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EPIDEMIOLOGY OF WATER MAGNESIUM;
EVIDENCE OF CONTRIBUTIONS TO HEALTH

Mildred S. Seelig, M.D., M.P.H., Master of American College of Nutrition; Adjunct Professor of Nutrition, School of Public Health, University of North Carolina, Chapel Hill (in Press: Proceedings of Mg Symposium, Vichy, France 2000)

 

INTRODUCTION

Epidemiologic investigations of effects of magnesium (Mg) intake on morbidity and mortality, predominantly from cardiovascular disease (CVD), but also from other widespread disorders (Review1), were stimulated, first, by the 1957 observation by Kobayashi2 that apoplexy is most frequent in regions of Japan supplied with soft drinking water. Low levels of Mg and calcium, (Ca) in soft water were correlated with cardiovascular diseases (CVD), but especially hypertension in white men, 45 to 64 years of age in the United States (U.S.), by Schroeder in 1960.3 By 1966, he deemed Mg to be the major protective hard water factor,4 but where water hardness is caused mostly by Ca, as in England, that was the mineral perceived protective in hard water's protection against ischemic heart disease.5-7 Attention was drawn by Karppanen and Neuvonen, in 1973,8 again to Mg (in soil and water) as protective in southwestern Finland, where the soil and water Mg is three times as high as it is in eastern Finland, and where there is half the IHD mortality. Studies, in 1997-1999, from Serbia9,10 and Taiwan,11-13 compared Mg and Ca in drinking water against several arterial diseases affecting the heart or brain, and found that it was Mg, more than Ca, that was protective. Since CVD is a major cause of shortened life expectancy, it is not surprising that areas in the U.S. with hard water and low CVD frequency, also have populations that live longer.14 Also shortening lives are cancers, and hard water in these areas reportedly have antineoplastic effects — partially by their anticorrosive effects that prevent leaching toxic minerals from pipes.15 Mg in water and soil seems to be protective against some neoplasms and Ca against others.11-21 Water hardness (both Mg and Ca) has a strong negative association with urolith disease, which is especially prevalent in southeast U.S.,22,23 also the area with the highest CVD rates and shortest life expectancy. In Japan,24 formation of calcific stones has been associated with low Mg/Ca content of water; and in Greece25 with low Mg/Ca in water and other beverages. Water supplies low in Mg have also been implicated in unsuccessful pregnancies (in Hungary), 26,27 poor fetal growth, and premature deliveries.26-28

HARD AND SOFT WATER AND VASCULAR AND HEART DISEASE

The potential value of Mg in water was first reported in 1697 by Grew,29 in England, who advised the use of epsom salts (Mg sulfate), not only for its cathartic effects, but for use in calcific uroliths, diabetes, headaches, and several neuromuscular complaints. Except for brief mention of "cardialgia" — which Grew referred to as "heartburn and other such pains" (angina?), and its diuretic effects, he made no mention of water-borne Mg in CVD.

Kobayashi,2 in 1957 in Japan, mentioned high sulfate content and acidity of soft water as factors in soft water that was associated with the high incidence of strokes in some regions of Japan. Schroeder suggested, four years later, that soft waters acidity might cause leaching out of toxic metals such as lead.30 Cadmium, which has been implicated in hypertension and other CVD,31-33 is also derived from pipes corroded by acidic soft water.31-34 Masironi in 1970,31 noted that death rates from hypertensive and ischemic heart disease (IHD) were substantially lower in people living in hard water regions than where the water was soft, and considered the cadmium content of soft water a contributory factor to hypertension. Nine years earlier, Morris et al5 had reported that the softer the water supply in England and Wales, the higher was the IHD death rate. Schroeder at first credited both Ca and Mg for lower rates of hypertension,2 but when he limited the analysis to white men 55 to 64 years of age, observed a strong correlation of soft water with IHD;35 in 1966 he attributed the protective effect to Mg.3 A 1973 report from Newfoundland, Canada, by Fodor et al36 reported high IHD mortality of men in a city with soft water, in contrast to a much lower rate in a city with hard water, which had seven times as much Mg in water as did the city with high IHD mortality. In the first of a series of studies in Ontario, Canada, published two years later, Anderson et al37 similarly found higher IHD death rates in soft than in hard water regions of Ontario, Canada. They attributed this to increased risk of sudden cardiac death from fatal arrhythmia, to which Mg deficiency, partially due to low water Mg, is contributory.38 Others from this Canadian group39-42 concluded, from their own and others' observations, that the risk of IHD death was greater in soft than in hard water areas by one to two orders of magnitude. In comparison with other water-borne minerals, they deemed Mg to be the most likely protective factor, an impression also gained by Sharrett43 in the U.S. from his 1979 evaluation of published data.

Studies from continental Europe, South Africa and Asia confirmed the protective importance of hard water in CVD. A study, reported in 1977,44 of 290 water supplies in Norway, supplying 1,700,000 people, showed that the ten hardest water communities had 5-10 percent lower mortality rates from CVD than did the 40 with the softest water. A provocative 15 year study of men, 40-59 years old, in two communities in Italy, briefly reported in 1979, disclosed a substantial increase in coronary heart disease mortality after five years, only in the community45 that had softened their drinking water. A fairly recent report from Tuscany, Italy, where the water is very poor in both Ca and Mg, indicates that the incidence there of sudden cardiac death is twice the European average.46

A South African study, in 1983, that showed Mg as the protective mineral, found a significant negative correlation in white men between arrhythmias and IHD deaths and the Mg content of their water.47 Protection by water-borne Mg against arteriosclerosis and deaths from myocardial infarction (MI) was shown in a 1986 study from Poland,48 and against hypertension and angina of effort in a 1988 report from Russia.49 Hypertension and deaths from CVD were about three times as prevalent in low water Mg localities in Spain, as where the water Mg was high.50 Among men, 50 to 69 years of age, who died in southern Sweden of acute Ml, the odds ratios for such deaths were inversely related to the water content of Mg (Rubenstein et al, 1996).51 For the group with the highest water Mg, but not Ca, the odds ratio, adjusted for age was 0.65. The findings from their 1999 study with women52 indicated that both Mg and Ca were protective against death from acute MI. A series of studies, in Taiwan, on the relative protection of Mg and Ca against arterial disease of heart or brain, were reported by Yang and colleagues in 1997-1999.11-13 Their analysis of over 17,000 deaths from strokes, compared with an equal number of deaths from other causes, in areas supplied with water containing different amounts of Ca and Mg, disclosed that adjusted odds ratios (95% confidence interval) were 0.75 for the group consuming water containing 7.4-13.4 mg/L of Mg, and 0.60 for water Mg below 13.5 mg/L. After adjustment of Mg levels, there was no difference between groups with different water Ca levels, which strengthened the premise that Mg protected against cerebrovascular accidents.11,12 Comparison of water Ca and Mg in areas where 2336 persons who had died from complications of hypertension, or from other causes, showed an inverse relationship of Mg, but not Ca in drinking water, to risk of death from hypertension.13 Yang et al53 similarly studied the relationship of water Mg to risk of death from diabetes, that is associated with high risk of CVD. Their comparison of 6781 diabetes-associated deaths from the same number of deaths from other cause, with levels of Mg in drinking water, indicated a significant protective effect of the Mg on risk of dying from diabetes.

Serbia, where mineral waters provide different concentrations of Ca and Mg, also provides data on the comparative protective values of the two cations in water.10,54 Surveys of 65 Serbian municipalities for mineral contents and CVD death rates, reported in 1998, disclosed that areas with drinking water rich in Mg (52-68 mg/L) and poor in Ca (3.5-12.4 mg/L) have very low mortality from CVD, but municipalities poor in Mg (<20 mg/L), and rich in Ca (>80 mg/L) have high CVD death rates.10 A less detailed study of the health of villagers who drank water from a spring with very high Mg (350 mg/L) and low Ca (24 mg/L) was better than that of inhabitants of 4 neighboring villages, who did not consume that water.

In England, where Ca is the main water hardness constituent, Crawford et al credited the lower CVD death rates in hard water, than in soft water regions to Ca, 6,7 but commented that hearts of those who died in accidents, regardless of the hardness of water, had low coronary and myocardial Mg levels.54 Chipperfield and Chipperfield,55,56 however, found that healthy men, who died of accidents in soft water areas in England, had lower myocardial Mg than did those in hard water areas. Anderson, Hewitt and Neri et al37-39,42compared the myocardial Mg of those who had lived in soft and hard water areas in Canada, and found the Mg content of heart muscle to be higher in hard than in soft water regions. Bloom and Peric-Goria57 reported myocardial Ca in autopsies after heart attacks in a soft water city, but not in a hard water city in the U.S., with high and low MI rates, respectively. They commented on the damaging effect of Ca influx into hearts during infarction, against which Mg is protective.

After having correlated the significantly greater myocardial Mg content of victims of accidental deaths in hard water areas of Ontario, Canada, than in the soft water regions that had higher death rates, Anderson et al37,38 speculated that the differences might be due to suboptimal Mg intake, and that low levels of water-borne Mg in soft water regions could be partially to blame. They suggested that the contribution of Mg in water to total dietary intake might be critical in soft water areas, leading to subclinical Mg deficiency, with increased risk of fatal arrhythmia after MI.38 Durlach et al58 pointed out that marginal Mg deficiency is a problem in developed countries, and hypothesized that Mg in water might thus be a determining factor in whether the Mg intake is adequate. A 1970 survey by Hankin et al in the U.S.59 disclosed that hard water contributes an average of 12% of the Mg ingested, but only 7% of the daily Ca intake. In 1979, Sharrett43 reported that hard water could contribute up to a fifth of the daily Mg needs, which might be enough to prevent deficiency in those with marginal dietary Mg. Feder and Hopps,60,61 later found that some American hard waters could provide up to 100 mg of Mg daily, and estimated that hard water, in some areas and by those drinking much water, might actually provide the recommended daily requirement (RDA) of Mg, but only a third the RDA of Ca. They demonstrated that the geographic similarity of American regions with hard water Mg, that was rich in Mg and Ca, and low cardiovascular death rates.61

Noting the growing evidence, by as early as 1971, of an association between water hardness and cardiovascular and other chronic diseases, the World Health Organization (WHO) started to investigate possible causal relationships.62 Masironi and Shaper63 concluded in 1981 that the predominant protective role of Ca is to protect against lead and other toxic metals (from pipes in soft water areas), but that the good epidemiologic evidence for association of Ca deficiency with CVD was not supported by animal experiments. They observed that the Mg hypothesis is strongly supported by animal studies and by the human pathology findings of low myocardial Mg in those dead of IHD, and that dietary Mg is usually low, but they concluded (on the basis of well designed epidemiologic studies) that it is the water Ca of hard water that is responsible for lowering CVD mortality. Review of epidemiologic data by Yamori and Misumishima in 2000,64 that included both water and dietary Mg, disclosed that Mg had consistent beneficial effects, that linked low Mg intake to CVD.

In view of the association of Mg deficiency with CVD, from epidemiologic, autopsy, clinical, and animal studies, Eisenberg suggested in 1992,65 that Mg deficit be repaired by increasing its intake, by addition to food or water or by supplements. Public health measures, such as education to change dietary habits, or adding Mg to water supplies, as appropriate means to reduce the risk of widespread CVD, were also considered in two 1997 publications in Israel66, and in the U.S.67

EFFECTS OF WATER MINERALS ON OTHER ASPECTS OF HEALTH

Longevity and Neoplastic Disease: Water-borne minerals affect life expectancy, not only by influencing CVD development, but also by their effects on cancer. Hopps34 discussed the epidemiologic evidence of the protective effects, primarily of Mg in hard water, against atherosclerosis and fatal arrhythmias, the major shorteners of life, and referred to reduction of corrosion of water pipes by both Mg and Ca in hard water,15 thereby lessening leaching out of toxic trace minerals that increase the risk of cancer. Sauer14 found that the areas of highest longevity of white men are in the midwest, and the lowest longevity are in the southeastern states — the areas with the lowest and highest CVD rates, respectively. Among those living in the midwest state of North Dakota are Americans born to recent European immigrants, who have low CVD incidence and long life expectancy..68 Enterline (personal communication) found, in a survey of that area, that the cited Europeans were Finns, who retained their high CVD risk factors: dietary, smoking, and alcohol, identical to that in Finland, where there is very high prevalence of CVD. The only clue he found to why their health and longevity are among the best in the U.S., was that their drinking water had unusually high Mg content. In the first third of the twentieth century, gastric carcinoma was associated with low levels of soil and water Mg (review, 197969). Use of Mg supplementation was attempted to repair the low blood levels of cancer victims, until it was found that Mg could increase tumor growth in animal models. The early epidemiologic findings were confirmed by evidence of high stomach cancer rates in the Ukraine, where soil Mg is low, and much lower mean gastric cancer rates in Armenia, where soil Mg is 2.5 times as high.70 Also reviewed69 were studies of induction of lymphomas and leukemias in rodent models by Mg deficiency, and development of leukemias in cattle and humans in areas in Poland with low Mg levels in soil and water.16 More nasopharyngeal carcinomas have been diagnosed in areas in China that have low soil levels of Mg, Ca and strontium, than where these alkaline earth minerals are not low.71 Hard water, and specifically its content of Ca, more than the Mg, found in regions of Taiwan where the incidence of cancer of the colon and rectum is low.17-20 In contrast, they found high water content21 of Mg to be more protective than Ca against prostate cancer.

Urolith Disease: The geographic prevalence of uroliths is the same as that of CVD and water hardness22,23,61 which can explain designation of the southeast of the U.S. as the heart attack-kidney stone belt. A strong negative association was found between water hardness and urinary stone incidence.23 The relationship of the relative concentrations of Mg and Ca in tap water, with urolith incidence, was examined in Japan.24 In basalt areas, where the Mg/Ca ratio was highest, there were fewest uroliths, in contrast to limestone areas, where the Ca/Mg ratio 24 was highest, and where urolith incidence was highest.24 A study of the Mg and Ca contents of drinking water in Athens, Greece,25 in relation to formation of urinary Ca crystal formation, disclosed that the water Mg was very low (5.7mg/L), and the Ca content and crystal formation was high (48.2 mg/L).

Spontaneous Abortions and Low Birth Weight Infants and Neonatal Mortality : Crawford et al72 reported that in England and Wales, the softer the drinking water, the higher was the infant death rate. As with CVD6,7 they attributed this to the Ca content of the water. A literature survey by Franz28 disclosed that at least 450 mg of Mg/day, to which water Mg can make a significant contribution, is needed during pregnancy, for successful outcomes. Investigations in Hungary, a country with very high rates of pregnancies terminating in spontaneous abortions, premature deliveries, and birth of low birth weight infants, of this and other causes, and high rates of neonatal deaths, have implicated low Mg content in drinking water as an important factor in Mg inadequacy during pregnancy.26-28,72 Water Mg, was estimated to provide half the daily intake, in 129 localities. Also considered contributory to latent Mg deficiency, that is of particular danger during pregnancy, when the Mg requirement is elevated, is the high Ca intake from milk and cheese, that is customary in Hungary.73 Early Mg supplementation, and its maintenance throughout pregnancy, improved the maternal and infant outcomes in low Mg areas.26,27,73

CONCLUDING COMMENTS

An evaluation of the published data led Marx and Neutra,71 to suggest the potential value of increasing Mg intakes. They commented that adding Mg to the water would be an intervention to lower IHD prevalence that does not require behavioral change, and that could result in tens of thousands of lives benefited and avoidance of millions of dollars in hospital costs. They urged funding agencies to give priority to determining the advantages versus possible risks of such Mg addition. Such programs that increase Mg intake might also reduce the prevalence of other serious conditions: cancer, uroliths, and poor outcomes of pregnancy.

REFERENCES

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2. Kobayashi J. (1957): Geographical relationship between the chemical nature of river water and death rate from apoplexy. Ber. Ohara Inst. 11:12-21.

3. Schroeder H. A.. (1960): Relations between mortality from cardiovascular disease and treated water supplies. J.A.M.A. 172:1902-1908.

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5. Morris J. N., Crawford M. D., Heady J. A. (1961): Hardness of local water-supplies and mortality from cardiovascular disease in the county boroughs of England and Wales. Lancet 1: 860-862.

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8. Karppanen H., Neuvonen P. J. (1973): Ischaemic heart-disease and soil magnesium in Finland. Lancet 2:1390.

9. Maksimovic Z. J., Jovanovic T., Rsumovic M., Dordevic M. (1998): Magnesium and calcium in drinking water and cardiovascular mortality in Serbia. Serbian Acad. Sci.Art, Belgrade, Yugoslavia, pp. 2-3.

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19. Yang C. Y., Hung C. F. (1998): Colon cancer mortality and total hardness levels in Taiwan's drinking water. Arch. Environm. Contam. Toxicol. 35:148-151.

20. Yang C. Y., Tsai S. S., Lai T. C., Hung C. F., Chiu H. F. (1999): Rectal cancer mortality and total hardness levels in Taiwan's drinking water. Environm. Res. 80:311-316.

21. Yang C. Y., Chiu H. F., Tsai S. S., Cheng M. F., Lin M. C., Sung F. C. (2000): Calcium and magnesium in drinking water and risk of death from prostate cancer. J. Toxicol. Environm. Health 60:17-26. 1

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26. Losonczy J., Adorjan G., Novak M., Toth M. O. (1989): Correlation between the incidence of preterm delivery and the concentration of magnesium in drinking water in Szaboics-Szatmar County, Northeast Hungary. Magnesium Res. 2:229-230.

27. Novak M., Losonczy J., Komafeld J., Toth M. O. (1989): Experiences on giving magnesium citrate to pregnant mothers. Magnesium Res. 2:230.

28. Franz K. B. (1987): Magnesium deficiency during pregnancy. Magnesium 6:1 8-27.

29. Grew N. (1697): Treatise of the Nature and Use of the Bitter Purging Salt contained in Epsom and Such Other Waters. Promotional Brochure.

30. Schroeder H. A., Balassa J. J., Gibson F. S., Valanju S. N. (1961): Abnormal trace metals in man: lead. J. Chron. Dis. 14:408-425.

31. Masironi R. (1970): Cardiovascular mortality in relation to radioactivity and hardness of local water supplies in the USA. Bull. W H. O. 43:687-697.

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37. Anderson T. W., Neri L., Schreiber G. B., Talbot F., Zdrowjewski A. (1975): Ischemic heart disease, water hardness and myocardial magnesium. Can. Med. Assoc. J. 113:199-203.

38. Anderson T. W., Leriche W. H., Hewitt D., Neri L. C. (1980): Magnesium, water hardness, and heart disease. In Magnesium in Health and Disease. Eds M. Cantin, M. S. Seelig, Spectrum, NY, NY.pp 565-571.

39. Hewitt D., Neri L. C. (1980): Development of the 'Water Story': some recent Canadian studies. J. Environm. Pathol. Toxicol. 4:51-63.

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47. Leary W. P., Reyes A. J., Lockett C. J., Arbuckle D. D., van-der-Byl K. (1983): Magnesium and deaths ascribed to ischaemic heart disease in South Africa. A preliminary report. S. Afr. Med. J. 64:775-776.

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53. Yang C. Y., Chiu H. F., Cheng M. F., Tsai S. S., Hung C. F., Tseng Y. T. (1999): Magnesium in drinking water and the risk of death from diabetes mellitus. Magnesium Res. 12:131-137.

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59. Hankin J. H., Margen S., Goldsmith N. F. (1970): Contribution of hard water to calcium and magnesium intakes of adults. J Am Dietet Assoc 56:212-224.

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61. Hopps H. C., Feder G. L. (1986): Chemical qualities of water that contribute to human health in a positive way. Sci. Tot. Environm. 54:207-216.

62. Andelman J. B. (1971): Water chemistry and analysis of trace elements in relation to hardness and cardiovascular mortality. Joint WHO/IAEA research project, Geneva, Feb.8-13.

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68. Syme S. L., Hyman M. M., Enterline P. E. (1964): Some social and cultural factors associated with the occurrence of coronary heart disease. J. Chron. Dis. 17:277-289.

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70. Bazikian K. L. (1973): The significance of magnesium salts in oncology. (Epidemiological, experimental and clinical observations). Proc of First Intl Sympos on Magnesium, 1971, ed J. Durlach, Vittel, France, pp. 593-606.

71. Bolviken B., Flaten T. P., Zheng C. (1997): Relations between nasopharyngeal carcinoma and magnesium and other alkaline earth elements in soils in China. Med. Hypotheses 48:21-25.

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73. Molnar B. G., Kovacs L. (1989): Experiences with magnesium substitution during pregnancy. Magnesium Res. 2:230-231.


This article is included with the permission of Dr. Mildred.S. Seelig and John Libbey Co Ltd. It is from the book Advances in Magnesium Research: Nutrition and Health

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