title: Is the quality of drinking water a risk factor for self-reported forearm fractures? Cohort of Norway.
abstract: CONCLUSIONS
  Compared to pH ≥7.0 in Norwegian municipal drinking water, pH <7.0 increased the risk of forearm fractures in the population-based Cohort of Norway (CONOR; n = 127,272). The association was attenuated (p > 0.05) after adjustments for indicators of bacteria and organic matter, which may signify an association between poor drinking water and bone health.
  
  
  BACKGROUND
  The Norwegian population has the highest rate of fractures ever reported. A large variation in fracture rate both between and within countries indicates that an environmental factor, such as the quality of drinking water, could be one of the causes of the disparities. Our aim was to investigate a possible association between pH (an important parameter for water quality) and self-reported forearm fracture and to examine whether other water quality factors could account for this association.
  
  
  METHODS
  Using Geographic Information Systems, information on the quality of drinking water was linked to CONOR (n = 127,272; mean age, 50.2 ± 15.8 years), a database comprising ten regional epidemiological health surveys from across the country in the time period 1994-2003.
  
  
  RESULTS
  The highest risk of forearm fracture was found at a pH of around 6.75, with a decreasing risk toward both higher and lower pH values. The increased adjusted odds of forearm fracture in men consuming municipal drinking water with pH <7.0 compared to water with pH ≥7.0 was odds ratio (OR) = 1.19 (95 % CI, 1.14, 1.25), and the corresponding increased odds in women was OR = 1.14 (95 % CI, 1.08, 1.19). This association was attenuated (p > 0.05) after further adjustments for other water quality factors (color grade, intestinal enterococci, and Clostridium perfringens).
  
  
  CONCLUSIONS
  Our findings indicate a higher risk of fracture when consuming water of an acidic pH; however, the risk does not only seem to be due to the acidity level per se, but also to other aspects of water quality associated with pH.
authors.affiliation: Division of Epidemiology, Norwegian Institute of Public Health, P.O. Box 4404, Nydalen, 0403, Oslo, Norway. Cecilie.Dahl@fhi.no
authors.forename: C
authors.initials: C
authors.lastname: Dahl
authors.forename: A J
authors.initials: AJ
authors.lastname: Søgaard
authors.forename: G S
authors.initials: GS
authors.lastname: Tell
authors.forename: T P
authors.initials: TP
authors.lastname: Flaten
authors.forename: T
authors.initials: T
authors.lastname: Krogh
authors.forename: G
authors.initials: G
authors.lastname: Aamodt
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D060766:Drinking Water / Q000009:adverse effects / Q000737:chemistry*; D005260:Female; D005543:Forearm Injuries / Q000453:epidemiology / Q000209:etiology*; D040362:Geographic Information Systems; D006801:Humans; D006863:Hydrogen-Ion Concentration; D008297:Male; D008670:Metals / Q000032:analysis; D008875:Middle Aged; D009664:Norway / Q000453:epidemiology; D058866:Osteoporotic Fractures / Q000453:epidemiology / Q000209:etiology*; D012307:Risk Factors; D057566:Self Report; D014871:Water Microbiology; D014874:Water Pollutants, Chemical / Q000032:analysis; D060753:Water Quality / Q000592:standards; D014881:Water Supply / Q000032:analysis / Q000592:standards*; D055815:Young Adult
chemical_list: D060766:Drinking Water; D008670:Metals; D014874:Water Pollutants, Chemical