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.
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