Spatial Analysis of the Relationship between Mortality from Cardiovascular and Cerebrovascular Disease and Drinking Water Hardness

By Ferrandiz, Juan; Abellan, Juan J. et al. | Environmental Health Perspectives, June 15, 2004 | Go to article overview

Spatial Analysis of the Relationship between Mortality from Cardiovascular and Cerebrovascular Disease and Drinking Water Hardness


Ferrandiz, Juan, Abellan, Juan J., Gomez-Rubio, Virgilio, Lopez-Quilez, Antionio, Sanmartin, Pilar, Abellan, Carlos, Martinez-Beneito, Miguel A., Melchor, Inmaculada, Vanaclocha, Hermelinda, Zurriaga, Oscar, Ballester, Ferran, Gil, Jose M., Perez-Hoyos, Santiago, Ocana, Ricardo, Environmental Health Perspectives


Previously published scientific papers have reported a negative correlation between drinking water hardness and cardiovascular mortality. Some ecologic and case-control studies suggest the protective effect of calcium and magnesium concentration in drinking water. In this article we present an analysis of this protective relationship in 538 municipalities of Comunidad Valenciana (Spain) from 1991-1998. We used the Spanish version of the Rapid Inquiry Facility (RIF) developed under the European Environment and Health Information System (EUROHEIS) research project. The strategy of analysis used in our study conforms to the exploratory nature of the RIF that is used as a tool to obtain quick and flexible insight into epidemiologic surveillance problems. This article describes the use of the RIF to explore possible assodatious between disease indicators and environmental factors. We used exposure analysis to assess the effect of both protective factors-calcium and magnesium--on mortality from cerebrovascular (ICD-9 430-438) and ischemic heart (ICD-9 410-414) diseases. This study provides statistical evidence of the relationship between mortality from cardiovascular diseases and hardness of drinking water. This relationship is stronger in cerebrovascular disease than in ischemic heart disease, is more pronounced for women than for men, and is more apparent with magnesium than with calcium concentration levels. Nevertheless, the protective nature of these two factors is not dearly established. Our results suggest the possibility of protectiveness but cannot be claimed as conclusive. The weak effects of these covariates make it difficult to separate them from the influence of socioeconomic and environmental factors. We have also performed disease mapping of standardized mortality ratios to detect dusters of municipalities with high risk. Further standardization by levels of calcium and magnesium in drinking water shows changes in the maps when we remove the effect of these covariates. Key words: environmental epidemiology, geographic information systems, hierarchical spatial models, relative risk, spatial smoothing. Environ Health Perspect 112:1037-1044 (2004). doi:10.1289/ehp.6737 available via http://dx.doi.org/[Online 15 April 2004]

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Cardiovascular disease is the primary cause of mortality in developed countries, with the exception of Japan. In Comunidad Valenciana, an autonomous region in Spain with approximately 4 million inhabitants, cardiovascular disease accounts for 35% of total female mortality and 46% of total male mortality (Melchor et al. 1998). Geographic variability within Comunidad Valenciana has been documented (Ferrandiz et al. 2000, 2002; Nolasco et al. 1992).

Previously published scientific articles have reported a negative correlation between drinking water hardness and cardiovascular mortality. Some results obtained in ecologic studies (Cradford et al. 1971; Lacey and Shaper 1984; Pocock et al. 1980) suggest that high levels of drinking water hardness (i.e., high concentrations of calcium and magnesium) are protective against cardiovascular diseases, mainly against ischemic heart disease.

Several surveys based on individual cases (Hall and Jungner 1993; Van der Vijver et al. 1992) have not confirmed the protective effect of calcium. Nevertheless, Rylander et al. (1991) and Yang (1998) suggest the beneficial effect of magnesium against coronary heart disease mortality as well as against cerebrovascular mortality. The results of these studies, obtained at the aggregated level, have been partially corroborated by case-control studies (Rubenowitz et al. 1996, 2000). These case-control studies, conducted in 18 southern municipalities in Sweden, found a protective effect of magnesium against acute myocardial infarction mortality but failed to find this effect for the total incidence in men.

A recent report by Marx and Neutra (1997) on the relationship between ischemic disease and magnesium in drinking water presented an analysis of several ecologic studies showing contradictory results, perhaps because the studies were not sufficiently specific to find the associations the investigators were exploring. …

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