVER ( 3 9 ) 271 . 5 27 . SHUSWAP ( 8 9 ) 270 .9 28. LILLOOET ( 2 9 ) 268 .7 29. ALBERNI ( 7 0 ) 267 . 7 30. BURNABY ( 4 1 ) 267.. 4 31 . NEW WESTMINSTER ( 4 0 ) 265..6 3 2 . VERNON ( 2 2 ) 264 . .8 3 3 . REVELSTOKE ( 1 9 ) 264 . .4 34 . LAKE COWICHAN ( 6 6 ) 263 . 2 35. SURREY ( 3 6 ) 262 . .9 36 . SOUTH OKANAGAN ( 1 4 ) 262 . 6 37 . LANGLEY ( 3 5 ) 261 . 3 38 . COWICHAN ( 6 5 ) 261 .2 39 . PRINCE GEORGE ( 5 7 ) 260. 1 4 0 . RICHMOND ( 3 8 ) 259. 3 41 . MISSION ( 7 5 ) 258 .6 4 2 . ABBOTSFORD ( 3 4 ) 256 .5 43 . KAMLOOPS ( 2 4 ) 255 .8 44 . SUNSHINE COAST ( 4 6 ) , 254.0 4 5 . QUESNEL ( 2 8 ) 251 .5 46. COURTENAY ( 7 1 ) 251 .3 47 . NECHAKO ( 5 6 ) 250. 2 48. MAPLE RIDGE ( 4 2 ) 249. 3 49 . CRESTON-KASLO ( 8 6 ) 246 .2 50. CHILLIWACK ( 3 3 ) 243 .3 51 . MERRITT ( 3 1 ) 242 .5 52 . SMITHERS ( 5 4 ) 242 .3 5 3 . GREATER VICTORIA ( 6 1 ) 235 .5 54 . WEST VANCOUVER ( 4 5 ) 235 . 4 55 . SAANICH ( 6 3 ) 229 . 9 56 . CARIBOO-CHILCOTIN 228 . 1 57 . WINDERMERE ( 4 ) 225 . 9 58 . GULF ISLANDS ( 6 4 ) 224 .0 59 . VANCOUVER ISLAND WEST ( 8 4 ) 222 .9 6 0 . QUALICUM ( 6 9 ) 222 .0 6 1 . SUMMERLAND ( 7 7 ) 220 .0 62 . CENTRAL OKANAGAN ( 2 3 ) 2 12. 6 63 . GOLDEN ( 1 8 ) 202 .8 64 . FORT NELSON ( 8 1 ) 198 .5 65 . BURNS LAKE ( 5 5 ) 183 .5 66 . COQUITLAM ( 4 3 ) 176 .7  65 of  British  Columbia,  province's area  school  for  quality  (see  mortality place  of  data  of  the  avalable  available  lacked  water  95  a l l heart  this  Kettle  data  should and  be  heart  district  school  district's  major  10,000, and and  the  because  the  decedents  was  and  school  only  districts  districts,  Valley,  this  population.  North  Arrow  Thompson,  Stikine,  and  from a l l analyses  cities  that  has  data  cities.  For  and  of  the  such as  different  example,  the  by  approximately the  cities, is  account school  Fernie,  water the  population  Fernie  water  the  each  by  of  Sparwood  by  of  supplied  i s represented  when  i s analysed  drinking  a population  Fernie  districts  information  proportion  is  whose c o m b i n e d  proportion  with  major  the  or  of  information  a  district  Sparwood,  In  distortion  by  city  district  i s apparent  substantial  two  eight  eight  population  districts's  school  no  because  accurately  It  disease  were e x c l u d e d  disease  described  Fernie  water  compared w i t h  Agassiz-Harrison,  school  Fernie  was  report.  There water  These  The  districts,  Only  the  data  9).  districts,  school  for c i t i e s .  Coast,  was  over  geographical  mortality  cities  of for  the  Table  school  Armstrong-Spallumcheen, in  and  74  Forks,  is  disease  information.  Grand  well-distributed  which  13,  these  of  partly  Central  1A,  residence  completely  Lakes,  heart  Maps  data  are  districts,  which  available  and  for  a  district's  (which  hardness,  9,601.  contain  calcium  and  (oQ>  MAP  I  A :  BRITISH SCHOOL  COLUMBIA DISTRICTS  HERRIII  3.? Hnpr 33 CuIlUrfACK •< -iNOCf^er.t 35 lANGLEY 3iJ ^L'f'C'EY ? Ci'iiNi'MCJOi-:  3  KIfecni.Ef  7  NEC  SC.  10  *nnuw  11  13  LAKES  3'  OELTA  TRAIL  39  RICHMOND  K E I T U  3D VANCOUVER  v*i  i.fr  fu-.-ct  TON  PEACE PEACE  Ol  RIVE'  fllvEf  GREATER VICTORIA  6? 63  GJ  i J :; (jc:i*i-r.,*H wcsiMiNsrrn rr.Niir.rrjK 4 1 B "i.'lNAHY i'  59 CO  E5 £1  SOCKE SAANICH  ISLANf  GULP  COwlCHAN LAKE  COWIC)  69 NiNAlMO OUALICUM 70  AI.OERNI  '/! CClJRIENAT ^ CiMl'UEll 44 N VANCOUVER <iS W VANCOUVER <i  emu:  'ii  SI.'NCHINE  II.*M  RIVER  MISSION  ?I  23  COAST  *?IH*;I!'.(;:JC -  ^'Al.l.UHChf.CN 2^ vEriMCr;  •" !  n  CUESMEL  00  ronr  B-«  VAH  LAKE  Su KEO'A<0  CoU\/fc:R. SCHOOL fioAftn O P P I C E  PRINCE C£OMOC  NELSO  I S L WE  VAM  Oi]  5;  KITIMAT  ei  CMARLOTIE  |30 3 CAf'UlGrj  VPJVI  SCUNO  <!) C E N T R A L  THOMPSON  >o u ri.i.oor.:  T'ne  -  SUHMERLANO  COAST :*o OLTCN B5 52 PRiMCE RijPE.'U CAniuoo - 5-i SMI IhEfiS Q? SIIKINE '5 B URN'S CENIRAI.  CH ILCO f * N 20  >K>E  AGASSU HARRISON  ?7  OKANAGAN  ?G  7G  69  I S L NO  Cr.ESTOM-KA  TEfiPACE  R9 SHUSWAP 02  n1 S H G A  (ol  MAP!3 T H E ;  I 0 3 LARGEST IWS1DE-  S c h o o l  CITIES DiSTRlor  iH  BRITISH COLUMfi/A l ^ O ,  ftoUfJ  }  DARKTS  \,  . T A B L E f,,  THE  103  LARGEST C I T I E S * I N  •  u  BRITISH  COLUMBIA,  /• V A N C O U V E R  414,281  2. SURREY  147,138  3- BURNABY  136,494  4- RICHMOND  96,164  %• D E L T A  74,692  £>• P R I N C E  GEORGE  7. KAMLOOPS  67,559 64,048  COQUITLAM  61,077  KELOWNA  59,196  /O. NANA I MO  47,069  //. C H I L L I W A C K  40,642  /2- NEW  WESTMINSTER  38,550  VANCOUVER  35,728  /3- WEST /</• NORTH  VANCOUVER  33,952  /tr-MAPLE  RIDGE  32,232  }(,.  VICTORIA  /7 PORT /£.  31,543  COQUITLAM  PENTICTON  27,535 23,181  /<?. M I S S I O N  20,056  20. VERNON  19,987  2/. PORT  19,892  ALBERNI  ^2-PRINCE  RUPERT  25- CRANBROOK 2-4-CAMPBELL 25-LANGLEY  1980  16,197 15,915  RIVER CITY  15,832 15,124  CITIES VJILU I M C L U D E 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 S T . J O H N  13,891  Z?.WHITE ROCK  13,550  29-POWELL  13,423  RIVER  30.KITIMAT  12,814  3/-ABBOTSFORD  12,745  ZZDAWSON  11,373  CREEK  ^.TERRACE  10,914  ^.SALMON ARM  10,780  3$. SQUAMI SH  10,272  36-TRAIL  9,599  57. N E L S O N  9,143 8,992  COURTENAY % WILLIAMS LAKE  .  8, 3 6 2  Vo.QUESNEL  8,240  HSIDNEY  7,946  Y2- SUMMERLAND  7,473  i/^KIMBERLY  7,375  1ft. C A S T L E G A R  6,902  COMOX  6,607  (^.COLDSTREAM  6,405  (ft. P I T T MEADOWS  6,209  tfg.MERRITT  6,110  L# M A C K E N Z I E  5,890  54. R E V E L S T O K E  5,554  t^FERNIE  5,444  5*.  PARKSVILLE  5,216  53.  PORT HARDY  5,075  5^,  SMITHERS  4, 5 7 0  5f. L A D Y S M I TH  4,558  5b. DUNCAN  4,228  57.  SPALLUMCHEEN  4,216  5%  •CRESTON  4, 190  SPARWOOD  4, 1 57  LO. R O S S L A N D  3,967  U.  3,921  HOUSTON  42. FORT  NELSON  3,724  FORKS  3,486  £3- GRAND GOLDEN  3,476  £S- KENT  3,394  bio. HOPE  3,205  lol. ELKWOOD  3,166  &jf. P R I N C E T O N  3 ,057  PEACHLAND lO. Q U A L I CUM  2,865 BEACH  2,844  7/. OSOYOOS  2,738  72-ARMSTRONG  2,683  7?. LOGAN  2,637  LAKE  TY.GIBSONS  2,594  ?£CHETWYND  2, 5 5 3  l(o• PORT M C N E I L  2,474  77.LAKE COWICHAN  2,391  H>. VANDERHOOF  2,323  ff, FORT S T . J A M E S  2,284  &J.GOLD  2,225  RIVER  $/.ASHCROFT  2, 1 56  %1.1NVERMERE  1 ,969  ^3-WARFI E L D  1 ,969  ^1/.CUMBERLAND  1 ,947  % . 100 M I L E  1 ,925  HOUSE  ff&.FRUITVALE  1 , 904  %1, O L I V E R  1 , 893  S&-ENDERBY  1,816  g^,BURNS L A K E  1 ,777 1 ,777  % • CHASE  °i1  TAHSIS  1 ,739  LILLOOET  1 ,725  fa PORT  1 ,668  ALICE  *,f.UCLUELET  1 ,593  fc.  1 , 569  MASSET  % . FRASER LAKE  1 , 543  NAKUSP  1 ,495  °l %• STEWART  1 , 456 1 ,430  fj. G R A N I S L E  c  /0O.HUDSON' S /o/.CACHE  HOPE  CREEK  1 , 360 1 ,307  /02.-LUMBY  1,266  /o? MONTROSE  1 ,229  72 magnesium  values),  the  water  quality  weighted  a c c o r d i n g to the c i t i e s '  greater  accuracy  waterborne those  calcium,  school  described  in  b.  from  disease  their  deaths  may  data  in  the  for  technique  is  water-hardness  d i s t r i c t s are  included  distribution  British to  of  be  due  1978.  age  twenty-one  district  includes  in  were  of  The  residence,  and  registration  under  of  prescribed  residence, recorded recorded according  sex, on  by  and  death  that  time  age  a  format  used  vital and  in  school  death.  and  other v i t a l and  events  that date  The  a m e d i c a l a t t e n d a n t on to  was  problems.  events  territorial  V i t a l S t a t i s t i c s or  or b i r t h  records.  heart  this  because  sex, age,  provincial  appropriate  These A c t s r e q u i r e a  of  of deaths  responsibility  governments  death,  cause  in  excluded  which  the  decedents  included  were  of  deaths  during  Only  to congenital  year  of  Columbia  for heart disease decedents  study  within  hardness,  Information  1956  years  under  Acts.  obtain  magnesium v a l u e s  and  school  y e a r s from  those  the  water  weighting  the geographic  study;  is  2,  of the  twenty-one  this  The  Appendix  examined  twenty-three  The  waterborne  Disease Mortality  heart  over  and  the  were  3.  Heart I  populations to  estimating  districts.  classifications Appendix  in  parameters  cause of  the by  reported of  death,  the decedent  cause  prescribed  be  other  of  death  registration the" W o r l d  be is form  Health  73 Organization the  and  International  recorded death,  which  municipality also  error  1.  sequence or  coded  affect  and  the  underlying  which  usual  offices.  mortality  The  cause  injury  Possible  data,  of m o r t a l i t y  The  decedents sources  and  of  which  l e d to death.  r e s i d e n c e of  of  hence  rates,  of the  include  following: Completeness of  Recording legal the the  time  data:  of  accuracy  of  d e p e n d s on  offices.  of  Coding  and  coding  of  rural  from the the  one  of  checked and  at  the  causes  of  death  cause  of  of  and  sex be  where p o s t a l  r e s i d e n c e may  be  are  of  death.  the  filing  in are  differ  to another.  medical  with  at  However  s h o u l d not  the  are  both  that there  the a The  largely  attendant, patient.  Errors associated with  insignificant.  significant, addresses  recorded  forms  information  death,  processing errors: age  time  that  cent.  for content,  It is likely  familiarity  thought  per  school d i s t r i c t  cause  r e s i d e n c y can areas  of  is  registration  misclassification  records the  coding  are  It  hundred  Death  in completion  deal  one  completion  provincial  great  of  approaches  of  proportion  who  registration:  documents and  errors  3.  of  (ICD).  of Diseases  events  reliability  registration 2.  of  township  relevant revision  the d i s e a s e or  in provincial  t h a t may  completeness the  declares  i s d e f i n e d as  the  i n the  Classification  statement  initiated  is  specified  and  Errors in  especially  rather than are  in  place  subsequently  74  coded.  In  this  disease  study,  that  of  c a t e g o r i e s of  in (see  the  heart  International 4).  Appendix  These  include:  Rheumatic  2.  Chronic  3.  Arteriosclerotic  4.  Other  5.  Hypertension  6.  Diseases the  listed Diseases  1.  of  i n c l u d e d seven  are  Classification categories  I  Fever  Rheumatic  Diseases  of  Heart and  of  the  Disease  Degenerative  Disease  Heart  w i t h or w i t h o u t the A r t e r i e s ,  Circulatory  Heart  System  Heart  Disease  V e i n s , and  Other  Diseases  75 C. R E S U L T S AND A N A L Y S I S Sex-specific calculated water for  age-standardized and these  hardness, each  waterborne  school  a.  little  of the observed  heart  forthis  of  study  heart  of  without  Heart  negative  f o r each category  with  without  values for  were  A closer  heart  Disease.  Heart  was  categories. In fact, i n negative  (5)  except  f o r a l l male  f o r category Hypertension  For females  Disease.  other  hardness and  correlation  for  (4) with  Other or.  thecorrelation i s  Hypertension  (5)  The o b s e r v e d  correlation  disease categories. a n a l y s i s of Table  10  will  highlight  o f t h e a s s o c i a t i o n between water  disease  correlation  and  The  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  any heart  importance  Heart  i n many  between water  was  disease  1956 t o 1978.  was 0.05. As  disease  Diseases  or  from  c a t e g o r i e s except  the  i n  toexplain  i n heart  statistical  thecorrelation  disease  was f o u n d  variation  the correlation  f o r many h e a r t  study  as described  a n a l y s i s a r e shown  itself,  Columbia  disease, a negative  obtained this  by  i n British  studies  Columbia  magnesium  10  hardness,  level  were  12.  Water  alpha  andwaterborne  inBritish  Water Hardness: Table  mortality  rates  compared w i t h v a l u e s o f  of the statistical  10, 11, a n d  very  were  calcium,  district  above. The r e s u l t s Tables  rates  mortality  mortality.  coefficients,  Column which  1 of Table describe  the  hardness and 10 l i s t s  the  the association  %  TABLE 10 CORRELATI ON BETWEN WATER HARDNESS AND AGE-STANDARDI ZED HEART DISEASE MORTALITY RATES COLUMN 1 SIGNIFICANCE R SQUARED CORRELATION ( R ) CATEGORY (MALES) 1.400-402 0.00839 0.46813 -0.09158 .410-416 0.00060 O.84486 -0.02455 .420-422 0.00727 0.49594 -O.08529 .430-434 0.03310 O.14372 O.18194 .440-447 0.00262 0.68296 0.05122 .450-468 0.01988 0.25876 -0.14101 .400-468 0.00237 0.69769 -0.04872 CATEGORY (FEMALES) 1.400-402 0.62219 -0.06227 0.00388 .410-416 0.62496 0.00376 -0.06129 .420-422 O.66955 05352 0..00286 .430-434 0.58993 06755 0..00456 0.94667 .440-447 00839 0..00007 O.38931 .450-468 10772 0..01160 O.57888 .400-468 06956 O..00484 KEY : 400-402 RHEUMATIC FEVER 410-416 CHRONIC RHEUMATIC HEART DISEASE 420-422 ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE OTHER DISEASES OF THE HEART 430-434 440-447 HYPERTENSION WITH OR WITHOUT HEART DISEASE 450-468 DISEASES OF THE V E I N S , ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM ALL HEART DISEASE CATEGORIES COMBINED 400-468  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 : 4 0 0 - 4 0 2 : RHEUMATIC FEVER 4 1 0 - 4 1 6 : CHRONIC RHEUMATIC HEART DISEASE 4 2 0 - 4 2 2 : ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE 4 3 0 - 4 3 4 : OTHER DISEASES OF THE HEART 4 4 0 - 4 4 7 : HYPERTENSION WITH OR WITHOUT HEART DISEASE 4 5 0 - 4 6 8 : DISEASES OF THE V E I N S , ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM 4 0 0 - 4 6 8 : 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 0.00606 -0.07787 0 54744 2.410-416 -0.06521 0.00425 0 61458 3.420-422 0.02186 -0.14786 0 25144 4.430-434 0.05000 0 08063 0.22360 5.440-447 0.00016 0.01252 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 0.01095 -0.10462 0 41837 3.420-422 -0.15821 0 21939 0.02503 4.430-434 0.00462 0.00002 0 97160 5.440-447 0.00134 0 77761 -0.03660 6.450-468 -0.13448 0 29736 0.01809 0.02358 7.400-468 -O.15356 0 23340 KEY : 4 0 0 - 4 0 2 : RHEUMATIC FEVER 4 1 0 - 4 1 6 : CHRONIC RHEUMATIC HEART DISEASE 4 2 0 - 4 2 2 : ARTERIOSCLEROTIC AND DEGENERATIVE HEART DISEASE 4 3 0 - 4 3 4 : OTHER DISEASES OF THE HEART 4 4 0 - 4 4 7 : HYPERTENSION WITH OR WITHOUT HEART DISEASE 4 5 0 - 4 6 8 : DISEASES OF THE V E I N S , ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM 4 0 0 - 4 6 8 : ALL HEART DISEASE CATEGORIES COMBINED  79 between  water  rates.  For  -0.09158, that  hardness  example,  the  a negative rheumatic  The  correlation  heart  disease  determine  number  which  reveals  between water  hardness  obtained  reason,  likelihood  mortality  i n Column 1,  mortality rates  coefficient  the  disease  coefficient  association exist  chance, and, f o r t h i s  to  heart  first  i s the c o r r e l a t i o n  and  by  and  f o r males.  c o u l d have  coefficients that  occurred  are tested  a real association  exists.  I n Column  amount  o f m o r t a l i t y a t t r i b u t a b l e t o water h a r d n e s s . F o r  example,  the  indicates  2, t h e R s q u a r e d v a l u e s  first  that  number  0.8  per  c a u s e c a n be e x p l a i n e d number  in  correlation could Also  Column  and  3 i t will  occurs However,  contrary  to  what  Diseases  of  the  Circulatory  Other  The  first  rheumatic  that  of t h e time.  the  Diseases  fever  of  strongest the  Heart  t h e a s s o c i a t i o n i s a p o s i t i v e one, might  Arteries,  be  expected.  Veins,  showed  the  deaths  f o r about in British  Category ( 6 ) ,  and Other  Diseases  strongest  water h a r d n e s s . T h i s  which a c c o u n t s  disease  0.00839,  the c a l c u l a t e d  46.8 p e r c e n t  be o b s e r v e d  with  System,  r e l a t i o n s h i p with  heart  hardness.  (R) o f w a t e r h a r d n e s s  i n Column  disease,  water  by c h a n c e a b o u t  2,  o f m o r t a l i t y due t o t h i s  that  association  the  Column  reveals  occur  (males).''  cent  by 3  in  h i g h l i g h t the  eight  category per cent  Columbia,  negative of heart of the  h a s n o t been  Other 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 o f t h e h e a r t , such as a r r y t h m i a , h e a r t b l o c k , and v e n t r i c u l a r fibrillation. 1  of  80 shown by o t h e r hardness. which and  In t h i s  measures  the death  combined The for  than  of  i n Schroeder's  obtained  by  disease  this  Columbia  hardness  categories  hypertension reported  i s indirect  by M a s i r o n i . might  negative  categories researchers  al  with heart  to  Arteriosclerotic  water  the  expected  In  of  a and  finding  that the strongest  between w a t e r and Other  Diseases  category  ( 5 ) , Hypertension.  disease  were  with  degenerative  coronary  noted water  heart  infarction occlusion,  Schroeder 1960b M o r r i s , C r a w f o r d , Heady 1968 M a s i r o n i , S h a p e r 1981 " M a s i r o n i , S h a p e r 1981; W i n t o n , McCabe 1 983  hardness Degenerative  (4),  myocardial  arteriosclerosis,  2  hardness  category  vary  and  study.  suggestion  contradiction to  been  or w i t h  of  were a l s o much  3  have  or  this  correlation  in this  ( 3 ) , Arteriosclerotic  Disease,  Heart,  et  the  a s s o c i a t i o n s would occur  category  relationship  The  1  between  females.  was -0.29 (and  obtained  study,  association  same  study  Morris  the c o e f f i c i e n t s  British  aneurysm,  coefficient  between w a t e r  f o r a l l heart  coefficient  sexes  positive  the  c h a n g e s o f water  the c o r r e l a t i o n  statistically-significant).  It  with  i s -0.04872 f o r m a l e s a n d -0.06956 f o r  both  higher  Heart  study,  rate  coefficients  and  t o vary  the r e l a t i o n s h i p  correlation  was  this  researchers  These by  many  hardness."  disease  or  of  includes  thrombosis,  embolism,  and  1  2  3  1970; Luoma  et  al  81 ischemic  heart  include  ventricular  postulated calcium to  any  previously  of  that  t h etheory  contributing hypertension. indicate between  hardness  and  mortality.  hardness  -  separately  strongest  1 2  a major The  calcium  such  and  3,  had  exist  4,  o r 5.  hardness  were an  does  of heart  constituents  magnesium  of  10, however,  associations  water  to  i s a  development  f a c t o r i nany type  either  as  trigger  evidence  of Table  that  major  t o see whether  of  water  considered independent  on m o r t a l i t y .  Waterborne  although  animal  categories  10 s u g g e s t s  be  individuals  Both Anderson and  the  water  to  calcium  in  I t was  dietary calcium  negative  appear  In  deficient  stronger  not  influence  presented  that  heart  deficiencies i n  occurrences,  that  Table  that  predispose  None o f t h e r e s u l t s  2  the  a magnesium d e f i c i e n c y c a n  factor  Furthermore,  disease  paper  infarction.  McCarron  1  of  and f i b r i l l a t i o n .  ions could  myocardial  stated  arrythmia.  and  i nthis  diseases  t h e above-mentioned  or  Heggveit  b.  arrythmia  a n d magnesium  aneurysm  support  A n d other  disease.  Calcium:  general, and  the correlation  heart  i t  Anderson e t a l M c C a r r o n 1983  disease  between  mortality  waterborne  i s  negative,  i s 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 .  inverse  t h e female  T a b l e 11  association heart  1975  disease  appears  between  category  ( 6 ) , Diseases  The  calcium of  82  the  Veins,  Arteries  Circulatory  System.  furthermore, anticipated manifest  (1)  be  i s more that  the heart  two strongest  of  Degenerative  magnesium  enabled  protective  disease.  this  played  a  (2) i t  role  i n  disease.  Disease  One  with  the  further  correlation  mortality  ratios.  be c o n t r a s t e d eta l  1979  f o r both  and  water  males  of waterborne may  i n this  hardness  are  report,  which with  T h e r e s u l t s a r e shown  1  was done was standardized  i n Table  t o the r e s u l t s of Table  not  they a r e  researchers.  analysis  possibly  and degenerative  associations  statistical of  ot i c  magnesium  of other  between  ( 3 ) , Ar t er i os cler  arteriosclerotic  findings  occurred  consideration  us t o seet h a t  against  are quite interesting.  associations  independent  Although  consistent  'Marier  where  a n dwhere  t o prevent  table  statistically-significant  can  be  would  Disease,  involved,  andcategory  Heart  This  a  Heart  muscle  i t would  i n Category ( 3 ) ,  calcium  negative  magnesium  females.  be  strongly  the  association;  effect of calcium  Degenerative  muscle  results  waterborne and  and  because  of  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  The  more  expected  strengthening c.  the protective  ot i c  Diseases  I ti s not a s i g n i f i c a n t  itself  the heart  might  Other  i t i s surprising that  Ar t er i os cler  and  13,  and  10,where t h e  83 correlation rates  was  instead  done of  using  age-standardized  ratios.  Standardized  analysis  produces a comparison  district  with  In  the table,  with  are  excess  values  below  100 a r e c o n s i d e r e d of  did  the  trends both  deaths  done  negative ratios,  t a b l e s 10 a n d  now  although  The  hardness,  waterborne  negatively  scattergrams  considered  than  with  the  as expected, results  can  values expected  often  ratios,  more  yielded  categories t h e same be  to  category.  which are  i n more  school  combined.  specified  rates,  ratio  than  general  observed  in  13.  independent  age-standardized  a  correlations  scattergrams follow.  less  standardized mortality  generally  were  t o have  mortality  than  100  and d i s t r i c t s  for  i n the s t a t i s t i c a l  The  above  of m o r t a l i t y ,  Age-standardized  stronger  f o r each  districts  an  informative  mortality  t h e mean o f a l l s c h o o l  have  number  of values  mortality  of  the  correlations  scattergrams of the  associated heart  would  disease have  show s c a t t e r  variable  calcium,  which  axes.  with mortality looked  which i s If  or waterborne  were  water  magnesium  sex-specific, rates, more  the like  SH  TABLE 13 CORRELATION BETWEN WATER HARDNESS AND AGE-STANDARDIZED HEART DISEASE MORTALITY RATIOS COLUMN 1 R SQUARED CORRELATION ( R ) SIGNIFICANCE CATEGORY (MALES) 1 .400-402 -0.13159 0.01732 . 29226 2.410-416 0.00363 0.00001 ,97690 3.420-422 0.13536 0.01832 .27851 4.430-434 O.17844 0.03184 .15173 5:440-447 0.08643 0.00747 49015 6.450-468 -0.24764 0.06133 04499 7.400-468 -O.11269 0.01270 . 36765 CATEGORY (FEMALES) 1.400-402 -0.05568 .65703 00310 2.410-416 -0.08274 50895 00685 3.420-422 7909 1 -0.03326 001 1 1 4.430-434 97475 -0.00397 00002 5.440-447 81006 00091 0.03015 6.450-468 87135 00041 -0.02032 7.400-468 77787 00125 -0.03539 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 V E I N S , ARTERIES, AND OTHER DISEASES OF THE CIRCULATORY SYSTEM 400-468 ALL HEART DISEASE CATEGORIES COMBINED  85 this:  AN EXAMPLE" t>T M ASSOCIATION WiTH A C0fU<£LATlori C 0 6 F F l c r E l * T OP O.HS ANP A R£&R£S5IM>I COEFPIC-tENT OF ~oa% —  In  this  relationships  study,  there  shown by t h e  w e r e no  d i s t i n c t negat i v e  scattergrams.  SCATTERS RAMS CORRELATION  BETWEEN  OF  WATEff> HARDriESS  A&g-STAND ARPtZLE-D M O R Y ^ L I T V OF  HO\ft.T  slftTE; T H f  THE  RESULTS  fiVrVTE-S  A M D S>£X~ S Pflft. SEVElvl  I  C  CATE1QOK.IES  PlStTASE FiRST  SEV.EVM  5 CA T T E  ft  A M.S  A'R.E  LATTER. STEVEN ScATT£"R.G.*sAM5 Age  F & K  Fo.R.  M A L E S  J  A N ! ?  PEMALETS  2 MAR 8 6 20:50:03 DOWN:  WH  A P I L O T STUDY OF THE R E L A T I O N S H I P U n i v e r s i t y of B r i t i s h Columbia WATER 2  HARDNESS 6  /G»-Ce>3 ^  BETWEEN  HKRDNSLSS  AKID  sex.-S Pet lF ic  ftfiC-STflNO  MU>,z.£D  M.RTALiTy  RATES  PoR. CHC-ONlC 2rtETUM/YTicHEART DISEflse'^/nB'-fiS  ^/t-)  10  WATER  14  ACROSS: 18  22  STANDARDIZED MORTALITY RATE 26  30  (per 34  [00,000*) 38  k  454  +  409  409  354  319  274  229  184  139  94  49  *  * 2  ** 2 ** * 2**3»2  * 12  20  28  32  40  OO  A PILOT  STUDY OF THE RELATIONSHIP BETWEEN WATER  University DOWN:  WH  409  HftRDrJESS  of B r i t i s h Columbia  WATER HARDNESS 1 3  (caCO  >*j/l-) 5  MVID Foft  7  ACROSS: 9  11  sen.-SPEC I Fi c RKSUMA-TIO  A G E -.STANTDARD IZ.EO MOK.rfli.iry  KATE3  PIEART D I S E A S E / M A L E ' S  STANDARDIZED MORTALITY 13 15  RATE 1f  19  409  184  94  CO  !:«?aS  6  20  DOWN  5 n ^ ™  ?r£l *Z% J£iir '' T  r  WATER HARDNESS 2 2  _l  +  1  B E T W E E N  W A T E R  M  h  _ _ _l  _  ACROSS:3  21S  +  +  454  *  t  o  "  *  A « - « ™ ^ «  C  STANDARDIZED  335  0 7  +  "  —  M  *  ^  MORTALITY  363  ^  .  RATE  391  .  .  .  Q  M  o  4 19  ^  L  i  r  y  _  6 - / 0 ^  447  s  }  454  409  364  319  274  229  184  139  49  265  321  349  377  405  433  2 MAR 86 20:51:17 DOWN:  WH  A PILOT STUDY OF THE RELATIONSHIP U n i v e r s i t y of B r i t i s h Columbia WATER HARDNESS 2 6  BETWEEN WATER —  ( C*CO> 10  14  ACROSS: 18  HARDNESS OTH-ER. 22  Ma  SEX-SPEC I F I c /\GE -J.TMa A U D i i E O r i o R T A L c r v RATES  D! 5 C A S E S STANDARDIZED 2G  t  CF T/+£~  REftftr/  MORTALITY 30  MALE^  (p^ttr 100,00a)  RATE 34  38 454  409  409  3S4  319  274  229  229  184  139  139  94  94  49  2 MAR 86 20:51:43  A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HACDWess U n i v e r s i t y of B r i t i s h Columbia WATER HARDNESS 3 9  DOWN:  ^Co.C0 15  ^j/ -) 1  3  ACROSS: 27  33  ftNfl  SEX'SPea Pie A<ic-jSTAMDA*.Dii£-i:> r\iK.TAi_ir¥  R A T E S  STANDARDIZED MORTALITY RATE (p*s- l o e j o o o ' ) 39 45 51 57 454  409  409  364  319  274  274  229  184  184  139  94  94  49  *  *  **  ***** * 2 * 2*2 2** -  *  12  18  24  30  36  42  48  54  60  31 2 MAR 86 20:52:13 DOWN:  WH  A PILOT STUDY OF THE RELATIONSHIP U n i v e r s i t y of B r i t i s h Columbia WATER HARDNESS 5 15  (ccuC0 25  BETWEEN WATER FOR.  rng/L)  3  ACROSS: 45  35  rtneOrvltSS  D I S E A S E S  Ar<D 5EX.-5PCC/PIC A^E-STrtKOftRDlZE-D MoKTALlTV RrtTETS  . F T » f  veiNjs  Aft-rE/ues,  AIJD  STANDARDIZED MORTALITY 55 65 75  ^ - H e R . rnsir/vs£VS o f  Tttr  cifttuLyv-rafiV  (_pe.r- {00,000)  RATE 85  95  454  409  364  319  274  274  229  184  139  94  49  49  .  »  2  * * *  * *  *  2 *  30  2 * *  * 2  4  2  40  60  70  80  90  100  s  33 2 MAR 8 6 20:52:42  A PILOT  STUDY OF THE RELATIONSHIP BETWEEN  University  DOWN:  WATER 208  of B r i t i s h  ^  (C«.C&-?> <^$/l~)  HARDNESS 242  276  310  SEX-5PETC1FIC l\CF-SYm\tmR.DIJFD  WATER rfnK.Drt£SS AMD  Columbia  A  u  ACROSS: 344  _  H  6  M  D i 5 e « f  r  MoRrfli.ir» I W T E :  o ! n  STANDARDIZED MORTALITY RATE 446 412 480  378  a  i  n  ( f D / M ^ E S  ('per l o o ^ o o ) 514 454  409  +  +  409  364  +  +  364  319  +  +  319  274  I +  I +  274  229  +  *  *  I I I + I  184  * *  * *  *  I  *  4  +  I *  + I I I I  * * »  * *  * * *  *  *  225  259  293  327  * .  2 «  361  *  * I I I I +  * * * 395  2 2  *  * * * * 429  * 2  94  + *  * *  *  *  *  * * *  139  I  *  *  184  I  *  * *  + 191  * .  *  + I I I I + I I I T*  49  *  *  +  I . 94  I I I + I  *  *  I 139  229  +  " 463  497  531  4  9  4  3H 2  MAR 8 6  20:53:15 DOWN:  WH  A  PILOT  STUDY  University WATER 1  OF T H E RELATIONSHIP  of B r i t i s h HARDNESS 3  BETWEEN  WATER  ArtD  Columbia  ^Co-COj, >->q/l-) 5  SEX-SPECIFIC  Ai.£-ST**IDftRD.£ E D  FoK. RttETu.rf'VTie STANDARDIZED  ACROSS: 7  11  13  MORTALITY 15  H(*T«LITV  KEft^-T" S I s e A S E RATE  £f«r17  R A T E S  /f&iA\-ES l » o , o o o ) 19  409  274  274  229  229  184  184  139  49  49  35 2  MAR  8 6  2 0 : 5 3 : 4 3  DOWN:  WH  A PILOT  STUDY  University  OF  THE RELATIONSHIP BETWEEN  of B r i t i s h  Columbia  (CtJiOj,  WATER HARDNESS  WATER  UflrRD klcTSS  ft*lD  (LHR^c  /O  H U E U M A T I C  STANDARDIZED  ACROSS 27  SEX •SPgci F i C AaF-STfti*DftRDi2fI> rteRTTVLiTv  33  3 9  HETrtR.T D i s e W s ^ / F t e r i A t r S  MORTALITY 4 5  RATE  £p£r 51  |oo,00£>^) 5 7  4 5 4  4 0 9  4 0 9  3 6 4  319  274  274  *  *  *  *  94  94  *  * 49  * * * * *  « * * 2 *  * 2  2  * 4  2  *  *  * *  12  * » 18  24  36  54  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 B r i t i s h Columbia p Kxo^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~) 449 507 565 623 159 217 275 333 391 6S 1 r  454  409  +  +  409  364  +  +  3S4  319  +  +  319  274  I +  I +  274  229  +  +  229  184  139  *  *  I I I + j I I + I  *  49  4  * *  I I I  +  *  *  * *  I I  * *  I  *  +  *  130  +  + 1 3 9  I *  * +  I * I * j * * + * * * * I * * j * * * * I 2 * 1 * * * * * * * * 2 * * + * * 2233* +  *84  I *  * *  I 94  * *  +  188  +  +  246  I I I  * *  I I I I  +  +  +  304  +  +  362  +  +  420  +  478  +  +  536  +  +  594  +  +  652  +  +.  7 10  94  +  4  9  97 2 MAR 86 20:54:40 DOWN:  WH  A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER l4ft«0NE:s.'S U n i v e r s i t y of B r i t i s h Columbia ._ WATER HARDNESS ( Cfl-CO 15  A  t-oR.  "VJ/L^)  ACROSS 27  ATJD  DT»f(L  ^cX-SffciFiCflcr-«Tfln/DflMin.EomRTftury / _  Pl«Se7VStT5 o p - T H E  -  H-EM.T /  R * T E T S  FfMAUTS  STANDARDIZED MORTALITY RATE 39  100,000.^  57  454  454  409  409  364  364  3 19  319  274  229  184  139  94  49  4  «22 6  3* *  * 12  18  48  54  60  38 2 MAR 86 20:55:06 DOWN:  WH  A PILOT STUDY OF THE RELATIONSHIP U n i v e r s i t y of B r i t i s h Columbia WATER HARDNESS 4 12  BETWEEN WATER HftRx>MESS Arte F6R.  ACROSS: 36  20  SEX -SPEtiPic A<ifT-STANr>ftR.DixeT> rloR-muXY RATE-s  l-fYPETM'FNSloNl/  44  STANDARDIZED 52  F f M A L E 3  MORTALITY 60  RATE  (r -'~ <  68  '••••so) 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  A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATER HAHDNE5S AMD SOL^  SPETOFIC  University  Ve^sIS AUD . T I , ^ t » ,  DOWN:  of B r i t i s h Columbia  WATER HARDNESS 18 a 4 o  ^  B  ^ /<-)  £a.&>3  —'  s  E  r  s  o  P  T  l  t  r  ACROSS:  7  28 no  l  ^ ji  1 Q  E;Q  O  mrfR.es  RATES  A6f-STrt^CA-fLD^FP MBRTA LI T Y  STANDARDIZED MORTALITY RATE 68 78  3 D  C  , p  5 e 3  ^  o  TWdRu^m.iV  P  SVST  F£f1ficLE~5  l°°,«<*>)  409  +  +  409  364  +  +  364  319  +  +  319  274  I * +  I +  274  229  +  •  *  I I I + I  184  *  *  I I  * *  *  I J + j j I I  *  *  * *  * *  +  * **  *  2  +  3  +  +  13  *  +  +  23  * *  *  *  ** * * * 2 * *  3 4  * *  *  *  *  T  4  184  I  *  *  + j  4g  I I I  * +  I  9 4  *  * *  I +  139  *  *  229  +  + I I ^ I  *  I I I I  *  * *  •  +  *  *  *  + 1 3 9  94  +  4  +  * +  33  +  +  43  +  +  53  +  +  63  +  +  73  +  +  83  +  + 9 3  +  +.  103  9  4  100 2 MAR 86 20:56:07  A P I L O T STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y of B r i t i s h Columbia WATER 214  HARDNESS 290  (CsJJS-*, 366  I *-) 442  WATER rfftR0M£5S p^P-. all. ItfARr  ACROSS: 518  594  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 crt-TE-djRIES c»nOi>jEi>/FfMflLE^  D I S E J U C  STANDARDIZED MORTALITY RATE (per670 746 822  loo.ooo) 898  454  409  364  364  319  319  274  274  229  229  184  139  94  49  4  +* . +176  * 2 * * • 423 * 252  404  480  632  708  860  S C A T T E R S R A M S  CL^RRELKTIOINI  BETTWEEtsl  HEART  DISEASE  R E S U L T S  W A T E " R B o f i ^ E T C A L H U M At\iD S E X - 5 P £ C j F l C  A G - E - S T A N D A R D IZ-EJD M O R . - r A L . i r V OF  OF  RArT&S  F O R SEVElst C A T G S Q R l E T S  101 2 MAR 86 20:43:12  A PILOT STUOY OF THE. RELATIONSHIP BETWEEN WATERBORNE CALCJUr-l AND .3 EX.-S PACIFIC A&E-STANDARDIZ.ED MORTALITY RflTCi U n i v e r s i t y of B r i t i s h Columbia fcf^ '«?tteu'n(=mc_ H"EBR.T TJ \se~f*SE /MfiiLES 1  WATERBORNE CALCIUM 1 3 81  73  65  57  49  33  25  17  /o  ^l/ ) 7 L  J  ACROSS: 9  11  STANDARD IZEO MORTALITY RATE (ffer 13 15 17  loo,Coo") 19 81  103  2 MAR 8G A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE <WD SCK-SPfC 1FIC A«-Sl>^Dft-R.Plz.eDrto^mu.ryR/yr§< 20:44:26 University of British Columbia pf^ CK*oMiC Rfrg-wi/vnc H - C T B T DisEfKF /, DOWN: CA WATERBORNE CALCIUM .(r*3& ACROSS: STANDARDIZED MORTALITY RATE Cf^ " / "" ) 2 6 10 14 18 22 26 30 34 38 0  M f t L f S  r l<  +  81  +  73  +  65  +  57  +  49  T  +  +  +  33 25  9 1  **  +  +  +  +  +  +  +  +  +  +  +  *  + .  I I  *  * * *  I + IJ  I I  *  **  +c  + 8 1  *  I  **  II  * * * *  +  4  + 3 3 + 2 5  I *  * *  +  + 4 9 + 4 1  " I ** I ** + I * ** ** I * I * * « * 2 * * * I * 2*2323 * + * O  +  + 5 7  +  .+  +  + 6 5  + I I  + I  +  >  *  I  17  +  c  + 7 3  T  41  +  >  +  +  8  * I I I I I I I  *  +  +  12  +  +  16  +  +  20  +  +  24  +  +  28  +  +  32  +  +  36  +  +.  40  17 +  9  +  1  I OH 2  MAR  86  2 0 : 4 4 : 5 5 DOWN:  A  PILOT  STUDY  U n i v e r s i t y  CA  of  WATERBORNE 195  81  OF  THE  R E L A T I O N S H I P  B r i t i s h  BETWEEN  C o l u m b i a  223  251  "  AjM  A C R O S S :  279  v  j.  . „  AND  SEOC-SPfraF-iC  _  ;  , STANDARDIZED  307  335  ftiiT-STANDARD ,-z.ef)  „  39  73  +  65  +  57  +  (_pe.<  RATE  1  419  loo,  o o o )  447  *  *  I  *  I  *  * *  *  * *  +  +  6  5  +  5  7  f  *  2 *  *  *  *  I  9  +  4  1  +  3  3  +  2  5  +  1  7  I  *  +  I  *  T  *  **  *  + I  4  I  *  I  J  +  I  *  +  *  J *  J +  *  I *  I +  +  181  3  I  I  1  7  I «  I  9  +  I  *  T  17  1  I  +  I  25  8  I *  +  33  + I  T  41  RATES  /  MORTALITY  363  MORTALITY*  + I  49  . _  r  C A L C I U M  C^UCitiM  WATERBORNE  * *  1  + 209  +  + 237  * *  *  *  *  *  +  » 265  +  *  +  + 293  * *  *  * *  *  * *  +  H 321  **  9  j j *  h  +  + 349  **  * * *  ^  1 377  *  -<  + 405  j  +  + 433  +  +  +. 46  1  1  [05 A P I L O T STUDY OF THE A r-iuu. U n i v e r s i t y of B r i t i s  2 MAR 86 20:45:24 DOWN:  B  WATERBORNE  CA  r  1  t  1  s  n  RELATIONSHIP  BETWEEN  WATERBORNE C A c ^ M L  Columbia  CALCIUM S  \ J)' 1 > 4  10  ACROSS. ,  Mo  of: m f H-erASr  STANDARDIZED 8  22  26  MORTALITY 30  RATE^^r  IftLCS 38  Bt  8 1  65  57  33  17  3  *  *  12  20  24  28  32  36  40  106 2 MAR 8S 20:45:49 DOWN:  CA  A P I L O T STUDY U n i v e r s i t y of WATERBORNE 3  OF THE RELATIONSHIP B r i t i s h Columbia CALCIUM 9  15  V  BETWEEN WATERBORNE  C A L C i ltr"l =r  21  ACROSS: 27  0 R  33  _  A N D  H-i-PEX-trw s  STANDARDIZED 39  73  G5  57  33  25  **** 2*2 *2*  18  24  5 f X - S P f T O F c c  36  10 rvl C  MORTALITY 45  A&e-STiwonf>.Diz£D " A L t T ^ RATE (f*r 51  M>R.TrtHTV  loo.-ooo) ' 57  RATETS  107 2 MAR 86 20:46:27  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 M s i r A s i T S OP ThC AscrETLi es, V !T> N S , f T C • / . r-lAi_£-S F o ( t  WATERBORNE CALCIUM 5 15  DOWN:  25  (C./^ ' 35 J  ACROSS: 45  STANDARDIZED MORTALITY RATE CP ' i°°.0Oo) 65 75 85 95 e  55  81  73  57  49  49  33  25  25  17  •2* 2 4 2 0  10  20  30  40  50  60  70  80  90  100  W A PILOT  2 MAR 86 20:46:58  STUDY OF THE RELATIONSHIP BETWEEN  University  of B r i t i s h  Columbia  WATERBORNE CALCIUM 208 242  CA  WATERBORNE  .  r o f i  (^V -) 1  276  ,  /  U  u  D  ACROSS: 344  310  AND S r X - S P r o F lc A £ T -  C A L C I UK!  l  S  c  f  t  S  c  -  A(LDVi€T> MART* I irv /U=FT££  cATreueiES  Ca-a.rtcD /  STANDARDIZED MORTALITY RATE 378 412 446 480  .ViAurs  loO;6o'o) 514  81  73  +  65  +  57  I  49  I +  *  *  *  *  t  *  5  +  5  7  I +  * * *  +  *  **  .  *  *  1  +  3  3  +  2  5  +  1  7  1  *  T  +  I  * *  T  *  T  *  *  T  I I  *  *  *  I  +  9  T  *  *  *  *  *  I  *  T  +  4  I 1  *  191  +  I  *  T* j +  9  I  I  1  6  4  * *  T J  9  +  I  T  17  3  I  *  4 1 +  25  7  +  j  33  +  * * +  +  225  +  +  259  +  +  293  * +  *  +  327  * *  * * +  *  *  i *  2 * 2 * * * * 2 *  +  361  +  +  395  +  +  429  +  I I +  * +  463  +  +  497  +  +.  531  1  103 2 MAR 86 20:37:33 DOWN:  MG  81  73  65  57  49  33  A PILOT STUDY U n i v e r s i t y of WATERBORNE 1  OF THE RELATIONSHIP BETWEEN WATERBORNE B r i t i s h Columbia  3  " 5  "  / ) L  7  ACROSS: 9  CALCIUM  AislB  PoR.  SMR 11  SEX-SPECIFIC A G £ T - - S T A N D A R D I^ETD TOR.TW.ITY RATETS _ R t f - r U ^ A - r i c tr£WR1 Di5t'.flSE"/F£MHi-£S  STANDARDIZED 13  MORTALITY 15  RATE 17  IOO,OOOJ) 19 81  2 MAR 86 20.38:05 DOWN:  MG  81  73  33  25  A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE W u i u r t AND ASriA's U n i v e r s i t y of B r i t i s h Columbia PbR Ch-R.orJiC- Rtte-a^Arric HETAR.T WATERBORNE CALCIUM 4 10  22  ACROSS: 28  " 34  HA DissASE-/FO-IALCS  STANDARDIZED MORTALITY RATE ^f^ 40 46 52  f_  10o,OOo") 58  /// 2  MAR  8 6  2 0 : 3 8 : 3 9 DOWN:  A  PILOT  STUDY  University  MG  of  OF  THE  RELATIONSHIP  B r i t i s h  For^ (^/L)  07?;  2 1 7  Ovuciu^i  Columbia  WATERBORNE CALCIUM 1 5 9  BETWEEN WATERBORNE  ACROSS: 3 3 3  AMD  4 4 9  1  AR.ToR.ioscLeRe.rft  STANDARDIZED  3 9 1  Asrlf. *  5 0 7  MORTALITY 5 6 5  AND  De&errJFRA-n ve H-CTH^T -  R A T E (per 6 2 3  DiserYStr-  100,006) 6 8 1  81  8 1  7 3  6 5  5 7  4 1  3 3  2 5  17  1 3 0  1 8 8  2 4 6  3 0 4  4 2 0  7  1 0  2 MAR 86 20:39:12 DOWN: MG  A PI LOT STUDY OF THE RELATIONSHIP BtlWttN WA I c KBUKNt OALClun flrVD A;5MR- 3 University of British Columbia pop^ o t h e r d i s e a s e ' s »FTH£ ft-E-ftRrr/FETiAUErs STANDARDIZED MORTALITY RATE^per 100,000*) WATERBORNE CALCIUM • (nfl/O ACROSS: 33 39 45 51 57 3 9 "15 21 27 J  73  65  57  33  25  17  * * * *2 •22 3* « 30  II ' / ( Z)  MAR 8S 39:4 1 MG  A P I L O T STUDY OF THE R E L A T I O N S H I P BETWEEN WATERBORNE U n i v e r s i t y of B r i t i s h Columbia E&K^ WATERBORNE 4  <LA1_C1U^ 12  20  28  C A L t W "  A r J  ^ yp f  s  R - r p J  0  i o  «Sn».\ r-I / f E M A c f S  STANDARDIZED 52  ACROSS: 36  MORTALITY 60  RATE / p e r ( O 0 , o o d f ) 65 76  8 1  65  57  33  22"  15  24  32  40  48  56  64  72  80  IIH 2 MAR 86 20:40:15 DOWN:  MG  73  65  49  33  25  A P I L O T STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y of B r i t i s h Columbia WATERBORNE 8  .CALX! U K 18  28  (T^J/lJ) 38  WATERBORNE C f t l X l u n AND p^R. D i s o v s e r s oF T H  ACROSS: 48  58  E  Asr\R. S" fR-reTye^,  STANDARDIZED 68  MORTALITY 78  TONS,  e"-ro /  FE>~<P<<~£rs  RATE Cper <00,00o) 88 98  \\5 2 MAR 86 20:40:48 DOWN:  A P I L O T STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y of B r i t i s h Columbia  MG  WATERBORNE C ^ i - C I U ^ 214 290 366  .(T^M 442  WATERBORNE C A L C I U M Pop, A L L . H E - A R T  ACROSS: 518  594  /Wt> A - S M * ' S S l t r f t s c C A T e-G-ay. vers  STANDARDIZED 670  aortoxJe-D/FEWAce-S  MORTALITY RATE ^ P - c <»«,ooo\ 746 822 898 _+  +  +-  73  65  57  33  25  * * ** *  176  2 *  2 * « *  *424  252  328  404  480  556  632  708  784  860  936  SCATTER GRAMS CORRELATION! £\G~£-- S T  BETWfeeN  A N D A R D \ UE D  OP r t e ^ f v r  DISEASE  OF  R E S U L T S  W A T E R 6 D P . M E  M&RTALITV  RATE-S  MAGNESIUM F O R . S EV/CKJ  AND  S^-SPFC\FIC  C / . T E & f l R.1-ES  R  86  :11  A  PILOT  STUDY  OF  THE  RELATIONSHIP  BETWEEN  WATERBORNE  U n i v e r s i t y of B r i t i s h Columbia WATERBORNE  1  .('•jl -) 1  l"]A-GrJ£:siUr\ 3  ACROSS:  f  0l<  M(\GM£"S(UM  RHc^r.c  A N D  .  H E R R X  STANDARDIZED  specific  wsovsr MORTALITY  AGe-.S77WOA<M>i:zED  MORTALiTr RATES (ASM*  / M A L E - . RATE  looj^oo^  5  SO  R 86 :42  A PILOT STUDY OF THE RELATIONSHIP U n i v e r s i t y of B r i t i s h Columbia  MG  WATERBORNE MAGNESIUM 2 6 +  +  +  +  +  BETWEEN WATERBORNE M i y J - J c s i u n A N D A5<n<^'s F O R cvifox-fic i^euMflnc K-£-*<vr  .(r^jl^ 10 +  14 +  +  ACROSS: 18 +  +  22 +  +  STANDARDIZED 26 +  +  D I S E T A S E " "  /n<«-f5  MORTALITY RATE (pur 30 34  IOaOOC>)  +  +  +  +  +  38 +  + .  60  +  +  6  0  54  +  +  5  4  I  *  I  48  +  +  4  8  42  +  +  4  2  36  +  +  3  6  30  +  +  3  0  +  2  4  +  1  8  +  1  2  I* 24  +  18  I I +  ^  *  I 1  * *  *  I  12  2 *  *  I T  *  I  *  + I  I  0  I  *  * *  j g  I  I I  * *  *  *  *  +  ** *  * *  I 2 1 * * 2 * * * * 2 2 2 + * * 3**422 2 +  0  +  +  4  +  +  8  *  +  +  12  +  +  16  +  +  20  +  +  24  I I + +  +  28  +  +  32  +  +  36  6  I I  +  +  40  O  R 86  A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE M A & * l C S H A . r \  :22  U n i v e r s i t y of B r i t i s h  MG  . (r^M  WATERBORNE MAGNESIUM 195  223  A M D  /VII-I«. S X  F O R , AHxewic.scL.t~R.o-nc A-NT> Dee-snJEr-A-rixtr  Columbia 251  279  ACROSS:  ..:  307  H-£)tRT-i>(.sSfi,Sxr/Mf\Le^  STANDARDIZED MORTALITY RATE (per loooOcA 335  363  391  419  447 60  60  3*»*  181  209  237  265  321  349  ** *** 405  461  AR 8G 0:51  WATERBORNE n f t f e T s m n fvrjp A s n « ' Pop. o n t r K . p i s e n o r s df- "TH-er  A PILOT STUDY OF THE RELATIONSHIP BETWEEN University of B r i t i s h Columbia  MG +  WATERBORNE MAGNESIUM 2 6 + + + +  ' 10 +  (^j/O 14 + +  ACROSS: 18 + +  STANDARDIZED 22 26 + + +  +  3  ftSVR.T  /WALE'S  (00,000)  MORTALITY RATE £ p e r 30 34 + + + +  +  38 +  + .  60  +  +  6  0  54  +  +  5  4  I  *  I  48  +  +  4  8  42  +  +  4  2  36  +  +  3  6  30  +  +  3  0  +  2  4  +  1  8  +  1  2  I 24  +  18  +  *  I  *  T  *  *  T  12  *  I +  Q  + T T J j* 4. + O  * *  I I *  *  I 6  *  *  J  T  I I  *  T  *  I  *  *  *  I I  *  *  *  *  +  * *  + 4  *  *  * 3 * * * * * 2 2********* + + + + 8 12  *  *  * *  **+ +  * *  + 16  +  + 20  * +  r + 24  +  + 28  6  I I I I  *  *  +  *  +  + 32  +  + 36  +  + +. 40  0  A PILOT STUDY OF THE RELATIONSHIP BETWEEN WATERBORNE W S I E S . U M U n i v e r s i t y of B r i t i s h Columbia PoRKVP^^TTEriMSio^i WATERBORNE MAGNESIUM 3 9  . 15  /"WO 21  ACROSS: 27  33  STANDARDIZED 39  /"rSi-if^'s / MA-UETS  MORTALITY 45  RATE (f"~ 51  ico^oo) 57 60  GO  *  *2**2*** * 2 2 2*** 2 12  * *** 36  54  60  «R 8G  A PILOT  ::13  Unwerslty  MG  STUDY OF THE RELATIONSHIP of B r i t i s h  BETWEEN WATERBORNE M A < W E S ' a / - i  p  Columbia  WATERBORNE MAGNESIUM 5 15 25  (-Wl-) 35  ACROSS: 45  . 55  ANIQ  M M R ' S  •»=- T H E " AArrtrR i e s ,  SiSEVvseTS  0Ri  STANDARDIZED MORTALITY 65 75  v / r i r J s , E T T C • //"><•> <-6"S RATE (per85  too,ooo^ 95 60  60  *  * *  *  * * * * * * * * * + * 2 * 2 *2* 2* 3 *2 * *  **  10  20  30  40  50  60  70  80  90  100  1R 86 2:57  A PILOT STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y of B r i t i s h Columbia WATERBORNE MAGNESIUM 208 242 276  (^/O 310  WATERBORNE fo_ a  ACROSS: 344  ftu  ("V««^rsiwM ArJD H-fflRT Pi5e"«se  378  ASn«.S  STANDARDIZED 412  MORTALITY 446  RATE ^ p c 480  60  W6,ooo) 514 60  * 191  225  259  ** *  327  * *222  +395  y  **  * 2 * +  429  L  463  497  MAR 8G : 20:02  A PILOT  STUDY OF THE RELATIONSHIP  University  MG  of  British  BETWEEN WATERBORNE  Columbia  WATERBORNE MAGNESIUM 1 3  pofk  H<W-I-MTSI«M RHeunfYriC-  ACROSS: 11  « « D  S£5I-5P«-IPI<I n < Z E - S - r w D t w » 2 £ D  H-E-frR-T  D(5E>.st_ / .  STANDARDIZED MORTALITY 13 15  .  RATE (per 17  MORTALITY RATES  fenfluCS loo,oo \ 19 0  GO  GO  18  +2 I  14 12  6  O  +* 12 I 12 12 +3 14 12 13 19 +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 H E A R T D i s r A S E T / f f f n <M_£TS WATERBORNE MAGNESIUM 4 10  (T^/ -) 22 1  16  ACROSS: 28  34  \l5  STANDARDIZED MORTALITY RATE ( p * r l o o , o o o ) 40 46 52 58 60  48  30  12 *  *  ** * * ** *  * * * 2 22** *** 2 22**2 32 ** 2 13  25  31  37  49  55  IIS) 2 MAR 86 20:21:29 DOWN:  A PILOT STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y of B r i t i s h Columbia  MG  WATERBORNE MAGNESIUM 159 217 275  f - j / O 333  WATERBORNE MA6-fJe"s>u.M  ACROSS: 391  449  » « = «5n«'s  STANDARDIZED 507  o i K « e  MORTALITY 565  RATE (p*<- ( O o , o o o ) 623 68 1  60  48  36  30  24  1Ef  * * *  130  *  * * ****2*2*** * *233** 2 188  246  304  362  420  478  536  594  652  710  2 MAR 86 20:22:20 DOWN:  MG  60  54  36  30  24  12  A PILOT STUDY OF THE RELATIONSHIP U n i v e r s i t y of B r i t i s h Columbia WATERBORNE 3  MAGNESIUM 9  15  ! N E rMftl<Je5iu« i/ttfjersiuf-' BETWEEN WATERBORNE  ACROSS: 27  33  /"+MT>  f i i n n s  IZ7  ,  STANDARDIZED MORTALITY RATE (per 39 45 51 _  100,000) 57  2 MAR 86 20:22:56 DOWN:  MG  60  54  48  42  36  30  24  18  A PILOT STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y of B r i t i s h Columbia WATERBORNE 4  MAGNESIUM... 12 20  WATERBORNE  ACROSS: 36  IZ8  i-|PrC-*t «iui-l A N D A S M R s FOK KYPfTftT-tTNs.ori / F f n A L f S  44  STANDARDIZED 52  MORTALITY 60  RATE (pz 68  r  100,000)  76  2 MAR 86 20:23:32 DOWN:  A PILOT STUDY OF THE RELATIONSHIP U n i v e r s i t y of B r i t i s h Columbia WATERBORNE 8  60  .30  18  MAGNESIUM 18  28  \Z3  BETWEEN WATERBORNE MA<W«>uM fl-rJn flS^K 5 FOR. P l ^ F ^ s e ^ s o f Tttfr A K T T T R I C S , V J T I M S , ACROSS: 48  58  STANDARDIZED MORTALITY 68 78  RATE CW 88  ""V  ) 98  0 0 0  2 MAR 86 20:26:40  130 A PILOT STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y o f B r i t i s h Columbia  DOWN:  WATERBORNE MAGNESIUM . 214 290 366  ("J /-) 442  WATERBORNE  ACROSS: 518  MWiJKiun /vr>/D *SMR 5 F O R . / ^ C H E T B R - T " T>.Sfc-7*se- C A - T E . R . E " S 594  STANDARDIZED 670  MORTALITY 746  RATE (per 822  c n R . ^ p / F m ^ S 100,000)  898  60  54  42  36  30  * 24  18  12  *** 23*2 2 * *323 2 176  252  328  404  480  556  632  708  784  860  936  13]  SCATTER.G-RAMS  CORRELATION!  BETWEEN!  AG-E- STTXNDftR-PIZ-EP O F  HEftRr  R E S U L T S  WATE<^HAR>Dlsl£SS>  HOPCTPKU )TV  D I S E A S E  OF  RATIOS  AND SEX. "SPflCl F | C  F&R.  S£V£l\l  C AT-EXSOR,igS  22 OCT 8.5 09:45:24 DOWN:  A PILOT STUDY U n i v e r s i t y of  DWHV  OF THE RELATIONSHIP British Columbia  BETWEEN THE HARDNESS  DRINKING WATER HARDNESS VALUE - 124 372 G20 868  +  8f\SeO FOR.  ON  THE  r-JALET ygAR,*  DEATHS  DUE  ACROSS: 1116  To  ICO  OF  SMR 1364  7  DRINKING  W A T E R  STANDARDIZED 1612  CATEGORIES,  HEART D15EASC  A N D  MORTALITY 1860  RATIO 2108  2356  MCO-M03. ( V r t E U M A T l C HETAB.T DISETfl-Se)  IT5S-I178  364  319  +2 2  2 3 +4 * 4 3 9 +6 1736  1240 S T A N D A R D HE'D  Mo;Vr7U-iTr  RATIOS  1984  2232  I33 22 OCT 85 "09:44:44 DOWN:  A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS U n i v e r s i t y of B r i t i s h Columbia DRINKING 20  DWHV  WATER 60  HARDNESS VALUE -100 140  ACROSS: 180  OF D R I N K I N G -  SMR 220  wftTER.  STANDARDIZED 260  HEPiR.r D I S E A S E  AND  MORTALITY 300  RATIO 340 454  t  409  BASED FOR  ol4 r*tr  MAXe  ytTAR.*  DEATHS  D u e To  I <-0  7  CATEGORIES  HlO - H i t L'C.HAONIC R H C U r l A T l C H r E f t f c T Dl S ^ f t S E ^ 409  1154.-197 8  364  319  274  274  229  229  184  184  i3g  139  £ I"  O  49  4  + +  0  +  2 + 40  +  +  *3 ** 3 +  80  * •* + + 120  +  + 160  +  + 200  +  + 240  +  + 280  +  + 320  +  + 360  +  +. 400  22 OCT 85 09:43:52 DOWN:  A P I L O T STUDY OF THE RELATIONSHIP U n i v e r s i t y o f B r i t i s h Columbia DRINKING 104  DWHV  WATER 210  HARDNESS VALUE 31S  BETWEEN THE HARDNESS  -422  ACROSS: 528  SMR 1  O F DRihlKlNG  WATER.  STANDARDIZED 634 740  AND  MORTALITY 846  HEART  DISEASE  RATIO 952  1058 454  454  + BASED  ofi  FOR. T H E  409  M A I X  yeARs  DEATHS l95t-/<)7  C U E  T o  ItD 7  CATeG-0«l£S  H AO - H10. (^ARTERiO S C L E R.OTK A^D  8  vece^CM-kilB  ')  409  3 19  3 19  274  274  229  229  < <n 184  184  O <-< 139  94  *333 « 2263 5 1  157  263  369  687  793  1005  22 OCT.85 09:42:53 DOWN:  A PILOT STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y of B r i t i s h Columbia  DWHV  DRINKING 15 _ H  WATER 45  +  i  HARDNESS VALUE -75 105  H  h  -)  H  THE HARDNESS  ACROSS: 135  OF- DR.1NK1NG- WATER, ArJD  SMR 165  STANDARDIZED 195  HEART  MORTALITY 225  135  DISEASE"  RATIO 255  285  + -  454  454 +" B A S E D 409  FoR  ON  MALE  THE y EARS  DEATHS  DUE T o  ICD7  CATE&OR.ICS,  H30-H3H  [ OTHER  DISEASES  OF THEf rttTARi ")  1156-1478  409  274  274  229  O  184  184  139  94  49  49  * 2* 30  * 60  *  *2 90  120  150  180  210  240  270  300  22 U C T 85 '09:42:05 DOWN:  A P I L O T STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y o f B r i t i s h Columbia DRINKING 15  DWHV  WATER 45  HARDNESS VALUE 75  -105  THE HARDNESS  ACROSS: 135  OF D R . I N K . I M 6 -  SMR"" 1  165  W A T E R .  STANDARDIZED 195  AND  MORTALITY 225  HEART  RATIO 255  285 +  454  +  409  DISEASE  BASED  FOR  O N  MUZ.  T H E yeARS  D E A T H S  DUE:  TO  ICO 7  CATETS-Otiers,  i<Ho-4H7  454  ^HYPERTEVISIOM)  409  1954 -I1T9  364  3 19  319  274  229  229  184  U  139  94  2 * * *» . * 60  *2 3  90  120  150  180  2 10  240  2 2 OC'f 8 5 09:41:08 DOWN:  A PILOT STUDY OF THE RELATIONSHIP U n i v e r s i t y o f B r i t i s h Columbia  BETWEEN  DRINKING WATER HARDNESS VALUE --  OWHV  9  27  45  63  THE HARDNESS  ACROSS:  OF PRII-JK.IN&-  SMR  A N D HEART  137  DISEASE;  STANDARDIZED MORTALITY RATIO  1  81  WATER  99  117  135  153  171 454  454  BASED Po*.  OH f-IALET  TRE"  ye"rtR.s  DEATHS  DUE To  ICQ 7  t A T f t f «RICS, H S o -M  « (DISEASES o F TKST ARTERIES,  iris , E r e )  /95i>-|?79 <  409  364  319  3 19  274  229 ~~1 n  o  184  184  139  139  +  L.  18  54  90  108  126  162  180  30  OCT  85  University  0 8 : 3 7 : 5 5  DOWN:  A P I L O T STUDY OF THE RELATIONSHIP  DWHV  of B r i t i s h  DRINKING  OF  DRINK-IMG  VJRTER.  AMD  HEAR.T  Columbia  59  DISEASE  STANDARDIZED  WATER HARDNESS VALUE  51  BETWEEN THE HARDNESS  G7  --  ACROSS:  75  SMR"*"  83  STANDARDIZED MORTALITY 91  99  USlivffr  MORTAL,™  158  JRATUS  RATIO  107  115  123 454  454  t  BASED  O M  FoR. T H E  MALE:  VKARS  DETATrtS  DUE  To  |CD  T  C A T E &OR.IES,  Hoo  - %  "3 (rtLL HEART  U R E A S E S  COI-IOINED)  IISt-1178  409  364  274  229  184  *  94  *  49  4  + . +47  63  71  S T A N D A R D I S E D  87  M O R T A L I T Y  103  RATIOS  111  119  127  22 OCT 85 C9:40:21 DOWN:  A PILOT STUDY OF THE RELATIONSHIP U n i v e r s i t y o f B r i t i s h Columbia  BETWEEN THE HARDNESS  STAIN/DARD I I E D  DRINKING WATER HARDNESS VALUE -172 51G 860 1204  DWHV  O P ORINKIM& WATER  SMR  ACROSS: 1548  1892  A N D HEART DISEASE: haftrdLirv  STANDARDIZED MORTALITY 2236 2580  USiMG-  RATIOS  RATIO 2924  454  +  8ASED FOR  409  Of-J FEMALE" D E A T H S THE  ytARS  X>UE" To I C 0 7  CATT»OK.IE;S , HOO - H O a . ( J J H E U M A T I C  H-£ A R . T D IS E A S  H54>-l')78  364  319  274  n  O  184  12 12 +4 12 14 13 19 +9 344  1032  1376  1720  5TArNDP.R.DlZE"D  2064  MORTALITY  2408 RATIOS  3096  3440  .IHO 22 0 < " T 85 09:s5":01 DOWN:  A PILOT STUDY OF THE RELATIONSHIP U n i v e r s i t y o f B r i t i s h Columbia  OWHV  DRINKING  WATER  12 _+  454  j.  K  --  60 +.  y  .  ACROSS:  84  SMR "  .  4.  132 +  W A T E R  STANDARDIZED  1  108  (  OF DRI^KlMG-  +  +  k  I +  364  +  ^0  ft  S£O  ON  FoR, T H ET  PEMAUT yETARS  DEATHS  Dus  T o  I C D 7  C A TETG-0 K.I E S ,  AMD  RATIO  180 -i  1  DISEASE  H E A R T  MORTALITY  156  +  g  4 0  HARDNESS VALUE  36  +  BETWEEN THE HARDNESS  204 y  h  228 1  4-  .. -  .  *  4lO-4(fc> (j-!fROf'IC RtiEUMArit  IrtART D l S O S c ) +  Il5t-|l78  '  +  319+  -J  I  +  229  +  If  *  fl 184  •  -  I  "  3  19  +  274  + I  229  *  I  94  *  .  49  +«  «  «  . 4.  1  24  4  +  48  . 1  .  . i  72  .  . •  .  . +  9S  *  .  2 +  +  139  +  94  +  49  t «.  j  •  2  I t O  364  + 1 8 4  +  +  J09  !  *  139  4  I  I  \  1  ^  +  274  454  *  . +  120  1  4  144  . +  ^  168  +  t  192  +  +  216  +  4.  240  22 OCT 85 09:38:09 DOWN:  A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS U n i v e r s i t y o f B r i t i s h Columbia  DWHV  ACROSS: 125  DRINKING WATER HARDNESS VALUE -53 71 89 107  OF Dftl*lKIM&  SMR 143  WATER.  A.ND  HEART-  DlsrftSET  STANDARDIZED MORTALITY RATIO 161 179 197 454  ^  BASED Fo A.  409  Or) F E r ^ A L S T THC  V6AR.S  DEATHS  0\x£~  To  ,CD7  4 1 o - f l O . (n«.re P*WSCi£P-ST\C  <^Tir&<)/?JErS,  HEART-  11 5fo "111  A.\lD P eCENFRA-, l MC)  P I S E A S r  409  364  319  229  229  184  184  O  139  94  94  49  4  + +  .  44  * 4-  +  62  +  +  80  +  32 23 * +  98  4.  + +  116  4-  +  134  4.  4-  152  4-  1-  170  +  +  188  4.  4.  206  4-  4..  224  22 OCT 85 09:37:07 DOWN:  A PILOT STUDY OF THE RELATIONSHIP BETWEEN THE HARDNESS U n i v e r s i t y o f B r i t i s h Columbia  DWHV  DRINKING 20 .4-  +  WATER HARDNESS VALUE 60 100  +  +  +  +  -140  +  ACROSS: 180  +  +  +  OP  SMR~^ 220 +  +  DRlrJKlMG- WATECFk  STANDARDIZED 260 +  +  MO  M2i  HGArRJT DISECA-.SE:  MORTALITY 300  RATIO 340  +  +  +  +  380 +  +.  +  454 454  +  I  I  + +  BASED F  o  a  ON T  H  E  "  F E M f t i r DEATHS  y^**  5  list  DUE o T  -i<?71?  , cD 7  H 3 o -H 3 4 ( °  T  ^  D  K  r  A  S  " °"  "  £ A R T  ^  409  +  364  364  319  319  274  274  229  r.  184  3 139  139  94  94  49  49  '2 * 2* 40  80  120  22-OCT 85 09:35:43 DOWN:  A PILOT STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y o f B r i t i s h Columbia  DWHV  DRINKING WATER HARDNESS VALUE -22 6G 110 154  THE HARDNESS  ACROSS: 198  O F DRINKING-  SMR ' 242  WATER- AND HEAB-T  STANDARDIZED 28G  MORTALITY 330  DISEASE  RATIO 374  4 18  454  +  409  SASETO FoP-  ON  THE  FEMALE  DEATHS  ye:ARS  \15<e  DUE  To  |CP1 CATE«*lES  y  HlO-^Hl  Lj+YPiTRTeNS v6INl)  -\17K  3G4  319  274  274  -4 229  O  184  184  139  139  O  * 88  * 2 2*  * 132  264  308  352  22 OCT 85 00:13:01 DOWN:  A PILOT STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y o f B r i t i s h Columbia DRINKING 5G  DWHV  WATER HARDNESS VALUE -74 92 110  THE HARDNESS  ACROSS: 128  OF- DRlNXlNtV  SMR ' 146  WATER-  A N O HEART  DISEASE  STANDARDIZED MORTALITY RATIO 164 182 200  218  454  1"pAseO  oN  FOR. T H E -  409  FCrlRLE yeA«-S  BEATriS  DUE T o  I CD  7  CATE60R1C.S  , t S O -4-G ? LDlS E"A5 F/S OF THE" ARTERIES,VEt N?, E T t )  llSto-I^S  274  o  2 4  + 47  3 4 65  83  101  2  • 137  209  227  -30 OCT 85 08:39:19 DOWN:  A P I L O T STUDY OF THE RELATIONSHIP BETWEEN U n i v e r s i t y o f B r i t i s h Columbia  DWHV  DRINKING 75  WATER HARDNESS VALUE - 91 • 107 123  THE HARDNESS  ACROSS: 139  0  F  SMR + 155  DRINKING-  WftreR  STANDARDIZED 171  AND H £ A e . r  MORTALITY 187  IH5  DlSfcftSE  RATIO 203 454  3A3ED F»R  409  ON  THE  FEMRUT  DEATHS  DUE: T o  I CD  7  tRTe«»R|ES,  4 0 O ~4 6 $  (jiLL  H £ART~  D 13  EASE'S  tun-lQjNrtO  I T 56> " I T 78  ySTARS  409  364  364  319  319  274  274  229  *  *  184  184  O  139  94  94  49  4  * *+ •22*23  + * 67  83  147  163  195  21 1  227  46 D. SUMMARY OF RESULTS The Columbia water  pattern  of  heart  i s not adequately  hardness  is  disease  i n v e r s e l y a s s o c i a t e d with heart  There were, of c o u r s e ,  the  used  in  were made i n o r d e r were  detailed  this  are  addition  previously  in  risk  t o water hardness.  important.  Diet  Part  disease  data.  for  In  heart  addition, disease i n  f a c t o r s may be  are noted  more  heart disease  or l i f e s t y l e  variations  These  I V , a n d i t may be t h a t  These o t h e r  and l i f e s t y l e  mortality  available  correct.  factors  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 heart  disease  s t u d y , and a number o f a s s u m p t i o n s  t o deal with the  suspected  that  a number o f l i m i t a t i o n s t o  s e v e r a l o f t h e a s s u m p t i o n s were n o t there  in British  e x p l a i n e d by t h e h y p o t h e s i s  mortality. data  mortality  account  for  i n B r i t i s h Columbia, or  would these  f a c t o r s be m a s k i n g any r e l a t i o n s h i p between  water  heart d i s e a s e m o r t a l i t y ? Comstock's study,  and  was m e n t i o n e d e a r l i e r controls  i n Maryland  status, marital the  few  in this thesis,  s t a t u s , and smoking h a b i t s .  hardness.  Comstock's mentioned  study; in  The  1  This  Allwright's  'Cornstock  1971  of  levels  of  was n o t s u p p o r t e d  ecological  review,  t h r e e c o m m u n i t i e s on s o c i o e c o n o m i c comparable l i f e s t y l e s ) ,  i s one  t o look a t s u b j e c t s s i m i l a r i n  water h y p o t h e s i s  the l i t e r a t u r e  which  socioeconomic  most r e s p e c t s , b u t who were e x p o s e d t o d i f f e r e n t water  hard  i n v o l v e d 412 c a s e s a n d  who were m a t c h e d f o r a g e ,  s t u d i e s which t r i e d  risk  study,  by  also  matched p o p u l a t i o n s of  s t a t u s (a way  to  ensure  and, a g a i n , the water hypothesis  was  147  not  supported.  populations lifestyle disease  with  levels  of  more  in British  exist  mortality,  activity,  levels  of s c h o o l  gathered.  This""  may  disease  water  hardness  high  in  i n t a k e among  The  population  working  characteristics More  would a l l o w  reveal  habits which  assumption  of  the  specific  factors  hardness  disease,  and h e a r t  Many  of  school  industries are  speculate  that  smoking,  drinking,  and  River,  of these  districts.  primarily  men  place  i n a high  study  school  then disease  J  to  the s i g n i f i c a n c e  them  who  and d i e t a r y  have risk  factors  was t h a t  there  I f there  districts  was  were  any  w h i c h do  association  mortality  might  no  higher  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 between and heart  be  One c o u l d  populations.  t o o r from  should  t o be made.  of t h i s  study  and serum  have  i n f o r m a t i o n on l i f e s t y l e s  of migration  hardness water  and  be  for  etc.)  the populations could  whether  the  risk  and paper  Powell  heart  information  mortality.  of  that  f a c t o r s and  populations  clarify  rates.  be  drinking,  disease  pulp  rates  further analyses  A major  rates  and  are higher  risk  elucidate  disease  mortality  cholesterol  migration  and  heart  mining  disease  there  category.  to  (e.g.Kitimat, T r a i l ,  heart  perhaps  mortality,  where  important  smoking,  of the v a r i o u s heart  heart  districts  help  may  To d e t e r m i n e  other  district  d i d n o t match  i n determining  provincial-wide  cholesterol  contributions  Columbia. these  study  and i t  important  between  physical  Columbia  to l i f e s t y l e ,  are  mortality  disease  British  respect  factors  associations heart  This  not water  between  have  been  1 48 masked.  The  suggest  that  of  movers  mobility migration to  statistics  of  is a significant  non-movers  is  similar,  the  factor.  d i s t r i c t s of M i s s i o n ,  Vancouver Island  River,  Central  Nechako.  and  \  Statistics  Canada  1981b  (vide  1  The  do n o t ratio  f o r example, in the  school  Okanagan,  province  bibliography)  North,  Peace  14<? D.  CONCLUSION Heart  today. in  disease  Heart  disease  roughly Owing  problem  epidemic  of  each  to  clarify  heart  to estimate  individual risk  heart  of  and  patterns  of  dietary  death.  of  factors  contribution  cholesterol risk  hypertension. risk  disease, i t  i tis difficult  the concomitant  and  1  specific  For example,  times  i t accounts  of heart  and  f a c t o r s of  There  are  many  a n d none a r e e a s y t o  disease  smoking, habits  of  relative  importance  be  no r e l a t i o n s h i p was f o u n d  heart  pattern  heart  mortality.  drinking,  should  be  stress,  sought  disease  to  mortality  o f many h e a r t  between  water  Information physical compare  on  activity, with  the  i n the d i s t r i c t s .  disease  risk  factors  The  might  assessed.  From  the results  There  appears  disease  of t h i s  to  mortality  be  study  no  and  l e v e l of analysis  Other  factors  risk  hardness  may  be  i n determining  Health  Statistics  water,  more  least  that: heart at the  Columbia;  important  disease  1985  between  at  in British  heart  Annual  one c a n c o n c l u d e  relationship  soft  ecological  World  the  modern  where  between d i e t a r y  disease  t h i s study,  hardness  then  of  i n the world  individually.  In  and  factor.  because  hyperglycemia,  suspected assess  exactly  the association  disease  obesity,  of a l l causes  t o the m u l t i f a c t o r i a l nature  difficult  1  health  i s the major  50 p e r c e n t  is  2.  a major  the technologically-advanced countries,  for  1.  i s  than  mortality;  water  1  3.  I f there heart analysis  i s any disease  relationship mortality,  are necessary  between more  hard  detailed  to detect i t .  50  water  and  methods  of  BIBLIOGRAPHY A l d e r s o n , M . , International Mortality F i l e , I n c . New Y o r k 1 9 8 1  Statistics.  Facts  on  Allwright,S.P.A., Coulson,A., Detels,R., e t a l . , M o r t a l i t y and water-hardness i n three matched communities i n L o s A n g e l e s . Lancet ( 2 ) , 1 9 7 4 :860-64 Altura,B.M., Sudden-death ischemic heart d i s e a s e and d i e t a r y magnesium i n t a k e - - I s t h e t a r g e t - s i t e coronary vascular 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 pattern of ischemic d i s e a s e . Can Med Assn J. ( 1 0 8 ) , 1 9 7 3 : 1500-04 A n d e r s o n , T . W . , A new v i e w (9),1978:374-76  of heart  disease.  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New J u l 21, 1977:  declining Eng J Med  Winton,E.F., McCabe,L.J., Studies relating t o water m i n e r a l i z a t i o n a n d h e a l t h . / Am Water V/orks Assoc (62), 1970:26-30 W o r l d H e a l t h O r g a n i z a t i o n , Health effects substances occurring naturally C o p e n h a g e n , 1979a World Health Organization, diseases, Seventh Rev. Geneva, 1957b. World  Health  Statistics  International Vol 1,  of in  the  removal of drinking-water.  Classification of Palais des Nations,  A n n u a l , 1985  Yano,K., Rhoads,G.G., a n d Kagan,A., C o f f e e , a l c o h o l and r i s k o f c o r o n a r y h e a r t d i s e a s e a m o n g J a p a n e s e men living i n H a w a i i . New Eng J Med ( 2 9 7 ) , 1 9 7 7 : 4 0 5 Z i e l h i u s , R . L . , H a r i n g , F . J . , Water Hardness and 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  Acta  C a r d i o l : Acta  Acta  Med S c a n d : A c t a  Am  J Clin  Nutr:  Am  J Epid:  Am J P u b l  Cardiologica Medica  American  Scandinavica  Journal  American Journal Health:  American  of C l i n i c a l N u t r i t i o n  of Epidemiology Journal  Ann  I n t e r n Med: A n n a l s o f I n t e r n a l  Br  J  Prev  Soc  Med:  British  of P u b l i c  Health  Medicine  Journal  of Preventive  Social  Medic ine Can  Med A s s n  Int  J Epid:  J : Canadian  Amer  Association  International Journal  JAMA: J o u r n a l J  Medical  of the American  Diet  Assoc:  of Epidemiology  Medical  Journal  Journal  of  Association  the  American  Dietetic  Association J  Amer W a t e r W o r k s A s s o c :  Works  Journal  of  the  American  Association  J  Chron D i s :  J  Clin  J  Env P a t h o l  Journal  Pharmacol:  of Chronic  Journal  Diseases  of C l i n i c a l  Toxicol: Journal  Pharmacology  of Environmental  Tox i c o l o g y J  Hyg: J o u r n a l  J  Nutr:  New Nutr  Water  Journal  of Hygiene of N u t r i t i o n  E n g J M e d : New Metab:  England  Journal  of Medicine  N u t r i t i o n and Metabolism 1 59-  Pathology and  1 hO  Nutr  Rev:  Nutrition  Prev  Med:  Preventive  Proc  Roy  Soc  Med:  Reviews Medicine  Proceedings  of  the  Royal  Medic ine Sci  Total  Env:  Soc  S c i Med:  Science  Social  of  the T o t a l  Science  and  Environment  Medicine  Society  for  16 1 APPENDIX 1.  3.  DEFINITIONS  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 blood  2.  1:  of  a  to  an  vessel  ANGINA  PECTORIS:  pain and  in  the  inadequate  blood  AORTA: t h e  large vessel arising  and  dilatation  distributing  oxygen  chest  supply  arterial  r e g i o n due  to the  from  the  heart left  blood  to every  of  heart  ventricle part  of  the  body 4.  ARRYTHMIA:  5.  ATHEROSCLEROSIS: a c h r o n i c and  irregular  hardening  of  beating  the  disease  arterial  in  walls  which  thickening  interferes  with  blood  circulation 6.  ARTERIOSCLEROSIS:  t h i c k e n i n g of  arterioles  or  smallest  arter ies 7.  CARDIOMYOPATHY: a n y  8.  CARDIOVASCULAR involving  the  system.  DISEASE: heart  It  9.  do  which  of  the  compared  10.  do  etiology with  characteristics the  or  etiology  of  the  blood  v e s s e l s or the  are  to  or  circulatory  International  330-334,  410-468  (8th r e v i s i o n ) s e l e c t e d as  ( c o n t r o l s ) have  i s t o be  which  pertaining  codes  groups are not  myocardium  by  393-458  respect  the  the  disease  Diseases  DESIGN:  (cases)  of  defined  r e v i s i o n s ) and  CASE-CONTROL they  and  is  Classification (6th/7th  disease  s t u d i e d , and to judged  whether  the  disease  the  groups  existing t o be  to  of  or  of are  past  relevance  to  disease  CEREBROVASCULAR D I S E A S E : p e r t a i n i n g t o  disease  of  the  1 63-  blood 11.  vessels  CONTROL: which  individuals  the etiology  potential factors 12.  13.  do  not  to  be  studied,  exposed  CORONARY:  of  or  that  to  arteries  coronary  that  but  reduces  ARTERIES:  the  the heart  CORONARY  blood  have  of the  causal  clot,  nerves,  o r an organ;  HEART  blood  or  pertaining  DISEASE:  flow  through  a  the  muscle  vessels  that  envelop  and  muscle  THROMBOSIS:  a blood  vessels,  CORONARY  a r t e r i e s t o the heart  CORONARY  to  encircle a part  CORONARY A R T E R Y D I S E A S E o r  by  the disease  t o t h e same p u t a t i v e  pertaining  attachments  nourish  have  of the disease  coronary  15.  who  i s  f o rbeing  condition  14.  of the brain  often  the occlusion leading  of a coronary  artery  to destruction  of  heart  a  of  the  muscle 16.  CORRELATION  COEFFICIENT:  interdependence value  from  correlation perfect 17.  to  +1,  a t - 1 , absence  indicating of  ranges  perfect  negative  at  blood  pressure  CALCIUM METABOLISM:  normal  calcium  0,  and  during  metabolism  changed  ECOLOGICAL CORRELATION: a c o r r e l a t i o n i n w h i c h studied  in  of t h e c a v i t i e s of t h e heart  DISORDERED been  that  correlation  D I A S T O L I C BLOOD P R E S S U R E : a r t e r i a l  has 19.  o f two random v a r i a b l e s  p o s i t i v e c o r r e l a t i o n a t +1.  expansion 18.  -1  measure  are  populations  rather  than  the units  individuals.  1&3 Correlations the 20.  found  individual  HARDNESS,  for  calcium HEART  95  of  i s  and  generally o r mg  23.  I S C H E M I C HEART D I S E A S E  of the heart  the  heart, major  form  MORTALITY area  usually  Last  1983  "milligrams  of  any  of  a  anemia supply  hardening  caused and  major  of  arteries.  A  the second  i s spread  to  class  the proportion the  by  abnormal forms  of  arteries, form  is  throughout the  infarction,  The  third  caused  by  defect of  of a p r o t e i n combined RATE:  liter.  i s a t h e r o s c l e r o s i s which  to myocardial  or a congenital  expressed  populat ion  1  lead  The  i s c h a r a c t e r i s e d by damaged v a l v e s ,  LIPOPROTEIN: consisting  form  w h e r e t h e damage  a n d may  infection  and  coronary  of water.  c o n d i t i o n of the  There are three  one m a j o r  progressive  cardiomyopathy  25.  local  functioning  including  24.  (IHD):  o b s t r u c t i o n of the blood  the  magnesium  diseases  mechanical  involves  forms i n  circulation  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 of  disease:  for  1  CaC03 p e r  organic  22.  heart  true  and waterborne  abnormal  or of the heart  populations.  of the hardness  per l i t e r " , an  not hold  of the l a t h e r that  calcium  hardness  DISEASE:  heart  index  per cent  carbonate  m a n n e r may  of these  an  waterborne  measurement  21.  members  WATER:  laundering, account  in this  mid-year  with  conjugated a  proteins  lipid  of deaths population  a s t h e number o f d e a t h s  i n a given of per  that  year area,  1000  of  16*t 26.  MYOCARDIAL resulting  INFARCTION: from  failure  27.  MYOCARDIUM: m u s c l e  28.  NECROSIS:  the  a  necrotic  of a l o c a l  tissue  death  area  blood  of  tissue  supply  of the heart  of  a living  tissue  i n a plant or  animal 29.  PATHOGENESIS:  30.  REGRESSION  FUNCTION:  variables,  two  o f one r e l a t i v e  to  of  disease  f o r persons  incidence  rate  acquiring  the disease.  RETROSPECTIVE: the  f o r those  that  measures  random the  mean  another ratio  of  exposed  not exposed.  which  condition  dependent  function  RELATIVE RISK: d e f i n e d as t h e rate  32.  of a diseased  given  regression  expectation 31.  the development  the  incidence  to a factor  t o the  The p r o b a b i l i t y  i s d i r e c t e d backwards  of  or to  past  33.  STENOSIS: n a r r o w i n g  of c e l l  34.  STENOTIC-THROMBOTIC:  a  walls  combination  of  stenosis  and  thombus 35.  STROKE: of  sudden  loss  loss  of muscular  of s e n s a t i o n and  rupture  S U R F A C E WATER: t h a t w h i c h  37.  SYSTOLIC  THROMBUS: a b l o o d formed  39.  i s found  of the c a v i t i e s  i n a heart  clot  with  dimunation  resulting  from  vessels i n the brain  BLOOD P R E S S U R E : a r t e r i a l  contraction 38.  consciousness  or b l o c k i n g of blood  36.  control  on t h e l a n d blood  surface  pressure  during  of the heart  occluding  a  blood  vessel  or  cavity  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  lesion  on  the  skin  40. UNCOMPLICATED preceding 41.  URBAN in  ANGINA  myocardial  PECTORIS:  community  without  a  infarction  RESIDENCE: i n t h i s  a  angina  with  report a  i trefers  population  to  residence  o f more than  1000  persons 42.  VASOCONSTRICTORS:  causing  constriction  of  the  blood  vessels 43.  VENTRICULAR instability lead  ARRYTHMIA  or disturbance  t o sudden  44. VULNERABLE susceptible  OR  FIBRILLATION: of the heart  an  electrical  muscle that  may  death  MYOCARDIUM: to injury  muscle  of any k i n d  tissue  of  the  heart  16.6  APPENDIX  For  2:  school  within,  a  will  used  TO  be  (population B)(water  to  value  it:  based find  WEIGHTED of  School  within  districts  weight,  CALCULATE  e.g.  DETERMINATION  To  B)  on  City  A:  City  #1  by  =  Districts.  (pop  these  cities,  hardness  value  A + pop  which  (4157)(180mg/L)  9601  values  A p p e n d i x 3:  of  values.  of  c i t y A ) + (pop  B)  has  two  major  water  cities  hardness  (Population=4157;  water  value:  by  in  city  mg/L)  divided  listed  water  Sparwood  773048  hardness  large  ( P o p u l a t i on = 5-1 44 ;  +  Weighted  one  population  (Fernie)  B:  weighted  divided  tnan  hardness  by  (5444)(142mg/L)  1521308  more  VALUES  VALUE:  Fernie  value=l80.0  + 748260  the  average  divided  district  calculate  with  c i t y A ) (water  value=142.Omg/L) hardness  OF WEIGHTED WATER HARDNESS  5444 158.5  for  Water  the  +  divided 4 157  by  (5444  + 4157)  =  mg/L  other  school  Classification  of  districts School  are  =  APPENDIX -3/ ; WATETf^  CLASSIFICATION  SCKoOL D I S T R I C T T£MAMET ^  LAA&EST  VJiTHI*! D I S T R I C T  ^LETTER. SCHOOL.  HARDINIESS  KftRDr-l&S6,  VALUE mj/u  VALUE;  SCHOOL  A- FE-RrJiEr B. S P A R V J O O P  2.. C R f l r J S R o o K (rt)  CRAMBROOK  3,  KIM3E:R.LV  H-  WllslDERr-lERX ( H ) |MV,£R(V1ERE  (S)  (S)  )go- 0  KIH&EKLV  NELSON  %  CASTLEGAR, (S)  CASTLEGAR  10.  ARR.OVAI  MAKUSP  LAKES  11. TRAIL, £s)  ]  <?7 0 /0.  15?. 5  DISTRICT'S  WEICrHTED  WClG-t+TED  WATERBORMC  WATEWBORME  CALC|U;N\ ' VALUE  r*)/l-  trJ PARErlXHESlS REFERS T o T H E WATER. O L A - S S I f r CflTIOrJ-i P\STR|CT^ H - - H-AR.D , S - S O F T , 6 L A I ^ K « E^lfeU-ReOr.-  I, FEXNlE (H)  7- NELSON  WETlCrHTED WATER  WATER.  CITY  OF  46.7  MAGNCSIUM VALUGT OP T t t G  l o . <J  ^7-0 3.1  O  205-O  3S  I 0-0  10.0  55". o  55~.0  HoT AVAILABLE  3.5  C\3I  a.I rvl.A.  rJ/A  T R A I L R&S5LAMD  13.-7  FRUITVAUC  .MoNTROSE"  IZ  GRftf^D  13  KETTLE  FORKS  CRAND  VAL-LEY  IH- SOUTH OKANA&AisI  15.  PEMriCTot^J  )lo, KEREMETOS  (s)  FORKS  MIDWAY  M.A. N/.A.  OLIVER.  133  OSoVOOS  3°°  PENTlcToM iO.H  ( t f ) KE-RfTMEOS 132.  f^-A-  N.A.  tf.A.  ISJ.A.  231-7  10. H 132-  M.A  65.3  |6.o  3-M  0.71 7.5  A P P E N D I X 3 : coNfiwueo:-  W/VTETR.  OF  CLASSIFICATION  Stf+ooL.  DISTRICTS  SCH-OOU PI S T R I C T j» Jff-  , MAME.  ^  L A R G E S T CITY W i T r t i H DISTRICT  WEIGHTED W n W f+AApNESS  WATER H*«J3.N«S  V^LUE 17..  P^iNceTOrJ (H)  IS..  <XX_DErJ  PrViMCETorJ  (H)  1% R E V E T U S T O K e  6s)  REVELSTOKC  VALUE: . ^ / L vTYLu.er I^A/U  S^.H  W £ | & H T E D W*TTEK8oK.J!r MA&WCStun  VALUE"  "-3 A-  7J . H[  iT.M  5-1  f 53  153  30,M  1 g. 1  HO.O  HQ. 0  ) 3, <g  J  SpAU-umCHEEM  LUM0Y  WEIGHTED WfrT*X8.ft/S MET CALCIUM  174.3  2.IO  WO.'?  1-7.7  Coi_D5TR.Eflr-\ KELOWMA:  23 OrMTRAt-OKANAG-AM ('u')  117 15.3  32.x-  34.Z Ct-tArSET 26. r4be.TH T"iTOMf>5or-i  CLfT^WflTER.  IN/.A.  27- CARlfioo-CH-ILCOT/M (v\\  |Oo MI LEI H o u s e "  HZ3  r 452- )  H46.6  WILLIAMS UAKE"  /<g<)  j <^  .  2-0". anersrtEL  Z<?.  M L L O O E T  (v\)  £H)  3o. SouTH C/VRiSoo (H)  OUESMEL  L I L L O O E T  CACHE" CR£EK. ASHCROPT  10.6  i-7  Ho.o  2.13  N.A. ^  M.ft'  2.13  jr-, 5z.?>  5-2.0  5 1  3  3  ' "  7  15  1  ^' ^  3LJI  37.5  I52.0  34.H  l<»\  \(p3  APPENDIX 3 corJTlrJyEP •,  LARGEST WITH-lr*  flERRlTT  31.  HOPE  (S)  OF SCrrOOL.  P'-TST-RlOPS  W£|&(fTCI>  Ciry  DISTRICT  31. nrRRi-rr (V) Hope:  c L.A SS I F I CAT 10 rJ  WftTER  42.  I  H3L,  2C-  56  s  i  56 33. C W I L L I W A C K (h)  CHILUIWACK  mo  3H. A G B O T S F O R D (s")  ABBOTSFORD  -S?  5o,i  3.  HI  I Mo  35  -36  LAM&LEY  SURREY  (s)  37  DELTA  3?"  RlCHMbMD  5  WHlTEB.OC<  5  (S)  RlCttMoMO  (s)  BUR.MAGY  Hi  MAPLC  5  5  5  -5"  5  (s) COQUITLAM  .5  0,16  0,16  3..0  0,16  5  1-0  Q./6  3"  .a.o  0-16  -5"  PORT MootiV  5  PORT D?(SUITLAH 5 PITT MEADOWS  .2.0  5  V A N C O U V E R .  t+AMey  RIDGE (s)  CO Q.Ut-TLA  5  8URMASY  (s)  o. 16  5  5  6uR.eev  MEW W E S T M > N S T E R ( S ) Nl. W t S T K I U S T E - R .  HI-  ^  CITY  T3EUTA  (s)  3*}. VAfslcouv.erR.  Ho.  LAMGLEV  (S)  N.A -  5  ^  Ol6  70  3  APPENDIX  SCHOOL  4fc  CoMTitvlUED  ',  W A T C R .  C L A S S I F I C A T I O N  LATEST  ^  CITy  WITI+IN DISTORT «H- M. VANCOUVER,  T  E  PCIWELL  H?. HOWE  RJVER.CS)  SoutslD^s)  CHARLOTTE(5)  /  5MiT*+er<5  Riv/eR,  ^ / L  D  E RB0»CN E  CALDIUM  WEIUHTCD WATtR&ORwe I-lA&KlESIUf-l  V A U U E  ^.Q O.Ik  M.5  ia, o  fV.A.  3o. 3  PRirJcC R u P e R T  O. b l  1.63  l ' ^ '  MftSSerT  ( n )  "j/l-  5  13. O  HACEN'SE>©R&  5 1 . P R I N C E : RuPE:R.-r( S)  5H.  D I S T R I C T S  2?.?  5QuAMi$H  4<^. C E N T R A L C O A S T  56. (SUEENl  G-iBSoWS  PGWULL  W A T  V/VLUC  5  COAS-TC5)  W&I&HTE.  W A T E R  h+ARoMESS  H5. VJ- VANCouv/eR^s) VI. V A N C O U V E R  SurJSrtiME  WE/G-HTED.  VALUE"  5  fe)  R  ITARDNESS  VANCoiWETR  "-(7.  S C t r O O L .  DISTRICT"  WMng  %.  OF  rJ. A..  N.A.  So. 2  0.13  Tsl. <°\ •  Kl.A. 0.31  '$  S M I T H C R S  hfOUSTOi-J  GRAIN 1 S LET  55  B U R . M 5  56.  N E C H A K O (ht)  L A K E C S )  u A K E  B U R N ' S  5o. 3  VANDJTRH-06F  3 d •  FRASER.  3<?. $  5o. •?  13.H  5o,X  57.  5^  LAKE:  PRINCET Cs€oK<bz(s) PR-irJcer G E O R G E 2.0M  PETACrr  SOUTH (H)  MACKEM2LIE"  | 15  FOPT  33?  ST. JOHN  DAWSOhJ  CREEK.  15.8  GC.l  5, «}  I £>2 /7 - a 7  CH E T W Y M D  11.°}  .22?,  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_  SCHOOL- PI S T R I C T $  weis-HTep LAR6E-3T  NAME  CITV  WiTHIrsI- Dl5TRi<^r,-  >+AN>iJi55  I+ARPKIES5  V A L U E -  V^LUE  (oO. PLACET R:. KjORXH. ( s ) R>R-T ST-J&HNi U U P ^ N ' S  61. &R,£A-T£T< VICT£>.RiPt(s)  VICTORIA  U2.  SAAWICH  £3,  fetf.  i»5. 66  Soc-Ke^  .SAAMICH  frULF  ^5)  I S L A N D S  CowicHAM LAKE  -  (5)  LS)  C^WlOUArN ( j ) 5  <o% NAMAinO Cs)  WATER.  WATER.  H*P£  > ^ / L  ^ej. | 3<J.  (^/L.  OuALiCun ( H )  SVDNIEV  It. o  16.6  G A N G -  34,5  34,5  ES  Or. 5  DwsJCP,^  15  MiSS^Mi  (S)  rvi-A. 0.-7?  o.G  7  LADVSKITH  11,5  QuA-uCun  S?.3  BEACH  7-7  o,54  5.1  4^.3  AL©ERI\M  45.4  11. CAMPBELL. RjVER (s)  M. A .  37.1  ~ N A N A I fAo  10. °)  I'S.H  UCLUELET 71 C&UR.TE-WAY (S)  r*y\-  VALUE:.  5-9  22.5  L A K ^ CoWlCHAtO  PORT  W£ISHTED W A T E R S ORNC MAGNESIUM  6  PARKSV.ILLE:  ALBERjvIl ("s)  Wi^TER&ORrJE CAl-O V A L U E **^/L-  3  7  70.  WFIG-WTETJ  to&.H  3T.S  6?l  DISTRICTS  M, A.  COURXEr^AV  C M M S E R L A M D  I -!  C0, M O *  ' ^ • ' ^  C A M P B E L L  MISSION  R I V E R -  I7..W  5.7  1  ^0.5  0,7&  .0.-73  2L6.5  1.  ?  /.O  L-73L  A*PPE"HDIX  8  coNTiMuep; WATER,  CLASSIFICATION)  SCHOOL DISTRJCT NA M E  77.  £o  $•-(  WITHIN  S W r l M e R i A N l D (^S)  K I T (MAT ( S )  VANCOUVER,  WATC'S.  CITY  I S L A N D VJ.  0I5TK.ICT  *^/LV A L U E P*  WCICHTF.D WATER HAR.DME"5-5 v^Lue  rsf./V  N.A. .  SHMMerR.LA-rJD  ^°  70  KITIMAT  9-5l  <?.5I  G-OLD K.IVE«.  of  SCHOOL  DiSTRt. C.T5  WEIGHTED WATETSGoRlMET CAULIUJ-\ V^-L-UC "^A-  32.  v\l £ " I G - H T E D W/VTERB0R.Kie r-lASMES./Ufi v/*i_uer ^ /  3.^  0.57  15  3,17  <25. vA^coiwex. ISLAND N1.  PORT  HARDY'  I 3.2,  CH) 10.1  PORT n c N f i L poRT CReSTosI-KASL0(fs)  S7. SxiK-ine "X?-  TERRACET-K/SH&AC'S)  Auce  CKfSTois) PEASE"  2.T 5 LAKE"  N  .a-  Nfi A.  M.A  13, M  ^•3  M.A.  TEftRACe:  STEWART 2% S H U S W A P ^ H )  i .«gx  5ALM6NI A R M  0."75  3*) 133-  133.1  5.?  APPENDIX  T:INTERNATIONAL CLASSIFICATION  VII.  OF  D I S E A S E S , 7 T H REV  DISEASES O F T H E C I R C U L A T O R Y S Y S T E M 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 401  Rheumatic fever (activo) (acute) Rheumatism, articular, acute or subacute Tonsillitis, rheumatic (acute)  Ulieumulie fever with heart involvement  T h i s 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 '* pancarditis ", 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  condition in 400 with endocarditis or valvular disease, subject to the limitations in the noto above  401.2 Active rheumatic myocarditis Rheumatic myocarditis, activo or acuto Any condition in 400 with myocarditis, subject to the limitations in the note above  401.3  Active rheumatic fever with other and multiple types of heart involvement Bheumatic : carditis (active) (acute) fever with heart involvement of unspecified nature heart disease, active or acute pancarditis (active) (acute) Any condition in 400 with other and unspecified types of heart involvement (comprising all terms in 434.1, 434.2, and 434.4) and with multiple types of heart involvement, subject to the limitations in the note above  402  Chorea  This title excludes Huutington's chorea (355).  402.0 Without mention of heart involvement Chorea NOS ) without mention of heart involveRheumatic chorea (acute) > ment of any type classifiSydenham's chorea ) able under 401 402.1 With heart involvement Chorea NOS , ... , , . , , •p., .. , , , . / with heart involvement of any Rheumatic chorea (acute) , , , .„ , , Sydenham's chorea \ ^ under 401 t y p e  c l  l f i a W e  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) : insufficiency stenosis valvular disoase  i /  . , , specified as rheumatic c  ^  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  T r i c u s p i d  ( v a l v e )  tricuspid valve *  ( 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 n o t ; 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  P u l m o n a r y  v a l v e  pulmonary valve specified as  :  rheumatic *  i  d i s e a s e «, • i n s u f f i c i e n c y  / i  stenosis  '  s p e w  l i e u  . r h e u m a t i c  a s  1  T h i s title excludes diseases of pulmonary valve (421.3), unless specified as rheumatic.  414  Other endocarditis specified as  A n e u r y s m  o f  v a l v e  D e g e n e r a t i o n E h e u m a t i c  o f  o f  h e a r t ,  c a r d i a c  v a l v u l i t i s  r h e u m a t i c  ( c h r o n i c )  ( 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  >  s t e n o s i s  \  T h i s title rheumatic.  415  excludes  ( c h r o n i c )  ( i n a c t i v e )  chronic endocarditis  Other myocarditis specified as  R h e u m a t i c  d e g e n e r a t i o n ,  E h e u m a t i c  m y o c a r d i t i s  p e r i c a r d i u m  :  s p e c i f i e d  (421.4),  a s  r h e u m a t i c  unless specified  as  rheumatic  m y o c a r d i u m ( c h r o n i c )  Other heart disease specified ns  A d h e r e n t C h r o n i c  r h e u m a t i c  v a l v e ,  :  e n d o c a r d i t i s  416  rheumatic  \ j  E h e u m a t i c N  O  S  m e d i a s t i n o p e r i e a r -  f  or  d i t i s  i  r h e u -  m y o p e r i c a r d i t i s  l  p e r i c a r d i t i s  /  rheumatic  c a r d i t i s , h e a r t  : c h r o n i c  d i s e a s e  o r  i n a c t i v e  ( i n a c t i v e )  ( c h r o n i c )  m a t i c  * W h e n more t h a n one valve is mentioned, priority in classification follows the order of listing in numbers 410-413;  17 k  ARTERIOSCLEROTIC  420  A N D D E G E N E R A T I V E H E A R T DISEASE (420-422)  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 Cardiac infarction or  Coronary (artery) : occlusion  throm-  bosis rupture Coronary (artery) : sclerosis aneurysm stricture arteriosclerosis thrombosis arteritis Kmbolism of heart atheroma Infarction of heart, myocardisease 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- • i r. • I any condition in 420.1 Cardiac angina \ Vasomotor angina / This title includes the listed conditions with mention of any condition in 442, 433, 440-447, or 450. It excludes them with mention of any condition in 420.1 (420.1). t  n  n  J  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 nonrheumatic 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 nonrheumatic tricuspid or other valvular disease.  421.1  Of aortic valve, not specified as rheumatic  Aortic (valve) : disease, heart endocarditis, chronic or NOS insufficiency regurgitation stenosis Atheroma of aortic valve Aortic valvular sclerosis  \ j / | I 1 /  not specified as rheumatic and without mention of mitral- disease  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. insufficiency stenosis 421.4  ) } )  u  specified as rheumatic and without mention of other valve  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 • disease' endocarditis incompetence obstruction regurgitation stenosis Valvulitis NOS  > '  . , . , , .„ , (chrome) not specified as rheumatic  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),Jand 440-447 (440-443).. . :  422.0 Fatty degeneration Patty degeneration : heart myocardium  Fatty : heart infiltration of heart myocarditis  in 450 "(49'M ) ° 1  e  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  422.1 With arteriosclerosis Cardiosclerosis Cardiovascular : arteriosclerosis degeneration disease 422.2 Other Atheroma Atrophy Calcification Degeneration brown calcareous of heart or ischemic myocardium mural muscular pigmentary Glycogenic infiltration 'Rupture Cardiac insufficiency Cardiac ossification  w i t  ' ' mention of any condition  Cardiovascular sclerosis Myocardial degeneration, with arteriosclerosis or synonym in 450  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  This title excludes the listed conditions with mention of any condition in 450 (422.1). O T H E R DISEASES OF H E A R T  430  (430-434)  Acute and subacute endocarditis  430.0 Acute and subacute bacterial endocarditis Endocarditis : bacterial infective lent a (acute) (chronic) (subacute) malignant purulent septic ulcerative vegetative Mycotic aneurysm This title excludes acute endocarditis specified as rheumatic (401.1).  430.1 Other acute endocarditis Aortic endocarditis i Endocarditis r acute or subacute, not specified as rheuMyo-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 .. .... Septic myocarditis . „ Toxic myocarditis This title excludes acute myocarditis specified m  432  ) , .„ , not specified as } . ^. rheumatic ] as rheumatic (401.2).  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 . . , , . _ \ not specified as rheumatic purulent ' suppurative 0  y  r  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 Heart block (any degree)  > Stokes-Adams syndrome 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 Disordered action of heart NOS • 434  of heart  O t h e r a n d unspecified diseases of h e a r t  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 : anasarca dropsy oedema  Congestive heart: disease failure  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, . „ , as non-rheumatic , ,r „ • , .chronic (•> specified Myopencarditis, chronic Pericarditis, chronic Constrictive pericarditis NOS Hydropcricardium NOS Haemopericardium NOS Pericarditis NOS r  This title excludes heart disease specified as rheumatic: acute (401, 402), chronic (410-416).  434.4 Unspecified disease Cardiac: decompensation dilatation (acute) hypertrophy Carditis : NOS acute subacute  of heart  Cor pulmonale Enlargement of heart " Heart disease " NOS Morbus cordis NOS Organic heart disease Ventricular dilatation Other disease of heart not classifiable 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  Hypertensive: cardiovascular disease heart (disease) -r v iJ iMyocardial degeneration, or any coni-t- Ann • i i . u / • dition in 422, with hypertension Any condition in 444 associated with conditions in 422, 433 and 434  heart disease  \ / ( ) ( I ] /  , , . hypertension -v.i scribed as  it  . , is de^ • benign &  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  Arteriolar nephritis Arteriosclerosis of kidney Arteriosclerotic nephritis „ . . „ . ., Hypertension of kidney Nephrosclerosis Any condition in 594 with hypertension  \ j / (  nephrosclerosis  . , , . • associated with conditions in 422,  Cardiorenal (hypertensive) : arteriosclerosis disease sclerosis  4  3  3  a  n  d  4  3  4  Cardiovascular renal (hypertensive) : disease 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).  O T H E R H Y P E R T E N S I V E DISEASE (444-447) Numbers 444-447 include the listed conditions with mention of any condition in 450. T h e y 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). W h e n terms in more than one of the numbers 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  H  Essential benign hypertension  Hyperpiesia Hyperpiesis Hypertension : NOS arterial benign  Hypertension: essential primary (benign) Any condition in 447 described as benign  if  T h i s 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 T h i s title includes the listed conditions with mention of any condition  in 590-594.  446  Hypertension  with  arteriolar  Arteriolar nephritis Arteriosclerosis of kidney Arteriosclerotic nephritis Bright's disease : \ NOS . . / chronic ( Nephritis (interstitial) : ( -^Qg \ chronic  nephrosclerosis  Hypertension of kidney Nephrosclerosis A n y condition in 594 hypertension  with  . , specified as £ ^ . . , arteriosclerosis r  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 Hypertensive vascular: ' degeneration disease  I ' .„ , not specified as ? °/ malignant h  e  n  n  This title excludes the listed conditious with mention of any condition in 594 (440).  D I S E A S E S OF A R T E R I E S (450-456)  450  General arteriosclerosis  This title excludes the listed conditions when reported as the underlying 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 and coronary general senile Arteriosclerotic vascular diseaso Atheroma of artery, except cerebral and coronary Calcareous degeneration of artery  450.1  Degeneration or sclerosis : aortic arterial arteriovascular vascular Endarteritis deformans or obliterans Senile: arteritis V \ endarteritis • ;  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) Aortic aneurysm specified as noDByphilitic Dilatation of aorta  Dissecting aneurysm of aorta Hyaline necrosis of aorta Rupture of aorta NOS • *.  This title includes aneurysm of abdominal aorta and dissectiong aneurysm, 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  453.1  Raynaud's phenomenon (secondary)  Thrombo-angiitis obliterans  Buerger's disease  Thrombo-angiitis obliterans (general)  453.2 Chilblains Chilblains Dermatitis congelationis  Pernio  453.3 Other Acrocyanosis Acroparesthesia simple (Schultze's type) vasomotor (Nothnagel's type) Erythrocyanosis  Erythromelalgia Other or unspecified peripheral vascular disease not classifiable under 453.0453.2  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 T h i s 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 Artcritis NOS aorta, non-syphilitic giant celled temporal  Disseminated lupus erythematosus (Libman-Sacks disease) Endarteritis NOS 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 lower extremity (any part) unspecified site Varicose ulcer lower extremity (any part) unspecified site  Varicose veins (ruptured) (ulcerated) lower extremity (any part) unspecified site Varix lower extremity unspecified site  4C1  Ilaunorrhoids  Haemorrhoids (rectum) (prolapsed) (thrombosed) (ulcerated) (strangulated) (bleeding) Piles (external) (internal) Rupture, varix, rectum Varicose veins, anus or rectum 4G2  Varicose veins of other specified sites  462.0 Varicocele Varicocele  462.1  Varicose veins, scrotum  Varicose veins of oesophagus  Phlebectasia, tesophagus Varicose veins, oesophagus  Varix, oesophagus  462.2 Other Phlcbcctasia, any site except as classifiable in 460-462.1 Varicose veins, varix, and varicose ulcer, any site except as classifiable 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 Phlebitis (suppurative) (septic) Thrombophlebitis  ', \  of any part of lower extremity  This title excludes the listed conditions if of puerperal origin (645. I 651, (i.H2) or complicating pregnancy (648.:!). 464  Phlebitis and thrombophlebitis  Endophlebitis Inflammation, vein Periphlebitis n,/.,. , .. , Phlebitis (suppurative) mi, . I/.,. Thrombophlebitis  ° ' i \ j  . f  »  n R  of other sites  .„ , ., , . .„ , P<f site and of any specified f\Q \owc* ^ i m t y , portai vein and intracranial venous sinuses f i e d  e x c e p f c  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 Pulmonary (artery) (vein) : apoplexy embolism  Puknonary (artery) (vein) : infarction (hemorrhagic) thrombosis  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 thrombosis 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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