101

CORRELATIONS BETWEEN CALCIUM, MAGNESIUM AND

HARDNESS OF WATER IN THE DRINKING WATERS OF
DECATUR COUNTY GEORGIA AND THE INCIDENCE OF
CARDIOVASCULAR AND CEREBROVASCULAR DISEASES
Abiodun A. Ojo* and Manju Sharma
*Atlanta Metropolitan College
Division of Science, Mathematics & Health Professions
1630 Metropolitan Parkway, SW
Atlanta, GA 30310
*E-mail: aojo@atlm.edu
Telephone: 404-756-4741
Fax: 404-756-4767
ABSTRACT
In this study, we are presenting some link between water hardness,
calcium and magnesium levels, cardiovascular diseases and cerebrovascular disease (CVD and CBVD) in Decatur County of Georgia,
USA. The drinking water samples from different regions and sources
were analyzed by using the ethylenediaaminetetraacetic acid (EDTA)
- metal complexation method. In the study we found that the surface
water sources (lakes, ponds and river water) contained low concentrations of water hardness ranging from 3.66mg/l to 33.05mg/L
and calcium and magnesium ranged from 3.15-30.15mg/L and
0.38- 2.90mg/L respectively. The municipal drinking waters
showed hardness; 37.23mg/L to 44.25 mg/L, calcium; and 3.06
mg/L to 4.45mg/L, magnesium. The drinking waters obtained
outside the municipal city limits mainly from boreholes (well ground
waters) showed geographic variations ranging from 43.69mg/L
to 68.06mg/L for hardness of water; and for calcium and magnesium ranging from 37.40 mg/L to 58.05mg/L and 2.00mg/L to
21.77mg/L, respectively. The mortality rate caused by CVD is lower
outside the municipal city limits compared to within the Bainbridge
city limit. The ratio of high calcium and low magnesium appears
to be responsible for an inverse correlation between the calcium
and magnesium concentrations to CBVD mortality rate in Decatur
County. A positive correlation between the levels of magnesium and
CBVD was observed. This study has raised question concerning the
involvement of magnesium levels in drinking water with CBVD and
its supposed beneficial effects against CVD.
Keywords: Calcium, Magnesium, Water Hardness, cardiovascular
diseases, cerebrovascular disease, CVD, CBVD, Decatur County

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INTRODUCTION
Several epidemiological studies (1 - 9) have documented evidence of
the relationship between the levels of magnesium and calcium in drinking
waters and mortality from cardiovascular diseases (10) (CVD). In a Japanese
study (2) using epidemiological analysis, higher mortality rates from cerebrovascular disease (CBVD) were observed in a population areas of Japanese
rivers with softer water compared to those with harder water for drinking
purposes. According to a British study (11) focusing on variation in mortality
from CVD based on the water hardness in 11 British cities between 1950
and 1960, water hardness increased in five cities and decreased in six cities.
It was revealed within the stated period that mortality from CVD in the UK
increased by 10% on average compared to 20% in the cities supplied with
softer water than before and compared to 8.5% only in the cities supplied
with harder water than before.
The protective effect of magnesium and calcium in drinking water against
CVD has been demonstrated in several studies (12 16), and it is an inverse
correlation. According to a study (3), soft water, hard arteries was the summary of its result after demonstrating the correlation between mortality from
cardiovascular disease in males aged 45 64 years and water hardness in 163
largest cities of the USA. Further, an ecologic study in Sweden (17) revealed
a significant inverse correlation between water hardness and mortality from
CVD for both males and females and a significant correlation between the
drinking water magnesium level and mortality from CVD in males. It was
found in all districts where the drinking water magnesium level was higher
than 8 mg/L (but not higher than 15 mg/L) that the CVD mortality rates
were lower. Additionally, another Swedish study (8) which focused on the
effect of the drinking water Mg and Ca levels on mortality from acute myocardial infarction (AMI) in females, found mortality rate is lowered by 34%
in the areas supplied with water containing greater than 70 mg/L calcium
compared to those where the drinking water calcium level was less than 31
mg/L. Also for magnesium, the mortality rate was 30% lower in the areas
where the water Mg content was greater than 9.9 mg/L compared to those
where the water Mg content was less than 3.4 mg/L. Other studies support
these findings (15, 18).
While health effects of most chemicals commonly found in drinking waters
manifest themselves after a long exposure only, the effects of calcium and in
particular those of magnesium on the cardiovascular system are believed to
reflect the current exposure which means that a couple of months are sufficient
for adaptation to a new source of water with low content of magnesium
and/or calcium (16). Adaptation in this context is the time within which the
intake of drinking water of inadequate composition may manifest itself by a
disorder of consumers health. Therefore, it is important to monitor levels
of magnesium and calcium in drinking water in any area in order to be able
to make informed conclusions on correlation with any disorder, particularly
that of CVD. This is even more important since some researcher say that the

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differences in mortality from CVD (or those in the incidence of other diseases)
could be explained by the effect of other cofounders such as physical activity, eating habits, obesity, alcohol consumption, socio-economic conditions
etc and that these confounders may give a false positive idea of the effect
of calcium or magnesium in water. However there is no reason to expect
that there could be any correlation between the lifestyle factors mentioned
and water hardness resulting from the environmental conditions (16). A few
ecologic studies (6, 19 21) have taken the confounders into consideration
in terms of their involvement in CVD morbidity and these studies have
confirmed (16) an inverse correlation between the drinking water Mg level
and the risk to population of developing CVD. In view of lack of complete
studies in this area, no health-based guideline value for water hardness has
been proposed by the world health organization (7). However, the WHO in
its Guidelines for drinking water quality (1990 -1993) admitted some weak
relationship between hardness and health (7).
The Water Quality Control Act defines the waters of the state to include,
in addition to surface waters: any ... springs, wells, and all other bodies of
... subsurface waters, ... lying within ... the state ... (22 24). The State of
Georgia possesses some of the largest and most pure aquifers in the world.
Except where they may become salty at depth, almost all of the aquifers can
be considered as potential sources of drinking water. These aquifers are underutilized for the most part, remarkably free of contamination or pollution, and
recharged from precipitation falling within the state on an annual basis. In
1990 (22- 24), about 24% public water supply comes from ground water,
92% for domestic uses, 59% irrigation water, and slightly more than half of
the water used industrially were from groundwater. In Georgia, groundwater is
the dominant source of water and extremely important to the life, health and
economy of the state. Ground water provides drinking water to about one third
of Georgias population of almost seven million. Most of the ground-water
withdrawals are in the southern part of the State where the aquifers are very
productive. Ambient ground-water quality, as well as the quantity available
for development, is related to the composition and character of the groundwater reservoirs and the nature of the geologic framework through which the
ground-water has moved. The three rock types - igneous, metamorphic and
sedimentary - compose the geologic framework for the ground-water reservoirs in Georgia (22- 24). The Valley and Ridge and the Cumberland Plateau
Provinces in northwestern Georgia are underlain by sinuous bands of layered
sedimentary rocks, including sandstone, shale, limestone, dolomite, and chert,
that have been folded and faulted. The complexity and close proximity of
different lithologic units result in an extremely complicated map pattern of
ground-water quality. Drilled wells in these sedimentary rocks normally range
from 50 feet to 1,300 feet in depth. Wells less than 50 feet deep commonly
obtain water directly from the soil or weathered rocks. The Blue Ridge and
Piedmont Provinces are underlain by metamorphic and igneous rocks which
are overlain by a regolith of weathered rock of variable thickness. While these

104

rocks are poorly permeable, they yield water to wells through fractures or
other geologic discontinuities, which are more abundant in the upper few
hundred feet of rock and at the transition zone between layers of different
rock types. In general, ground water is stored in the regolith and transmitted to wells via the fractures or discontinuities. Recent technologic advances
in siting Piedmont and Blue Ridge wells have led to increased well yields.
Wells sited on the basis of favorable hydrogeology have yields on the order
of 100 gallons per minute, whereas wells sited on the basis of convenience
generally yield about 20 gallons per minute (22 24). The Coastal Plain
Province includes three major subdivisions of water producing sedimentary
rocks. The first consists of limestone and dolomite and underlies the major
portion of the Coastal Plain. The second is primarily limestone and sand and
is limited to the southwestem part of the Coastal Plain. The third consists
mainly of sand and some gravel and is located south of the Fall Line adjacent
to the Piedmont Province. These Coastal Plain sedimentary rock units are
layered and the layers dip gently to the southeast. Regional flow of ground
water generally follows this dip. Single wells can produce water from one
or more of these layered, ground-water reservoirs. Georgias aquifers grade
into one another, leak into one another, vary naturally with respect to quality over short distances and behave differently at different times of the year
or during different cycles of pumping. By far, the bulk of Georgias ground
water, accessible by standard drilling methods, is generally suitable for human
consumption (22 24).
The current study is an ecological investigation on the levels of magnesium, calcium and hardness in drinking waters (surface waters, springs, wells,
and other subsurface waters; in addition to commercially available waters)
of Decatur County Georgia. It is conducted in order to contribute to the
epidemiological and ecological understanding of the relationship between
the levels of magnesium, calcium and hardness in drinking waters and the
mortality due to CVD and CBVD in a rural community of Decatur County,
Georgia, USA. The Georgia Department of Human Resources Division of
Public Health, Office of Health Information & Policy supplied ten year data
on mortality due to CVD and CBVD regionally used for this study.
MATERIALS AND METHODS
Samples Collection
Water samples were collected in sample bottles from different sites
Figure 1 shows the map of Decatur and the water sample numbers. Bottled
waters were purchased from commercial centers and used as supplied. The
Decatur County municipality water is the main source of water for Bainbridge
city and provides drinking water for residential, elementary/high schools, and
college areas. Its water quality has remained unchanged for more than 10
years. Table I gives the details of each location.

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Figure 1: Map of Decatur County Georgia with sample numbers

Table IA: Concentration levels in mg/L of Ca and Mg, hardness of water,
and ratio of Ca to Mg in Decatur County waters
Sample A: Lake and Pond
[Ca+2]
[Mg+2]
Site
(mg/L)
(mg/L)
1
6.72
2.43

Hardness
[Ca+2+Mg+2] (mg/L)
9.15

Ratio of
Ca:Mg
2.76

3.15

0.38

3.66

8.29

7.6

1.74

9.34

4.37

10.83

6.08

Hardness
[Ca+2+Mg+2] (mg/L)
18.6

Ratio of
Ca:Mg
13.99

7
9.3
1.53
Sample B: Flint River
[Ca+2]
[Mg+2]
Site
(mg/L)
(mg/L)
2
17.36
1.24
3

30.15

2.9

33.05

10.39

16.32

1.52

17.84

10.73

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Sample C: Underground/Borehole
[Ca+2]
[Mg+2]
Hardness
Site
(mg/L)
(mg/L)
[Ca+2+Mg+2] (mg/L)
8
55.7
3.18
58.88

Ratio of
Ca:Mg
17.51

41.76

3.18

44.94

13.13

10

37.4

6.29

43.69

5.94

11

40.35

4.15

44.5 0

9.72

12

41.47

21.77

63.24

1.9

13

42.77

3.5

46.27

12.22

14

58.05

60.05

29.02

46

45.11

12.95

68.06

3.48

47
54.5
3.9
58.4
Sample D: Educational Institution
[Ca+2]
[Mg+2]
Hardness
Site
(mg/L)
(mg/L)
[Ca+2+Mg+2] (mg/L)
15
44.25
3.06
47.31

13.97
Ratio of
Ca:Mg
14.46

16

42.3

3.18

45.48

13.3

17

40.07

4.02

44.09

10.2

18

41.26

4.37

45.63

9.44

19

42.3

3.65

45.95

11.58

20

42.08

3.23

45.31

13.02

21

43.43

3.17

46.48

14.24

22

41.51

4.28

45.79

9.69

23

41.97

3.46

44.43

12.13

46.76

10.86

Hardness
[Ca+2+Mg+2] (mg/L)
45.34

Ratio of
Ca:Mg
12.9

24
42.82
3.94
Sample E: Residential Waters
[Ca+2]
[Mg+2]
Site
(mg/L)
(mg/L)
25
42.08
3.26
26

42.13

3.68

45.79

11.45

27

41.49

3.73

45.22

11.27

28

39.2

3.61

42.81

10.85

29

37.23

3.77

41

9.87

30

42.08

3.42

45.5

12.3

31

42.15

3.73

45.88

11.3

 107

32

38.95

4.45

43.4

8.75

33

41.79

3.41

45.2

12.25

34

42.63

3.27

45.9

13.03

35

41.07

4.08

45.15

10.06

Table IB: Sample F: Commercial Water Samples

36

[Ca+2]
(mg/L)
65.3

[Mg+2]
(mg/L)
10.3

Hardness
Ratio of
[Ca+2+Mg+2] (mg/L)
Ca:Mg
75.6
6.34

37

74.3

10.2

84.5

7.28

38

83.31

2.95

86.2

28.24

39

36.3

4.5

40.8

8.06

40

11.5

4.2

15.7

2.73

41

3.62

4.5

8.12

0.8

42

2.92

1.33

4.24

2.19

43

1.62

0.99

2.61

1.63

44

158.08

11.52

169.13

13.72

45

18.59

13.99

32.58

1.33

Site

Reagents
Analytical grade chemicals purchased from Fisher Scientific were used
throughout the study without further purification. To prepare all the reagents
and standard solutions, deionized water was used.
Method
Standard EDTA solution, 0.01 M was prepared fresh from ethylene
diamine tetra-acetic acid disodium salt, Na2C10 H14O8.2H2O, 99.8% purity,
Fisher Scientific. Ammonium Hydroxide buffer solution, pH 10.0 (Fisher
Scientific), 0.01 M Magnesium Chloride (99.4% purity from Fisher Scientific)
were all prepared fresh daily. Standardization of EDTA and the compleximetric
titration procedures employed have been previously described (1). Eriochrome
Black T solution (Fisher Scientific) and Hydroxy Naphthol Blue (Fisher Scientific) were used as indicators when determining total concentrations of [Ca2+
and Mg2+] and concentration of [Ca2+] respectively. All the titrimetric experiments were carried out in triplicate. The analytical results were reproducible
to within 3% error limit.

108

Results
Tables I A & B gives the analytical results for the concentrations of
calcium, magnesium and hardness of water (the sum of the concentrations
of calcium and magnesium) for each sample according to the location site
number shown in Figure 1.
Table II gives the classification of the various water sources in Decatur
County according to previously employed guidelines (21, 25).
Table II: Classification of water samples on the basis of total hardness
Sample
Description
Lake and Pond

1, 5, 6, 7

Hardness
(mg/L)
3.66 10.83

Flint River

2, 3, 4

17.84 33.05 Soft

Underground
and Borehole

9 11, 13
8, 12, 14, 46, 47

43.69 46.27 Soft

58.40 - 68.06 Medium Hard

Educational
Institutions

15 24

44.43 47.31 Soft

Residential

25 35

41.00 45.90 Soft

Commercial

40 43,
45
36 - 39
44

2.61 15.7
32.58
40.80 86.20
169.13

Sample numbers

Hardness
Description
Very Soft

Very Soft
Soft
Medium Hard
Hard

Table III gives the mean, median and range of the calcium and magnesium
contents in relation to the various water sources in Decatur County.
Table III: Mean, median and range of calcium and magnesium content in
Samples A through F

Lake And Pond Water source (n=4)
Ca2+(mg/l)
Mg2+(mg/l)
Mean SD
6.69 1.28
1.52 0.46
Median

6.72

Range
3.15-9.30
Flint River source (n=3)
Ca2+(mg/l)
Mean SD
21.27 2.76

1.53
0.38-2.43
Mg2+(mg/l)
1.55 1.49

Median

17.36

1.24

Range

16.34-30.15

0.51-2.90

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Ground water source (n=9)

Ca2+(mg/l)
Mean SD
41.47 6.90
Median

Mg2+(mg/l)
3.9 3.53

41.76

3.5

Range
37.4-58.05
School Tap water source (n=10)
Ca2+(mg/l)
Mean SD
42.20 7.2
Median

2.00-21.77
Mg2+(mg/l)
3.63 3.54

42.08

3.65

Range
40.07-44.25
Residential Tap Water source (n=11)
Ca2+(mg/l)
Mean SD
40.99 10.31
Median

3.06-4.37
Mg2+(mg/l)
3.67 4.91

41.69

Range
37.23-42.63
Bottle water source (n=10)
Ca2+(mg/l)
Mean SD
45.55 12.98

3.68
3.26-4.45
Mg2+(mg/l)
6.45 9.55

Median

36.3

4.5

Range

1.62-158.08

0.99-13.99

Table IV, obtained from the Georgia Department of Human Resources

Division of Public Health, Office of Health Information & Policy gives the ten
year data on CVD from 1994 to 2003 trend in Decatur County. These data
on CVD include deaths due to arteriosclerosis, coronary artery disease, heart
valve disease, arrhythmia, heart failure, hypertension, orthostatic hypotension,
shock, endocarditis, diseases of the aorta and its branches, disorders of the
peripheral vascular system, and congenital heart disease.

110

Table IV: Cardiovascular disease (cvd) data from 1994 -2003 in Decatur
County

1994

Number of
CVD Deaths
in Decatur
County
106

Mortality Rate due

to CVD in Decatur
County (per 105
population)
398.5

1995

85

316.9

12.6

1996

82

303

12.1

1997

62

226

9.2

1998

48

172.3

7.1

1999

74

263.7

10.9

2000

71

251.4

10.5

2001

53

188.2

7.8

2002

47

166.4

6.9

2003

49

173.7

7.2

Year

Percentage of
CVD Deaths in
Decatur County
15.7

Figure 2 shows that the trend for the number of CVD deaths, and the
mortality rate per tenth of a million populations in a ten-year period in Decatur County decreased slightly until 1998 and then became relatively steady.
However, statistical averaging would appear to indicate that there was no
significant change in the high death rates due to CVD in Decatur County.

Figure 2: Cardiovascular disease (CVD) mortality rate and number of deaths

in Decatur County Georgia

 111

Figure 3 is a graph showing the concentration of major cardiovascular

diseases obtained (Georgia Department of Human Resources Division of
Public Health, Office of Health Information & Policy) by using the census
tract for Decatur County between 1994 and 2003 for all races, ethnicities,
sexes, marital statuses and all levels of severity. The areas are defined as (A),
the lowest; (B), lower; (C), moderate; (D) higher; and (E), highest numbers of
death (and or mortality rate) in Decatur County.

Figure 3: Number of deaths, major cardiovascular diseases by census tract,

Decatur County, all years (1994-2003)
The percentage of deaths (Figure 3) is based on the census tracts recorded
for the period 1994 to 2003 in Decatur County. It appears that a significant
percentage of deaths due to CVD were recorded for the general areas SE,
East and NE of Bainbridge. This pictograph confirms the problem of CVD
in Decatur County particularly in and around the vicinity of Bainbridge city.
Figures 4 and 5 pictorially show the mortality rate and percentage of
deaths due to CBVD in Decatur County respectively. Here, the problem is
more specific because we can definitely confirm high incident of deaths due
to cerebrovascular disease (CBVD) in and around the city of Bainbridge.

112

Figure 4: Mortality rate caused by cerebrovascular disease in Decatur County

between 1994 and 2003.

Figure 5: Percentage of deaths caused by cerebrovascular disease in Decatur

County between 1994 and 2003.

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Analysis
Table II gives the classifications of the hardness and descriptions of the
hardness of all the water sources in Decatur County. Lakes, ponds and river
are surface waters and expectedly the hardness of the water samples (1
through 7) are considered soft (3.66 mg/L 33.05 mg/L). The municipal
water samples (#15-#35), the source for the water of Bainbridge City and
its vicinity were classified as soft (41.00 mg/L 47.31 mg/L) as well. The
hardness of underground water samples collected outside city limits ranged
from 43.69 mg/L to 68.06-mg/L. The borehole water samples closer to the
Bainbridge city environ have soft water while those in other parts of Decatur
County have medium hard water hardness classification. This result appears
to suggest that geographical soil condition may be responsible for the sources
of calcium and magnesium in the drinking water. The hardness of water for
commercially available drinking water samples varied from very soft to hard
(2.61 mg/L to 169.13 mg/L).
The drinking water sources in and around the city of Bainbridge varied
between 41.00 mg/L and 47.31 mg/L and considered soft according to table
II strongly supports the soft water, hard arteries (3) relationship which confirms the general correlation between the high incidence of CVD and CBVD
deaths (Figures 3, 4 & 5) and the soft water content in the Bainbridge city
areas. This observation is in agreement with the literature (3, 7, 8, 12 16,
21). In terms of hardness, we cannot explain the CVD death rates in areas
outside of Bainbridge vicinity. But when we look at the concentrations of
calcium and magnesium in these areas, some correlations can be observed
with respect to source of their drinking water groundwater/borehole. In the
North West of Decatur County (sample 14), the magnesium concentration
(2.00 mg/L) is very low but the calcium (58.05 mg/L) is high. The incidence
of CVD and CBVD deaths are the lowest in this area. In the North East
of Decatur County (samples 8, 9 and 47), the calcium concentrations are
relatively high compared to relatively low magnesium concentrations. The
South East (sample 13) is too close to the Bainbridge city and it revealed
similar patterns with city result. In the South West (samples 12 and 46), the
magnesium concentrations are relatively high and the calcium concentrations are high. These observations appears to suggest that the higher the
calcium concentration the lower the risk of CVD and CBVD deaths in the
areas. This is in agreement with previous conclusions (26). In Table III, the
mean, median and range of calcium and magnesium concentrations in the
water samples from various sources are provided. The lake and pond waters
have mean calcium and magnesium concentrations of 6.69 1.28 mg/L
and 1.52 0.46 mg/L respectively and the lowest sources of drinking water
calcium and magnesium. In Decatur County, the highest source of drinking
water calcium and magnesium was the ground water sources with the mean
concentrations of calcium and magnesium of 41.47 6.90 and 3.9 3.53
mg/L respectively.

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Comparison between CBVD mortality rate and the percentage of death

from 1994 - 2003 and the mean concentration of calcium and magnesium,
as well as the hardness in Decatur County, are given in Table V.
Table V: Regional classification and relationship between CBVD and mean
water hardness
CBVD
Disease
Mortality
Rate Per
100,000

% Of
Deaths
by
CBVD

MEAN
[Ca]
(mg/L)

NW

378.3

4.8

58.05

2.00

60.05

Medium
Hard

NE

601.6

9.6

55.60

3.54

58.64

Medium
Hard

SE

612.9

8.3

42.77

3.50

46.27

Soft*

SW

661.6

6.1

43.29

17.36

65.65

Medium
Hard

CEN

990.3

71.2

41.60

3.60

48.80

Soft

Regional
Location
in Decatur
County

Mean
Mean
Water
[Mg]
Hardness
(mg/L)
(mg/L)

Hardness
Description

Soft* water hardness description here can be misleading because the underground water is similar and very close to Bainbridge Area (Central Decatur
County)
The mortality rate, 990.3 per 100,000 and the percentage of deaths,
71.2% from CBVD recorded for the central region (the Bainbridge area
and vicinity) are the highest and correlates with soft water concentrations
of calcium, 41.60 mg/L and magnesium, 3.60 mg/L. In the northeastern
and northwestern regions of Decatur County the mortality rate from CBVD
respectively are 378.3 per 100000 and 601.60 per 100000, the lowest of all
regions. This observation correlates very well with the higher concentrations
of calcium, 58.05 mg/L (NE) and 55.60 mg /L (NW) (and low magnesium
concentrations). We found unusually high magnesium concentration in the
SW region averaging 17.36 mg/L, but cannot understand its role with the
CBVD in this region. This calls for further research.
Table VI gives the summary of correlation coefficient obtained when the
mortality rates due to CBVD and concentrations of calcium, magnesium and
hardness of waters are plotted in Figures 6A, 6B, 7A, 7B, 8A, and 8B for
the drinking waters of Decatur County by regions.

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Table VI: Correlation between cerebrovascular disease mortality rate in

Decatur County Georgia and concentrations of calcium, magnesium and
water hardness
Decatur County Drinking Water
Correlation
Hardness Of
Coefficient
Water
All Regions
0.2021
Excluding SW
Region

0.4067

Calcium

Magnesium

0.5476

0.0119

0.6069

0.5414

Figure 6: Graph on the left: Correlation between CBVD mortality rate

by region in Decatur County and drinking water calcium concentration
Graph on the right: Correlation between CBVD mortality rate by region
in Decatur County (excluding southwest region) and drinking water calcium
concentration

116

Figure 7: Graph on the left: Correlation between CBVD mortality rate

by region in Decatur County and drinking water magnesium concentration
Graph on the right: Correlation between CBVD mortality rate by region in
Decatur County (excluding southwest region) and drinking water magnesium
concentration

Figure 8: Graph on the left: Correlation between CBVD mortality rate

by region in Decatur County and drinking water hardness
Graph on the right: Correlation between CBVD mortality rate by region
in Decatur County (excluding southwest region) and drinking water hardness

 117

An inverse correlation (0.4067) is observed between water hardness

and the mortality rate from CBVD in all regions except for the southwestern
area. The mortality rate from CBVD is also inversely related to the calcium
concentration (R2 = 0.6069). The magnesium concentration is negatively
correlated (R2 = 0.5414) with the deaths from CBVD.
DISCUSSION
Calcium and magnesium are involved in numerous metabolic functions
and are absolutely essential for the maintenance of a healthy body. Multiple
studies have shown that intestinal absorption of valcium from drinking water
or mineral water is as effective or even more effective as compared with that
from dairy products (27 32). In this study, we used drinking water samples
from Decatur County to evaluate the role of soft and hard water (sum of the
concentrations of calcium and magnesium) on cardiovascular diseases (CVD
and CBVD) mortality. The water hardness of Decatur County varies geographically (table V). The municipalitys water quality has not varied during the last
decade, and is the main source of drinking water for the City of Bainbridge
and its immediate townships (central region, CEN). The CEN drinking water
was determined to be soft water (Table V). This region recorded the highest
number of deaths caused by CVD and CBVD (Figures 3, 4 & 5). The following geographical areas, NW, NE, SE, and SW (Figure 3) have medium hard
drinking water (underground well water sources) and low incidents of CVD
deaths. The variation in mortality from CVD has been shown to be related
to the water hardness (11). The current study supports similar studies (13,
33, 34) that water hardness showed protective effects against CVD and low
mortality due to CVD.
The concentration of calcium was found to be higher in the ground water
of NW (mean 58.05 mg/L) and NE (mean concentration 55.06 mg/L). This
area of the county also recorded low concentrations of magnesium (mean 2.00
mg/L and 3.50 mg/L). It is observed that the incident of CVD and CBVD
are the lowest in the county (Table V). The other regions (CEN, SW, and SE)
have softer water (lower calcium concentrations) and high incidence of CVD
and CBVD. These results show a relationship between cardiovascular diseases
and Calcium. The calcium in the drinking water could be an important source
of calcium than in food (1) in terms of cardiovascular health, and so dietary
calcium may not necessarily be the only main source of calcium intake for the
health of the human body. This means that hard drinking water may provide a
meaningful amount of calcium to life (35). Epidemiological studies have shown
that dietary calcium is inversely associated with blood pressure (36 39).
With much of the epidemiological literature suggesting a relationship between
dietary calcium and blood pressure, it would seem reasonable to accept that
the intake of calcium could reduce the risk of cardiovascular events such as
strokes that are commonly associated with hypertension. The ground water
mean concentration of magnesium, 17.36 mg/L in the Southwestern area
was found to be oddly higher than concentrations of magnesium in other

118

regions of Decatur County (Table V). However, we did not find any extra support and significant association between the high magnesium concentration
and mortality from CVD or CBVD.
A statistically significant link between water hardness, calcium, magnesium and mortality from CBVD is demonstrated in our study (Table VI, Figures
6, 7 & 8) of Decatur County unlike the study (14) of North Dakota drinking
waters where they only found a statistically slightly significant link between
water hardness and geographical differences in mortality from CBVD. Our
study (Table VI and Figure 6) shows the inverse correlation between calcium
concentrations and mortality rate due to CBVD in Decatur County. This correlation revealed that combinations of higher calcium and low magnesium
in all regions excluding the Southwestern area offer more protective effects
against cardiovascular diseases. This observation suggest that the higher the
calcium concentration the lower the risk of CBVD death in the areas (Figure
6B). This is in agreement with previous conclusions (17, 40, 41). Similar
statistically significant correlations (Table VI, Figure 8B) were found for water hardness and CBVD across all regions except the SW areas of Decatur
County. These results on water hardness across Decatur County is in agreement with the Japanese study (2) using epidemiological analysis to show that
there is a higher mortality rate from CBVD (stroke) in area with more acid
(soft) water compared to those with more alkaline (i.e. harder) water when
used for drinking purpose. That is, water hardness showed protective effect
against CVD (33).
In this study, we found that the concentrations of magnesium showed
positive correlation to CBVD mortality rate. This indicates that high magnesium level is considered higher risk for CBVD. These results do not support
the hypothesis that magnesium is the key water factor in relation to mortality
from heart disease (42). Moreover, our studies do not appear to be consistent
with other epidemiological studies that found association between magnesium
in drinking water and heart disease mortality (3, 43 45). These studies were
carried out in Sweden, Finland, USA, Canada and South Africa. However, two
large geographical studies that found no evidence to support this association
were both carried out in UK (41, 46). The ratio of calcium to magnesium is
not clear in this study. The bottle water samples studied show variation in
the hardness and concentration of calcium and magnesium. No correlations
can be made in this regard.
CONCLUSION
This study have shown that individuals living in soft water areas have
correlated incidence with significant higher mortality rates due to CVD and
CBVD; whereas individuals drinking water with high calcium and hardness
water concentrations are more likely to be protected against the incidence
of heart diseases since there is an inverse correlation between them. This
study raises the question about the contribution of magnesium as the key

 119

water factor because it was not possible to conclude any definite causal relationship. Further research is needed in order to understand the relationship
between cardiovascular diseases in this County and other mineral content
of the drinking water, as well as the beneficial and harmful effects of these
minerals in commercially available bottled waters so that we can provide
valuable information on public choices in this regard.
ACKNOWLEDGEMENT
The authors are grateful to the Georgia Department of Human Resources
Division of Public Health, Office of Health Information & Policy for providing
data on CVD and CBVD in Decatur County Georgia. As former Faculty and
staff of Bainbridge College, we express our appreciation for the opportunity
to conduct the research.

REFERENCES
1. Widdowson EM: Minerals in Human Nutrition Br. Med. Bull. 10,
221-222, 1944.
2. Kobayashi J: On geographical relationship between the chemical
nature of river water and death rate from apoplexy. Berichte des
Ohara Instituts fur landwirtschaftliche Biologie Okyama University
11, 12-21, 1957
3. Schroeder HA: Relation between mortality from cardiovascular
disease and treated water supplies, JAMA 172, 1902-1908, 1960.
4. Sharrett AR, Feinleib M: Water constituents and trace elements in
relation to cardiovascular disease, Preventive Med. 4, 20-36, 1975.
5. Hewitt D, Neri LC: Development of the water story: some recent
Canadian studies. In: Calabrese EJ, Moore GS, Tuthill RW, Sieger
TL (eds.), Drinking water and cardiovascular disease. Pathotox Publishers, Park Forest South, 51-63, 1980.
6. Zeighami E.A., Morris M. D., Calle E. E., McSweeny P. S., Schuknecht
B. A: Drinking water inorganics and cardiovascular disease: a casecontrol study among Wisconsin farmers. Chapter XIV In: Calabrese
E. J., Tuthill R. W., Condie L., (Eds). Inorganics in Drinking Water
and Cardiovascular Disease (Advances in Modern Environmental
Toxicology, vol. IX). Princeton, NJ, Princeton Scientific Publishing;
135-158, 1985.
7. WHO: Guidelines for drinking-water quality, Recommendation, World
Health Organization, Geneva, 2nd ed. Vol. 1, 1993.
8. Rubenowitz E, Axelsson G, Rylander R: Magnesium and Calcium in
drinking water and death from acute myocardial infarction in women,
Epidemiology 10, 31-36, 1999.
9. Rubenowitz E, Molin I, Axelsson G, Rylander R: Magnesium in drinking water in relation to morbidity and mortality from acute myocardial
infarction, Epidemiology 11, 416-421, 2000.

120

10. Masironi R, Miesch AT, Crawford MD, Hamilton EI, Geochemical

environments, trace elements, and cardiovascular diseases, Bull.
World Health Organ. 47,139 150, 1972.
11. Crawford MD, Garner MS, Morris JN: Changes in water hardness
and local death rates. Lancet 2, 327 329, 1971.
12. Sauvant MP, Pepin D: Drinking water and cardiovascular disease,
Food Chem. Toxicol. 40, 1311 -1325, 2002.
13. Erb BD: Water hardness and cardiovascular death rates in Tennessee.
Tenn. Med. 90, 314 316, 1997.
14. Dzik AJ: Cerebrovascular disease mortality and water hardness in
North Dakota. S. D. J. Med. 42, 5 7, 1989.
15. Crawford MD, Garner MJ, Sedgwick PA: Infant mortality and hardness of local water supplies. Lancet 1, 988 992, 1972.
16. Kozisek F: Health significance of drinking water calcium and magnesium, National Institute of Public Health, Feb., 2003.
17. Rylander R, Bonevik H, Rubenowitz E: Magnesium and calcium in
drinking water and cardiovascular mortality, Scand. J. Work. Environ.
Health 17, 91 94, 1991.
18. Rylander R: Environmental magnesium deficiency as a cardiovascular
risk factor, J. Cardiovasc. Risk 3, 4 10, 1996.
19. Punsar S, Karvonen MJ: Drinking water quality and sudden death:
observations from West and East Finland. Cardiology 64, 24 34,
1979.
20. Luoma H, Aromaa A, Helminen S, Murtomaa H, Kiviluoto L, Punsar
S, Knekt P: Risk of myocardial infarction in Finnish men in relation
to fluoride, magnesium and calcium concentration in drinking water.
Acta. Med. Scand. 213, 171 176, 1983.
21. Novikov JV, Plitman SI, Levin AI, Noarov JA: Hygienic regulation
for the minimum magnesium level in drinking water (in Russian), Gig.
Sanit. No. 9, 7-11, 1983.
22. Gordon, D.W., 2009, Groundwater conditions and studies in the
Albany area of Dougherty County, Georgia, 2008: U.S. Geological
Survey Open-File Report 20091244, 54 p.; available online at
http://pubs.usgs.gov/of/2009/1244/.
23. Stewart, L.M., Warner, Debbie, and Dawson, B.J., 1999, Hydrogeology, water quality, and potential contamination of the Upper
Floridan aquifer, western Albany area, Georgia: U.S. Geological
Survey Water-Resources Investigations Report 994140, 42 p.;
available online at http://pubs.usgs.gov/wri/wri99-4140/.
24. U.S. Environmental Protection Agency, 2000, Maximum contaminant levels (Part 143, National Secondary Drinking Water Regulations): U.S. Code of Federal Regulations, Title 40, Parts 100 149,
rev. as of July 1, 2000, p. 612614.

 121

25. Silverstein H and Denniston M: In Laboratory Experiments for CHEM

1211L & 1212L 2003 2004 Edition by Hunt/Block/McKelvey
with contributions from the Georgia Perimeter Faculty, Brooks/Cole
Thomas Learning 2003.
26. Sharma K: Calcium to Magnesium Ratio, http://www.enerex.ca/
articles/calcium_to_magnesium_ratio.htm, 2006.
27. Halpern GH, de Walter JV, Delabroise AM, Keen CL, Gershwin
ME: Comparative uptake of calcium from milk and a calcium- rich
mineral water in lactose intolerant adults: Implications for treatment
of osteoporosis. Am. J. Prev. Med. 7, 379-383, 1991.
28. Heaney RP, Dowell MS: Absorbability of the calcium in high calcium
mineral water. Osteoporos. Int. 4, 323-334, 1994.
29. Guillemant J, Le HT: Guillemant S, Delabroise AM, Arnaud MJ:
Acute effects induced by a calcium-rich mineral water on calcium
metabolism and on parathyroid function (letter). Osteoporos. Int. 7,
85 86, 1997.
30. Couzy F, Kastenmayer P, Vigo M, Clough J, Munoz-Box R, Barclay
DV: Calcium bioavailability from calcium-and sulfate-rich mineral
water, compared with milk, in young adult women. Am. J. Clin.
Nutr. 62, 1239-1244, 1995.
31. Van Dokkum W, De La Gueronniere V, Schaafsma G, Bouley C,
Luten J, Lateg C: Bio availability of calcium of fresh cheeses, enteral
food and mineral water. A study with stable calcium isotopes in young
adult women. Br. J. Nutr. 75, 893-903, 1996.
32. Wynckel A, Hanrotel C, Wuillai A, Canard J: Intestinal calcium absorption from mineral water, Electrotel. Metab. 23, 88-92, 1997.
33. Yang CHY, Chiu JF, Chiu HF, Wang TN, Lee CH, Ko YC: Relationship between water hardness and coronary mortality in Taiwan. J.
Toxicol. Environ. Health 49, 1-9, 1996.
34. Nerbrand C, Lars A, Ragnhild AL: per Nyberg and Svardsudd K,
The influence of calcium magnesium in drinking water and diet on
cardiovascular risk factor in individuals living in hard and soft water
areas with differences in cardiovascular mortality, BMC Public Health,
3, 21, 2003.
35. Murray MM, Wilson IC: Lancet ii, 23, 1945.
36. McCarron D, Morris C, Cole C: Dietary calcium in human hypertension. Science, 271, 267-269, 1982.
37. McCarron D, Morris C, Holly J, Stanton J: Blood pressure and
nutrient in take in the United States, Science, 224, 1392 1398,
1984.
38. Stitt FW, Crawford M, Clayton DG, Morres JN: Clinical and bio
chemical indicators of cardiovascular disease among men living in
hard and soft water areas. Lancet 1, 122-126, 1973.
39. Ackley S, Barrett-Connor E, Suarcz L: Dairy products, calcium and
blood pressure. Am. J. Clin. Nutr 38, 457-461, 1983.

122

40. Nerbrand C, Svardsudd K, EK J, Tibblin G: Cardiovascular mortality and morbidity in seven countries in Sweden in relation to water
hardness and geological settings. The project: myocardial infraction
in mid Sweden, Eur. Heart J. 13, 721-727, 1992.
41. Crawford MD, Gardner MJ, Morris JN: Mortality and hardness of
local water supplies. Lancet i, 827-31, 1968.
42. Maheswaran R, Morris S, Falconer S, Grossinho A, Perry I, Wakefield J, Elliott P: Magnesium in drinking water supplies and mortality
from acute myocardial infarction in north west England, Heart 82
(4), 455-460, Oct. 1999.
43. Rubenowitz C, Axelsson G, Rylander R: Magnesium in Drinking Water and Death from Acute Myocardial Infraction, Am. J. Epideminol.
143, 456 62, 1996.
44. Anderson TW, Le Riche, WH: Sudden death from ischaemic heart
disease in Ontario and its correlation with water hardness and other
factors. Can Med Assoc. J, 105, 155-60, 1971.
45. Leary WP, Reyes AJ, Lockett CJ, Arbuckle DD, van der Byl K:
Magnesium and deaths ascribed to ischaemic heart disease in South
Africa. S Afr. Med. J., 64, 775 776, 1983.
46. Shaper A. G., Packham RF, Pocock SJ: The British regional heart
study: cardiovascular mortality and water quality, J. Environ. Pathol.
Toxicol. 4-2, 3, 89 111, 1980.

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