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Proactive Approaches to Reduce Environmental Exposures: Avoidance, Lifestyle Changes, and Practical Resources 

Proactive Approaches to Reduce Environmental Exposures: Avoidance, Lifestyle Changes, and Practical Resources
Chapter:
Proactive Approaches to Reduce Environmental Exposures: Avoidance, Lifestyle Changes, and Practical Resources
Author(s):

Aly Cohen

DOI:
10.1093/med/9780190490911.003.0014
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date: 17 January 2018

Key Concepts

  • Increasing numbers of toxic chemicals are found in water sources, food and food packaging, personal care and cleaning products, building materials, and indoor air, and human exposure to electromagnetic radiation has been increasing steadily.

  • Weak chemical legislation has given rise to more than 87,000 commercially available chemicals, and very few have been tested for safety before going to market.

  • Exposure to harmful chemicals during vulnerable periods in human development poses the greatest risk to health.

  • Limited environmental health training has left clinicians ill equipped to handle the overwhelming burden of disease that continues to rise from chemical and radiation exposures.

  • Clinicians often focus on treating symptoms of disease, whereas the focus of this chapter is on approaches to prevent disease.

  • The human body has evolved excellent innate detoxification mechanisms that can be harnessed, maximized, and supported through dietary changes, improved sleep, exercise, stress reduction, sauna use, and appropriate supplements to help eliminate many harmful chemicals.

  • If given the right information and practical tools, both patients and clinicians can make better choices to reduce chemical and radiation exposures, reduce the chemical body burden, and improve health and well-being.

Introduction

Environmental chemicals have far-reaching molecular and physiologic impacts on human health. The shear enormity of toxins that are woven into the fabric of day-to-day human life makes educating patients a daunting task for physicians. Most of the more than 87,000 chemicals commercially available lack third-party safety testing; either testing is currently unavailable or there is unwillingness to finance these important safety studies, particularly for safety in pregnancy and in infants, children, and other vulnerable groups. Indeed, there appears to be no end in sight for industrialization and chemical utilization, and the current revised chemical safety regulations are inadequate in both the United States and the European Union.

Often, medical educators are left to the “precautionary principle” to guide us to common-sense changes to improve health. This principle was delineated in the Wingspread statement: “When an activity raises threats of harm to human health or the environment, precautionary measures should be taken, even if some cause and effect relationships are not fully established scientifically.”36 The key element is the matter of acting in the face of uncertainty, because hazard data are available for only a very small number of chemicals in commerce. As practitioners, we must use the available science and our own medical training to guide patients to mitigate exposure to an array of chemical and radiation risks, through common-sense information and well-vetted available resources. This chapter discusses practical approaches to limiting chemical exposures in the home and workplace and gives guidance to clinicians on how to integrate chemical awareness and educational resources into the daily workflow of patient care. The goal is to prevent disease rather than just treat symptoms.

Diet

Hippocrates stated in 460 bc, “Let food be thy medicine and medicine be thy food.” Yet, modern day physicians still struggle to convey to their patients appropriate concepts of nutrition, caloric intake, and food choice. Add to this discussion information on food additives, preservatives, and synthetic packaging that leaches chemicals into food and beverages, and the challenge to educate patients within a 15-minute visit can be quite frustrating.

Processed foods contribute to body burden of chemicals and to the overwhelming burden of chronic illness in the United States. Ingredients such as sodium, high fructose corn syrup, trans fats, and synthetic food additives and preservatives have been shown to increase risk for obesity, diabetes, hypertension, stroke, and heart and liver disease (collectively referred to as metabolic syndrome), as well as immune system disease in both adults and children.14,68,71,85,92,112,117,133,150,151 Other chemicals in food and food packaging can contribute to endocrine disorders, infertility, neural tube defects, reduced anogenital distance in male offspring (a biomarker of reduced fetal masculinization), decreased sperm count and quality, developmental delay and attention deficit hyperactivity disorder (ADHD), as recognized by the World Health Organization, the Endocrine Society, the American Academy of Pediatrics, and the American Academy of Obstetricians and Gynecologists.5,26,30,37,155

Prevention of health effects from environmental toxins not only involves avoidance of chemicals in various foods but also requires intake of appropriate nutrients that may counteract the harmful effects of some chemicals. When humans are nutrient sufficient, they are also better equipped to handle toxin exposures. Folic acid, a water-soluble B vitamin also known as folate or vitamin B9, is commonly found in green leafy vegetables and has been shown to offset the damaging effects of bisphenol A (BPA) in exposed offspring.38 Omega-3 fatty acids, which are found in fish, eggs, nuts, oils, chia and flax seeds, and leafy greens, have been shown to offset the toxic effects of BPA, lead, mercury, and dioxin in both human and animal studies.3,95,100,118

Appropriate iodine supplementation in pregnancy and nursing can offset the effects of various environmental pollutants such as nitrate, thiocyanate, and perchlorate, which can disrupt normal thyroid function and affect fetal brain development and cognition.121 Quercetin, an antioxidant flavonoid found in apples and onions, has been shown to be protective against polychlorinated biphenyls (PCBs) and methylmercury in animal studies.11,120 Children with sufficient intake of iron, calcium, and vitamin C absorb less lead,74,124,139,159 and studies found that children who were iron deficient were more likely to absorb cadmium, which is associated with adverse health effects.132,140

Cruciferous Vegetables

One group of vegetables that requires special attention is the mustard or Brassicaceae family, which have strong detoxification properties. Included in this family are cabbage, Brussels sprouts, broccoli, Chinese broccoli, kohlrabi, kale, collards, and cauliflower. Among other nutrients such as vitamin C, phytochemicals, carotenoids, calcium, and fiber, brassica vegetables contain large amounts of sulfur-containing compounds called glucosinolates, which may be responsible for their detoxification properties. Sulphoraphane is a naturally occurring isothiocyanate found in cruciferous vegetables; it is an inducer of phase II antioxidant and detoxification enzymes with anticancer properties.9 Through the increase in phase II detoxification, xenobiotic metabolism may affect the elimination or neutralization of carcinogenic and mutagenic factors and consequently inhibit DNA methylation and cancer development. Indole-3-carbinol (I3C), a natural anticancer indolecarbinol from cruciferous vegetables, and DIM (diindolylmethane) have been shown to increase the ratio of the more benign form of estrogen (2-hydroxyestrone) to the more pathologic form (16α‎-hydroxyestrone), reducing the risk of developing hormone responsive cancers, such as breast, prostate, and ovarian cancers.1,19,75

Dietary Recommendations

Basic diet recommendations include eating whole, unprocessed foods; produce in an array of colors (e.g., carrots, beets, green vegetables, yellow squash, blueberries, strawberries); limited sodium, sugar, trans fats, and food additives (e.g., artificial coloring, preservatives, flavoring, emulsifiers/stabilizers); and produce that is organic and/or cleaned to removed pesticide residue.

Additional dietary recommendations include the following.

  • Steam and broil foods rather than frying or grilling. Heterocyclic aromatic amines (HCAs), which are potent mutagens/carcinogens, are formed during the cooking of meat at high temperature. The levels of HCAs produced in cooked meats vary depending on the cooking method, time of cooking, and type of meat being cooked. The application of oregano oil, rosemary oil, black pepper, and several other spices during processing may reduce the formation of these (HCA) mutagenic compounds.50,131 In addition, cooking procedures that release or remove fat from red meat can reduce the total concentrations of these contaminants in the cooked meat.39 With cruciferous vegetables such as broccoli and cauliflower, cooking sous vide (under vacuum) helps retain the most bioactive compounds, compared with steaming and microwaving, although this often comes at the expense of plastic exposure when using a sous vide oven with plastic interior.40

  • Limit intake of canned foods. Diet can be modulated to reduce exposure to food packaging chemicals such as BPA, a high-volume, synthetic compound found in epoxy resins that line the interior of cans and in plastics used in food packaging. Although humans are exposed to BPA through exposure to thermal paper (e.g., currency, receipts), dust, and contaminated air,67 the assumed primary means of exposure is through ingestion,90 primarily due to a lack of information regarding the likely common household products that BPA might be used in (see Chapters 1 and 2). In one crossover study, 75 participants were served canned soup for lunch over a 2-week period, with all other dietary routines maintained. Then, the same 75 participants were served fresh, unpackaged soup for lunch over the following 2-week period. Testing showed a 1000% increase in urinary BPA in participants after the canned food period compared with the fresh, unpackaged soup period.20

  • Food storage options of concern include glazed pottery. According to the Centers for Disease Control and Prevention (CDC), food should not be stored in glazed pottery originating from outside the United States due to potential lead contamination.23 Safer choices for food storage and preparation include glass bakeware and food-grade 18/8 (18% chromium and 8% nickel) stainless steel (stamped on the bottom of container).

  • Choose fresh, unprocessed, organic foods. Choosing to eat foods that are truly organic provides the advantage of reducing intake of pesticide, fungicide, and herbicide residues. In addition, one meta-analysis found that organic crops, on average, have higher concentrations of antioxidants and lower concentrations of cadmium than nonorganic comparators across regions and production seasons.10 If choosing nonorganic produce, check the “Dirty Dozen & Clean Fifteen” list from the Environmental Working Group (EWG) (Table 14.1), which is updated yearly. EWG research has found that people who eat five fruits and vegetables a day from the Dirty DozenTM list, consume an average of 10 pesticides a day. Those who eat from the “Clean Fifteen” (i.e., the 15 least contaminated conventionally grown fruits and vegetables) ingest fewer than 2 pesticides daily.

  • Food preparation. Although rinsing of produce reduces levels of pesticides, it does not eliminate them entirely. White vinegar can be added to clean warm water, using a ratio of 1 part vinegar to 4 parts water. Soak and mildly agitate produce for 5 minutes, then rinse with clean water. Peeling of produce also can reduce pesticide ingestion, but many of the best nutritional assets of the produce will likely be wasted with this approach. In general, it is best to instruct patients to eat a variety of colorful fruits and vegetables, rinse all produce, and buy organic whenever possible (see Table 14.1).

Table 14.1 2016 Shopper’s Guide to Pesticides in ProduceTM

Dirty DozenTM (Highest Pesticide Levels—Buy These Organic)

Clean FifteenTM (Lowest in Pesticides)

  • 1. Strawberries

  • 2. Apples

  • 3. Nectarines

  • 4. Peaches

  • 5. Celery

  • 6. Grapes

  • 7. Cherries

  • 8. Spinach

  • 9. Tomatoes

  • 10. Sweet Bell Peppers

  • 11. Cherry Tomatoes

  • 12. Cucumbers

  • 1. Avocados

  • 2. Sweet Corn

  • 3. Pineapples

  • 4. Cabbage

  • 5. Sweet Peas (frozen)

  • 6. Onions

  • 7. Asparagus

  • 8. Mangoes

  • 9. Papayas

  • 10. Kiwi

  • 11. Eggplant

  • 12. Honeydew Melon

  • 13. Grapefruit

  • 14. Cantaloupe

  • 15. Cauliflower

Dirty Dozen +

  • Hot Peppers

  • Kale/Collard Greens

Copyright © Environmental Working Group, https://www.EWG.org/foodnews/. Reproduced with permission.

Seafood And Freshwater Fish

Almost all seafood contains pollutants in varying amounts, including PCBs (polychlorinated biphenyls), polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), polychlorinated diphenyl ethers (PBDEs), perfluorinated acids, and mercury. Consuming too much seafood can lead to brain and nervous system effects, especially in a growing fetus, because methylmercury seamlessly crosses the human placenta connecting mother and fetus. Other effects from high mercury levels include defects in fine motor coordination, speech, sleep, and gait and neuropathy. PCBs are highly lipophilic and are concentrated in fat. Mercury is concentrated in muscle.

By cutting away fat (primarily in the skin) before cooking fish and by grilling, broiling, or baking fish, as opposed to sautéing or frying, one can reduce exposure to these chemicals. Choosing fish with lower chemical contaminates is another means of lowering exposure. Larger fish bioaccumulate mercury through the ingestion of smaller fish, which are lower on the food chain. Ingestion of large fish such as shark, swordfish, and tuna should be limited. According to research by the U.S. Environmental Protection Agency (EPA) in 2007, canned tuna accounts for 28% of Americans’ exposure to mercury. Based on testing in 2014, Consumer Reports currently disputes the recommendations of the U.S. Food and Drug Administration (FDA) and EPA, which call for pregnant women, breast-feeding mothers, and women trying to become pregnant to consume 8 to 12 ounces of fish per week. They contend that because of its popularity and variable content of mercury, canned tuna should not be consumed at all by pregnant women.27 This is just one example of the dominance of corporate profits (referred to as cost-benefit analysis) over the public health in decision making by regulatory agencies such as the EPA (see Chapter 11).

Many other fish are safer and can be eaten several times per week without increased health risk. Smaller fish from cold water, for instance, tend to have lower amounts of contaminants; these fish include salmon, mackerel, anchovies, sardines, and herring (SMASH). Smaller fish also retain the same health benefits of larger fish in terms of their long-chain omega-3 fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), which have been found to reduce inflammation. Sardines may be an exception to this rule, however, given that new research from Europe shows higher levels of contaminants than previously thought. Sardines are often sourced from shallow waters in close proximity to human activity and effluent waters.17

Another recommendation is to avoid most farm-raised fish, which are extremely high in PCBs because of the feed used in cultivating them; it is often composed of other contaminated seafoods that are concentrated with PCBs because they are rich in lipids. According to testing by the EWG and other independent groups, farmed salmon contains 5 to 10 times the PCB level of wild salmon.45 Freshwater fish may contain contaminants from local manufacturing (e.g., perfluorinated chemicals [PFCs], methylmercury), pesticides, fertilizer, human and animal sewage, and other run-off constituents. Although the EWG considers farmed-raised U.S. haddock and freshwater trout to have low levels of mercury, it is best, considering our constantly changing environments, to have patients contact their state Fish, Game, and Wildlife Department for important fishing advisories before consuming freshwater fish.

To reduce exposure to PCBs, trim the fat (skin) from fish before cooking. Also, choose broiling, baking, or grilling over frying; these cooking methods allow the PCB-laden fat to cook off the fish. When possible, choose wild Alaskan salmon instead of farmed, and eat farmed salmon no more than once a month. Check the resources listed for fish sustainability and safety specific to your patient population.

Web Sites and Smart Phone Apps to Help Choose Healthier Foods

Environmental Working Group smartphone apps: Food Scores, Dirty Dozen, Healthy Living

Monterey Bay Aquarium smartphone app: Seafood Watch

SeafoodWatch.org: The Super Green List

EWG’s Seafood Calculator: http://www.ewg.org/research/ewg-s-consumer-guide-seafood/seafood-calculator

EWG’s Consumer’s Guide to Seafood: http://www.ewg.org/research/ewgs-good-seafood-guide/executive-summary

FDA: Fish: What Pregnant Women and Parents Should Know http://www.fda.gov/downloads/Food/FoodborneIllnessContaminants/Metals/UCM400358.pdf

Water

Water is critical for all human biologic processes, but contaminated water can cause a host of health issues and even irreparable damage. The U.S. Safe Drinking Water Act (SDWA) passed in 1976 was intended to ensure safe drinking water for the public. Under the SDWA, the EPA sets standards for drinking water quality in all of the 160,000 public water systems in the United States. The SDWA does not apply to residential wells, nor does it apply to bottled water, which is overseen by the FDA.

Currently, the SDWA mandates the monitoring and regulation of 91 contaminants in public water, including microorganisms, organic and inorganic contaminants, and several radionucleotides.147 In addition, several disinfectants used to clean ground and surface water for drinking use, as well as their byproducts, are permitted up to standardized levels. Levels designated as “safe” are based on effects in an adult man who drinks 2 L of water daily. Residential well water in the United States requires no water testing for corrosive or toxic chemicals (e.g., lead, mercury, arsenic, other pesticides) until or unless the property is sold, at which time only limited chemical testing is mandated. Many unregulated and regulated chemicals are now being identified in thousands of homes, hospitals, and schools throughout the United States. In 2015, extremely high levels of lead found in the drinking water in Flint, Michigan, sounded the alarm for thousands of municipalities across the country to take a stronger stance on lead identification and remediation. For many, this attention may have come too late. Fetuses, infants, and children are at greatest risk for the irreversible neurologic effects of lead exposure, and contrary to EPA statements, there are no safe levels of lead in the human body.6,146

Other harmful chemicals that are now pervasive in municipality water systems, such as PFCs, can be lowered using carbon filtration but are not listed among the 91 chemicals monitored by U.S. law.13,21,105

It is therefore advisable to recommend to patients that additional water filtration (i.e., pitcher, sink, or refrigerator filters that must be maintained and replaced regularly) may limit the exposure to many low-level toxic chemicals. Patients with residential well water should undergo water testing at least once per year for carcinogenic ground contaminants such as arsenic and for heavy metals from plumbing contamination (e.g., lead, copper, mercury). Only reverse osmotic and ion exchange filters can remove lead from tap water adequately. Most water pitchers use granular-activated carbon and resins to bond with and trap contaminants. These filters are effective at improving the taste of water, and many will also reduce lead, chlorinated chemicals, and other contaminants, depending on the filter quality.

Additional recommendations include the following:

  • Use glass or stainless steel water bottles.

  • Avoid commercial sports bottles, even if labeled “BPA-free”; often BPA is replaced by other harmful plasticizers or epoxy resins such as bisphenol S (BPS) and bisphenol F (BPF).

  • Do not reuse plastic water bottles to avoid bacterial contamination and increased leaching of chemicals as the bottles age.

  • Avoid water from blue carboy water containers often found in office water coolers; they likely contain BPA.

  • Bottled water should be used if elevated levels of harmful chemicals are found in drinking water.

Resources

Private well information and management: http://www.epa.gov/privatewells

Environmental Working Group information on filter options: www.EWG.org

EPA Safe Drinking Water Hotline: https://www.epa.gov/ground-water-and-drinking-water/safe-drinking-water-hotline

Sleep

Encourage Quantity And Quality Of Sleep

The elucidation of sleep and its critical role in the maintenance of health has increased dramatically over the past few decades. Decreased quantity and quality of sleep, whether due to sleep disorders or lack of proper sleep patterns, have been linked to cardiovascular disease risk factors such as hypertension, obesity, diabetes, and dyslipidemia.18,80,97 Research has revealed that sleep plays a vital role in chemical clearance and that the human brain has a system similar to the lymphatic system which helps to clear waste products and toxins from the fluid in and around the brain.156

It is therefore wise to promote quality sleep for patients using the following advice:

  • Create a routine. Encourage patients to maintain a regular sleep-wake schedule, including on weekends, allowing for 7 to 8 hours of time spent in bed for adults, 9 to 10 hours for teens, and at least 10 hours per night for school-aged children (Table 14.2).4,22,24 Exposure to morning light is important for reduction of sleepiness and improved psychomotor performance.109

  • Limit screen time. Eliminate computer, smartphone, and tablet use 60 minutes before sleep time. Dim your computer light, use a blue light filter (smartphone apps: f.lux, Midnight, Night Screen, Twilight), or use orange-tinted glasses 1 to 2 hours before sleep to reduce brain stimulation that can interfere with sleep initiation.

  • Create a comfortable sleep environment. Keep the bedroom cool, between 65° and 70°F; block out all light from windows, under doorways, and from digital clocks, or use an eye mask.

  • Encourage adequate daily exercise. This allows for the body’s natural desire for sleep to occur.

  • Limit use of medicinal sleep aids and stimulants. Reduce prescribing of pharmaceutical sleep medications. Limit alcohol intake, particularly after dinner. Encourage patients to reduce caffeine intake and stop caffeine intake at least 8 to 10 hours before sleep time because of its long half-life.106

  • Reduce stress. Use daily relaxation routines, such as 4-7-8 breathing (4-second inhalation through nose, 7-second hold, 8-second exhalation through the mouth), along with guided meditation (e.g., Relax and Rest, Headspace, and Zen smartphone apps) and journaling.

  • Reduce toxins. Change out bedding made with synthetic materials (e.g., polyester, rayon) for those made with 100% cotton materials; avoid bedding labeled “wrinkle-free” because it is often treated with formaldehyde and other chemicals. Improve bedroom air quality by reducing off-gassing of synthetic furnishings, floors, walls, or carpeting. Add a high-efficiency particulate air (HEPA) filtration system, and encourage the addition of air-purifying houseplants (e.g., spider plants, peace lilies, Areca palm) into the bedroom. Clear all sources of electromagnetic fields (EMF) from the bedroom (e.g., television, stereo, alarm clocks, lamps) because EMF suppresses endogenous melatonin.87,134

  • Supplement use for sleep. Preferably, supplements should be used only on a short-term basis.

  • Melatonin. A dose of 0.3 to 0.5 mg orally or sublingually at bedtime can be used, especially for patients with associated circadian rhythm disorder or jet lag. A time-release formulation is often most effective because the peak concentration with short-acting formulations occurs after only about 4 hours. A very-low-dose, 0.2 mg TR (time release) melatonin formulation has been approved in Europe for those older than 55 years of age. It is advised to take the TR formulation 2 hours before bedtime.

  • Valerian. For adults, a 300 to 900-mg standardized extract of 0.08% valerenic acid can be used, or a tea of 2 to 3 g dried root steeped for 10 to 15 minutes can be taken 30 to 120 minutes before bedtime, for 2 to 4 weeks to assess effectiveness.

  • Hops. Prepare hops in a 5:1 ethanolic extract and take 1 to 2 mL, 30 to 60 minutes before bedtime.

  • Explore medical conditions and test or treat appropriately. Diagnose chronic pain, alcohol and drug use, obstructive sleep apnea, restless leg syndrome, severe anxiety/depression, post-traumatic stress disorder (PTSD), heavy metal toxicity, head injury, or other conditions as contributors to insomnia and treat appropriately.

Table 14.2 Sleep Recommendations by Age Group

Age

Recommended Amount of Sleep (hours/day)

Newborns

16–18

Preschool-aged children

11–12

School-aged children

At least 10

Teens

9–10

Adults (including the elderly)

7–8

From Centers for Disease Control and Prevention. 2016. How much sleep do I need? National Heart, Lung, and Blood Institute sleep guidelines. http://www.cdc.gov/sleep/about_sleep/how_much_sleep.html.

Exercise

Exercise serves many important roles in human physiology, including maintenance of muscle strength and tone, bone development, increased serotonin release, and toxin removal through perspiration and mobilization of lipids (and lipophilic toxic chemicals) from fat. Exercise, in the presence of adequate caloric intake and nutritional status, has also been shown to result in liver hypertrophy and induction of detoxification enzyme systems, increased antioxidant enzymes, and increased glutathione in several organs. Sweating (see next section) has been shown to help eliminate chemicals such as BPA, PCBs, PFCs, and heavy metals.15,41,86,157

Sauna and Sweating

In addition to the health benefits of sauna therapy through stress reduction, lowered blood pressure, and decreased pain levels, sauna or steam bathing has been shown to be an effective method for driving toxins out of the human body.57 The traditional sauna creates surrounding air temperature as high as 160° to 200°F (~70°–90°C) with 25% humidity; in comparison, steam rooms are typically heated to 120° to 130°F at 100% humidity. In response to the heat, blood flow is diverted to the skin to cause cooling while also releasing excess sodium, nitrogen, and toxins. Sweating has been shown to be an effective route of elimination for both metallic toxicants such as mercury and organic toxicants such as hexachlorobenzene.91,129 It has also been shown to augment the liver’s detoxification mechanisms. Studies have shown that subjects exposed to PCBs, solvents, methamphetamines, heavy metals, PFCs (used with waterproof and nonstick products), and flame retardants had clinical improvement after sauna therapy.52,77,81,123,128,130

Although appropriate use of sauna therapy is safe for most people, caution should be used in people who have unstable cardiovascular conditions such as recent myocardial infarction or stroke, recent surgery, multiple sclerosis, acute lung infections, or pregnancy complications.29,57 Lower-temperature infrared sauna, which are typically heated to 120°F, can be a good alternative for people who cannot tolerate conventional sauna or steam room therapy and may offer similar health benefits. Improved clinical results have been seen in patients with rheumatoid arthritis, ankylosing spondylitis, and Sjögren’s syndrome.107,142,149

Personal Care

Reduction of chemical body burden can be done and begins with what we choose to put onto our skin. The results from the 2015 HERMOSA Intervention Study revealed a dramatic reduction in urinary metabolites of specific phthalates, parabens, triclosan, and benzophenone-3 when 100 Latina teens had their personal care products swapped out for safer versions over a 3-day period.58

Human skin acts like a sponge and absorbs the chemicals in personal care products in the same way it might absorb common pharmaceutical drugs purposefully designed to enter the body via the dermal route (e.g., Dramamine, nicotine, and lidocaine patches; nitroglycerin and diclofenac ointments). Choosing safer personal care products requires some knowledge as to what ingredients to avoid, and this can be acquired through the use of technology and available phone apps, such as the EWG’s Healthy Living smartphone app and the EWG website: www.ewg.org/SkinDeep. These sites offer easy-to-navigate safety ratings for almost 80,000 products, along with available ingredient data and related health risks.

Here are a few basic recommendations:

  • Use fewer products overall, especially during pregnancy. Check safety and ingredients in personal care products used, and change out products containing contaminants for safer options.

  • Avoid products with antimicrobial ingredients, such as triclosan (e.g., liquid soap, toothpaste), bactroban, microban, and triclocarban (bar soap), which can result in endocrine disruption and antibiotic resistance.

  • Avoid products with “parfume” or “fragrance,” which may contain 200 or more undisclosed, proprietary chemicals that may pose allergy and cancer risk, but are considered to be trade secrets.

  • Avoid retinyl palmitate or retinol in moisturizing and lip products; they increase the risk of skin cancer.

  • Avoid shampoo and conditioner with fragrance, polyethylene glycol (PEG) and polyethylene, ceteareth, DMDM hydantoin, and parabens (e.g., propylparaben, isopropylparaben, butylparaben, isobutylparaben), which confer cancer and developmental risks.

  • Avoid nail polish containing formaldehyde, formalin, toluene, and dibutyl phthalate (DBP), which pose allergy, developmental, and cancer risks.

  • Avoid personal care products that contain dermal penetration enhancers that increase dermal absorption of toxic chemicals. They break down the protective barrier in the epidermis, which is why they are used in drugs designed for transdermal absorption. Among the most commonly used enhancers are isopropyl myristate, propylene glycol, and various alcohols.76

Cleaning Products

Most household cleaning products contain ingredients that have not been tested for human safety. As with personal care products, fragrance or parfume may contain a cocktail of harmful chemicals. Active ingredients listed on the label typically are added chemicals that kill bacteria, viruses, or mold (e.g., triclosan, bactroban, triclocarban, microban). Substances that release 1-4 dioxane and formaldehyde are caustic chemicals that may infiltrate households and get reapplied daily to household surfaces. The word “organic” or “natural” applied to a cleaning product has no legal value unless the product carries the U.S. Department of Agriculture (USDA) Organic label. Many cleaners contain respiratory irritants, allergy triggers, chemicals that may cause chemical burns with skin contact, and chemicals that are highly toxic if ingested by infants or toddlers. It is therefore advisable to recommend that patients use safe cleaning products with known ingredients that are safe for skin contact and air quality.

Buy Products That Are Safe For Household Cleaning

Avoid products that contain ammonia, chlorine bleach, or nonchlorine bleach substitutes such as oxygen bleach, which are corrosive and irritating to skin. Use the EWG website to understand labels and choose safe products sold on the market at accessible, big box stores http://www.ewg.org/guides/cleaners.

Make Your Own Products

Do-It-Yourself Household Cleaning Products

Ingredients For Homemade Cleaners:

  • Salt can be used as an abrasive and to clean pots and pans.

  • White vinegar takes off soap scum, breaks up grease and mineral deposits, and acts as a deodorizer.

  • Baking soda absorbs odor and is a mild abrasive.

  • Lemon juice cuts grease and mineral build-up.

  • Organic or pure essential oils (e.g., peppermint, lavender) can be used for fragrance.

  • Fragrance-free and color-free liquid soap (not antibacterial soap) may be used.

  • Washing soda or sodium carbonate cuts grease but may scratch waxed, fiberglass, or aluminum floors or pots.

  • Sodium percarbonate (wear gloves to avoid skin irritation) is a bleach alternative that works well to whiten a tub, a sink, or even clothes without bleach.

Warning: Never mix chlorine bleach with vinegar, ammonia cleaners, or other acidic substances because they can release chloramine and chlorine fumes.

Recipe for All-Purpose Spray Cleaner

  • Empty spray bottle

  • 2 cups of very hot water

  • 1 teaspoon of liquid castile soap (not antibacterial or with added fragrance or parfume)

  • 1/2 teaspoon of washing soda

Combine all ingredients in the bottle and shake to dissolve the washing soda.

Recipe for Dishwashing Soap

  • Empty bottle or large jar

  • 2 cups of water

  • 2 tablespoons of liquid castile soap (not antibacterial or with added fragrance or parfume)

  • 1 teaspoon vegetable glycerin

Combine the castile soap and water in the empty container. Add the glycerin, stir, and apply to sponge or add to clean sink with warm water.

Sources for More Household Cleaner Recipes:

The Smart Human: http://thesmarthuman.com/educational-resources/

Healthy Child Healthy World: http://www.healthychild.org/easy-steps/green-spring-cleaning-9-diy-recipes-for-natural-cleaners/

Clean Mama’s household cleaner recipes (printable PDF): http://www.cleanmama.net/wp-content/uploads/2013/04/cleaningrecipepic2.png

Clean Air

Air, an essential for human life, should be clean and free of contaminants, even if an odor is not apparent.56 The fastest route of entry into the human bloodstream, aside from venipuncture, is via inhalation. It should be emphasized to patients that as humans who walk freely in and out of structures and open air space, we do have control over the quality and safety of the air we breathe, especially in our homes and work environments. Important, practical changes to furnishings, air filtration, cleaning products, and air freshening activities can greatly mitigate risk of asthma exacerbation, allergy symptoms, and chronic long-term exposure.

Clinicians can share the following simple recommendations to improve air quality for adults, children, and the growing fetus:

  • Smoking. Tobacco smoke contains 300 or more individual chemicals (e.g., benzene, toluene, BPA, lead, mercury) in each cigarette and filter. The term first-hand smoke describes inhalation by the person who is smoking; second-hand smoke refers to those inhaling smoke from a smoker nearby; and third-hand smoke refers to the residual chemicals that land on furnishings and objects in the environment of a smoker. A recent journal article stated that smoking cessation, along with other lifestyle changes (e.g., weight loss, exercise, reduced alcohol consumption), could prevent roughly half of all cancer deaths in the United States.136 It is therefore advisable to make every effort possible to reduce cigarette smoke and its residue, especially around pregnant women and children. The lifelong health consequences of developmental exposure to chemicals in cigarette smoke include obesity and other metabolic diseases, respiratory diseases, and cancer.62

  • Furnishings. Many furnishings (e.g., drawer fronts, cabinets, shelving), bought whole or assembled, contain wood made with medium-density fiberboard. This fiberboard, also known as pressboard, often contains urea-formaldehyde resins that off-gas into small spaces such as bedrooms and home offices as formaldehyde, which the National Cancer Institute has identified as a known carcinogen. Without appropriate ventilation, indoor air concentrations can reach extremely high levels, resulting in symptoms of headache, nausea, rash, and confusion. Other sources of formaldehyde include permanent-press or dry-cleaned clothing, draperies, wrinkle-free linens, glues and adhesives, and some cleaning and personal care products. Instruct patients to avoid furniture made of pressboard. If formaldehyde-treated furniture is purchased, it should be aired out for several days before use, in a well-ventilated garage or basement. Alternatively, one can use exterior-grade pressed wood products, which contain lower concentrations of phenol-formaldehyde resins. In addition, polyvinyl chloride (PVC) flooring and wall coverings containing phthalates, which act as allergens, are implicated in respiratory symptoms, asthma, and allergies.

  • Personal care products. Avoid hair-straightening treatments (e.g., Brazilian, keratin) with constituents containing formaldehyde or breakdown products such as quaternium 15, bronopol (or 2-bromo-2-nitropane-1,3-diol) diazolidinyl urea, DMDM hydantoin, imidazoliidinyl urea, and sodium hydroxymethlglycinate. These products are banned in Canada and the European Union.

  • Cleaning products. Avoid use of carpet powders, cleaning products with bleach or other lung irritants, and products containing fragrance or parfume. Limonene and other citrus fragrances are often added to cleaning products and should be avoided because of their ability to form formaldehyde when interacting with ozone in air.

  • Candles and air fresheners. Avoid synthetic candles made with substances such as limonene, which is used to make citrus fragrance. When burned, limonene reacts with ozone in household air to create formaldehyde. Recommend that patients avoid or use fewer scented candles and choose organic candles made with 100% beeswax. Soy candles, although better than typical candles made with petroleum and byproducts, may be adulterated with synthetic fragrance and should also be avoided unless more information about their composition is available.

  • Air pollution. Discuss with patients and children about increased air pollution exposure from automobile exhaust, and brainstorm ways to limit exposure to idling buses and cars, especially before and after school is in session. Check daily air quality websites and apps to safely manage time spent outdoors.

Resources

EPA website: https://airnow.gov/ allows you to check air quality index forecast and alerts by zip code

EPA smartphone app: Air Now

American Lung Association smartphone app: State of Air

Stress

Although many clinicians might not consider stress to be an environmental “toxin,” it plays a major role in the normal functioning of human cellular processes, hormonal feedback, and mechanisms of detoxification.127 Chronic stress releases cortisol and has been shown to kill memory cells in the hippocampus, reduce immune system function, and even contribute to the development of dementia.138 Crowe and colleagues showed that greater reactivity to stress predicted a higher risk of dementia in individuals who reported a high incidence of work-related stress, primarily based on how the individual reacted to that stress, not on the work-related stress itself.8,31 Increased stress can often interfere with food choice and quantity, energy levels, sleep patterns, and social interaction. There is also extensive evidence that stress during pregnancy can have life-long consequences for disease in offspring.44,59

Many modalities exist to help to alleviate stress and should be discussed with patients. These include

  • Breathing exercises

  • Yoga, Tai Chi, and Reiki

  • Mindfulness meditation

  • Physical activity and exercise

  • Expressive activities such as dance, arts and crafts

  • Journaling

  • Connecting with friends, community and spiritual support

  • Connecting with nature and pets/animals

  • Seeking guidance through cognitive therapy

  • Acupuncture, energy medicine

  • Reduction in technology use, noise reduction

  • Aromatherapy

Dietary Supplements

Human health and well-being depend on a diet that not only excludes foods and additives that are generally harmful to human health, but includes foods that are nutrient dense and nourishing for effective biologic activities. Besides adequate amounts of protein, complex carbohydrates, and healthy fats, many vitamins and minerals are integral to human health for genomic maintenance and stability. Niacin, folate, magnesium, vitamin B12, and vitamin B6 are all necessary for effective DNA repair. Niacin is necessary to maintain telomere length; zinc, copper, and manganese for superoxide dismutase maintenance; zinc for proper function of the protective TP53, important for cell cycle regulation; and calcium for regulation of chromosome segregation during mitosis. Methionine metabolism requires selenium, and deficiency can lead to telomere shortening. Antioxidants such as vitamin C and vitamin E prevent DNA damage and lipid peroxidation.48

Can too much of a good thing be bad for you? Yes, in fact this is true in the case of many vitamins, minerals, other dietary supplements and hormones. Examples include adverse effects associated with both hypervitaminosis A and hypovitaminosis A, as well as hyperthyroidism and hypothyroidism. Many micronutrients demonstrate U-shaped toxicity curves, meaning that either very low or very high levels can cause harmful health effects. Copper and iron, for instance, have to be maintained at appropriate levels; excess concentrations, beyond the capacity of available protein binding sites, can result in hydroxyl radical generation that may damage lipid membranes and DNA. Glutamine, an amino acid often used to promote a “healthy gut,” has been found to cause several health issues when taken chronically.65 Surveys indicate that about 20% of Americans use at least one herbal supplement, and at least 25% of herbal supplement users take one or more prescription drugs, raising the potential for herb-drug interactions.12,43 Patients with chronic illnesses use more medications and herbal supplements than the general population, further increasing the risk for interactions.98,153 A number of herbal preparations from the Indian subcontinent and China have been found to be adulterated or contaminated with molds, fungi, insects, pesticides, and heavy metals, often due to poor sourcing and manufacturing. This dangerous possibility should be discussed with patients and their parents.113

It is prudent to be well informed about all substances patients are consuming in order to manage their health. Many herbal and nutritional supplements have been found to bind and/or increase elimination of various toxic substances from the human body. The following sections discuss a few of the supplements that are widely used for this purpose.

Resources

To learn more about herb-drug interactions:

Herb, Nutrient, and Drug Interactions: Clinical Implications and Therapeutic Strategies, by Mitchell Bebel Stargrove, Jonathan Treasure, and Dwight L. McKee (Mosby, 2007)

Memorial Sloan Kettering Cancer Center: About Herbs, Botanicals & Other Products https://www.mskcc.org/cancer-care/treatments/symptom-management/integrative-medicine/herbs

Mayo Clinic: Drugs and Supplements http://www.mayoclinic.org/drugs-supplements

National Institutes of Health, National Center for Complementary and Integrative Health: Herbs at a Glance https://nccih.nih.gov/health/herbsataglance.htm

Cleveland Clinic: Herbal Supplements: Helpful or Harmful http://my.clevelandclinic.org/services/heart/prevention/emotional-health/holistic-therapies/herbal-supplements

Natural Medicines Comprehensive Database: http://naturaldatabase.therapeuticresearch.com/home.aspx?cs=&s=ND

Milk Thistle

Milk thistle (Silybum marinum) is an herb that has historically been used to treat liver and biliary disorders. It was famously found to counteract the poisonous effects of amatoxin from the Amanita mushroom, which is found in many parts of the world.152 Silymarin, a compound in milk thistle, is a flavonoid. Like several other flavonoids (e.g., quercetin, genistein, green tea polyphenols137), it works by modulating the cytochrome P450 (CYP450) system in the liver via phase II detoxifying enzyme activation; an increase in these enzymes (e.g., such as UDP-glucuronyl transferase, glutathione-S-transferase, quinone reductase) results in detoxification of many xenobiotics and carcinogens.

Studies have shown positive effects of milk thistle on acute poisonings including organic solvents141, chronic hepatitis B and C infection, and alcoholic liver disease.116 An increasing number of clinical trials and animal studies show application in oncology, not only in reducing the long-term hepatic and cardiovascular effects of cancer treatment but also as a chemopreventive agent and possibly for direct cancer treatment.54 Although flavonoids have been recognized to exert antibacterial, antiviral, anti-inflammatory, antiangiogenic, analgesic, anti-allergenic, hepatoprotective, estrogenic, and anti-estrogenic properties, not all flavonoids and their actions are beneficial. The German Commission E currently recommends the use of milk thistle for dyspeptic complaints, toxin-induced liver damage, and hepatic cirrhosis and as a supportive therapy for chronic inflammatory liver conditions.79

Although it is generally well tolerated, with rare reports of a mild laxative effect, additional clinical research is needed before its daily use can be recommended in primary prevention of environmental chemical exposures.64 Safe dosing for daily liver function health is 250 mg once or twice daily (of an extract standardized to provide 80% silymarin).

Glutathione And N-Acetyl-Cysteine

Glutathione (GSH) is a ubiquitous intracellular thiol present in all human tissues. Besides maintaining cellular integrity, GSH has multiple functions including detoxification of xenobiotics and synthesis of proteins, nucleic acids, and leukotrienes. GSH is also involved in regulating the expression of proto-oncogenes and apoptosis, and it is thought that the development of diseases such as cancer and human immune deficiency may be affected by varying levels of cellular GSH. Its depletion in the lung has been associated with the increased risk of lung damage and disease.

Researchers have looked at the therapeutic effects of N-acetyl-cysteine (NAC) on the lung damage in smokers and in mice models of acute liver injury from acetaminophen.33,99 Exogenous delivery of GSH or its intracellular precursor NAC may have benefit as a chemotherapeutic approach.115 In addition to stimulating glutathione synthesis, NAC enhances glutathione-S-transferase activity and promotes liver detoxification by inhibiting xenobiotic biotransformation.73

Use of NAC varies based on indication. Safe, daily use of NAC in healthy individuals for routine chemical exposure ranges from 100 to 400 mg. Food sources of cysteine include whey protein, as long as the product is not hydrolyzed or blended, which can denature its structure.

Prebiotics And Probiotics

Humans have been living symbiotically with bacteria for millennia. Human intestines harbor the largest collection of microbes, consisting of between 10 trillion and 100 trillion organisms. Until recently, medicine has largely ignored this intricate microscopic world, which is an integral part of our genetic landscape and of our genetic evolution.

New research has shown the value of probiotic supplementation for reversal and prevention of a whole host of human illnesses, including type 1 diabetes, ADHD, Clostridium difficile infection, and obesity. During antibiotic therapy, probiotic use, together with the addition of prebiotic and probiotic foods (Table 14.3), may counterbalance the indiscriminate depletion of various beneficial bacteria, which can take up to a year to repopulate.

Table 14.3 Prebiotic and Probiotic Foods

Prebiotic Foods

Probiotic Foods

  • Onions

  • Jerusalem artichokes

  • Garlic

  • Leeks

  • Bananas

  • Jicama

  • Chicory root

  • Burdock root

  • Asparagus

  • Dandelion greens

  • Peas

  • Eggplant

  • Chinese chives

  • Soybeans

  • Sugar maple

  • Yogurt, cottage cheese, kefir

  • Green tea

  • Garlic

  • Breast milk

  • Sauerkraut

  • Yogurt

  • Kimchi

  • Kombucha tea

  • Kefir

  • Soft cheese

  • Pickles

  • Microalgae

  • Poi

  • Miso soup

  • Tempeh

  • Natto

  • Breast milk

Probiotics have been studied as potential detoxification tools for many substances, including heavy metals, BPA, and PCBs.70 The most commonly studied probiotics include Lactobacillus rhamnosus GG, Lactobacillus reuteri, Saccharomyces boulardii, and various strains of Bifidobacterium; they are commonly used for generalized bowel health and for treatment of irritable bowel syndrome and diarrhea, and are readily available in most pharmacies.

Children and Chemicals

Infants and children spend time at home, in school and daycare centers, in cars and school buses, as well as in recreational and occupational environments (e.g., synthetic turf, swimming pools). Given their vulnerable periods of growth and development, practitioners should advise parents to avoid exposure of their children to chemicals when at all possible. Playing in and around grass and farmland sprayed with pesticides and herbicides should be avoided; if dermal exposure occurs, immediate removal with soap and water should be undertaken.119 This also applies to the use of pesticides and other toxic chemicals on carpets and elsewhere in the house. Encourage parents to explore the cleaning products used in their children’s daycare centers, air quality and air freshener use in school buildings, and pesticide use in playground areas and schoolyards.

Patient Information for Choosing Safer Products

Environmental Working Group website: www.EWG.org

Smartphone apps: Healthy Living, Think Dirty, GoodGuide

Fertility and Pregnancy

Fertility is multifaceted, but environmental chemical exposures should be explored if one experiences the inability to become pregnant despite frequent, carefully timed, unprotected sex for 1 year. Both men and women should be counseled on avoiding chemical exposures before trying to become pregnant. Sperm and eggs take months to develop and their quality and quantity may be affected by various chemicals, medications, and radiation effects, such as those from cell phone use.2,34,53,88,114,158,160 Chemical exposure of the growing fetus during pregnancy is of particular concern because of the vulnerability of the fetus and the bioavailability of many toxins, which can affect both short- and long-term health outcomes.28,30,35,63 Cord blood and epidemiologic studies have shown that children are routinely exposed to chemicals via vertical transmission, making it prudent to share with patients not only risks but healthful, preventive measures to reduce xenobiotic exposures.21,46,51,125,154 Pregnant mothers with specific occupational exposures (e.g., solvents, ethers, cleaning products, radiation) should be counseled appropriately.82 The following sections describe some specific recommendations.

Personal Care Products

Coach patients on reducing their use of personal care products such as makeup, antiperspirants, creams, lotions, hair dyes, and nail treatments. Help them choose better products using the Healthy Living smartphone app from EWG.

Clean Food And Water

Ask patients about their water source (e.g., tap water, well water, bottled water) and discuss water filtration options or send them to the EWG’s water filter guide (see earlier “Water” section). Encourage pregnant patients to eat clean, unprocessed foods; to eat organic produce and dairy products whenever possible; and to wash nonorganic produce well with safe cleaners and/or vinegar.

Seafood Consumption

In 2014, the FDA and EPA recommended that pregnant and breast-feeding women and women trying to become pregnant should consume between 8 and 12 ounces of fish per week. However, based on intensive testing, Consumer Reports disputed this recommendation and does not recommend consumption of any fish by pregnant women, particularly canned or fresh tuna. It seems prudent to discuss fish consumption with all pregnant patients and those trying to become pregnant and to share important resources for healthier fish options.

Resources

Monterey Bay Aquarium: Seafood Watch smartphone app and website www.MontereyBayAquarium.org/search?term=seafood+watch

EWG’s Consumer Guide to Seafood and Calculator www.EWG.org/seafood

Consumer Reports: Choose the Right Fish to Lower Mercury Risk Exposure (August, 2014)

FDA: Fish: What Pregnant Women and Parents Should Know http://www.fda.gov/downloads/Food/FoodborneIllnessContaminants/Metals/UCM400358.pdf

Clean Air

Encourage patients to stop smoking and to avoid second- and third-hand smoke (see earlier section “Clean Air”). Encourage pregnant patients to remove synthetic air fresheners, candles, cleaning products, carpet sprays and powders, fresh dry cleaning, and other sources of airborne chemicals from their home and workplace. Look up cleaning products and make better product choices using EWG’s Guide to Healthy Cleaning (EWG.org/guides/cleaners).

Toys

Avoid imported toys, costume jewelry, and toys found in discount stores because they are subject to fewer regulations and less oversight for heavy metals such as lead, plasticizers (e.g., phthalates, BPA), and other harmful chemicals. Avoid older, hand-me-down toys manufactured before regulations were instituted for several phthalates (2008)144 and for lead content in toys (1978).145

Mobile Phones And Tablets

Unfortunately, safety standards for mobile phone use have not been updated in over 19 years, since they were first designed. Tablet testing, used to create standards, was based on use by a 220-pound man sitting 8 inches from the device. Therefore, it makes reasonable sense to tell pregnant women, as well as both men and women looking to conceive, to keep mobile phones a safe distance from the fetus and to avoid carrying cell phones in bras and in pants pockets (see the later section on “Radiofrequency Radiation”).

Tools for the Clinician

It is generally believed that the role of the physician is to guide patients toward health and well-being. Limited training on environmental health topics is one reason why many physicians do not share this information with patients; lack of time is another, as physician-patient contact has dramatically decreased over the past several decades. A follow-up visit with a physician today may likely consist of questions on chronic disease management, a brief physical examination, and discussion of pharmaceutical management and safety, all in 15 minutes of allotted time. Topics on prevention, dietary intervention, exercise, environmental health, and other recommendations compete for mention during this short window of time. Now more than ever, physician understanding and willingness to convey to patients the crucial associations between chemicals and disease is of paramount importance.

Humans spend varying amounts time in a plethora of environments that may pose health risks. We spend on average 12 hours per day in our homes and hundreds of hours of our lifetime in automobiles. Children spend more than half of their lives in school and recreational environments, and they may engage in sports, crafting, and other hobbies. The most efficient way to help patients make changes to mitigate exposures is to first obtain a strong environmental history (i.e., home, work, school, hobby, and recreational exposures).25,96,103,104,122 It is especially important to ask parents of small children about occupational exposures to harmful chemicals; often these chemicals can be brought into the home via shoes and clothing. Removing contaminated clothing and shoes outside the home and washing work clothing separately can dramatically reduce cross-contamination.

Resources for Taking an Environmental History:

National Environmental Education Foundation: www.neefusa.org/resource/pediatric-environmental-history

Centers for Disease Control and Prevention: www.cdc.gov/workplacehealth promotion/

Clinicians can also check environmental factors and sources of pollution that effect their patients by zip code using a tool set up by the EPA: EnviroMapper for Envirofacts http://www.epa.gov/emefdata/em4ef.home

Or check local air quality conditions by state or zip code: http://www.airnow.gov

Asthma home environment assessment checklist (English and Spanish): NEEF Asthma Environmental History Form http://www.neefusa.org/resource/asthma-environmental-history-form

Hazardous Chemicals in Healthcare Settings

Healthcare settings are a major source of chemical exposure for both healthcare workers and the patients whom they serve. Use of plastics in medical equipment has revolutionized lifesaving procedures, in large part because of the transparency, flexibility, and versatility of expandable plastic materials. However, along with these benefits comes the added chemical exposure from untested plastic ingredients and those already known to be unsafe. According to the FDA, medical devices that may contain BPA and diethylhexyl phthalate (DEHP)-plasticized PVC include intravenous bags and tubing, catheters, enteral nutrition bags, and respiratory, bypass, and dialysis equipment. For example, blood bags can consist of 70% DEHP. BPA and DEHP readily leach into blood, air, and other fluids with which they are in contact.

Healthcare workers are exposed to harmful chemicals daily, including mercury via blood pressure gauges, thermometers, thermostats, fluorescent lights, and dental amalgams; BPA and phthalates via intravenous bags and tubing, esophageal bougies, Foley catheters, and respiratory tubing; BPA in dental sealants, dental composites, and thermal paper; flame retardant chemicals in hospital and office furniture, bedding, and electronics; PFCs in stain-resistant carpeting and furniture; vinyl in examination gloves; and triclosan and other antimicrobials in hand and equipment sterilizers.

Exposure to chemicals in healthcare settings may be disproportionate. Nurses are at increased risk for chemical and pharmaceutical exposures.110 For the littlest patients, the neonatal intensive care unit (NICU) is among the most plastic laden of all medical environments. Being in a NICU results in dramatically elevated urine levels of various plasticizers including DEHP and BPA in neonates.16,49,108,126

In premature infants, the body burden of plastic chemicals increases exponentially with every needed medical procedure. Underdeveloped organs and reduced phase II glucuronidation pathways greatly limit their detoxification capabilities and increase circulating exposure to plasticizers and other plastic components. In one study, urinary BPA concentrations were highly correlated with DEHP concentrations, suggesting that PVC medical equipment was a significant source of exposure for these two endocrine disrupting plasticizers. Infants with high-intensity exposure to DEHP-containing medical products had an almost nine-fold increased body burden compared to those with low-intensity exposure.16 In another study, a nursing research team at Simmons College in Boston studied 55 infants, most born prematurely, who spent at least 3 days in a NICU. The urine of newborns who had received treatment with four or more NICU devices contained 36.6 ng/L of BPA on average, a level that was almost three-fold higher than that of the babies treated with three or fewer devices. Roughly one fifth of the babies had been treated with at least four medical devices, but respiratory devices, not intravenous tubing, proved to have the strongest link with elevated BPA levels.42

There is something that practitioners can do to mitigate human exposure to dangerous plastic materials in medical devices: change them out for devices containing safer materials that currently exist.60,61 In 2003, Glanzing Clinic in Vienna, Austria, became the first PVC-free pediatric unit worldwide, and since that time, many European NICUs have followed. In 2013, France passed laws banning the use of tubes containing di-(2-ethylhexyl) phthalate (i.e., DEHP) in pediatric, neonatology, and maternity wards in all of their hospitals. Other phthalates considered for removal included dibutyl phthalate (DBP) and butyl benzyl phthalate (BBP). Unfortunately, another phthalate, diisononyl (DINP), which shows evidence of similar toxicity to DEHP, is beginning to replace DEHP in many PVC products; the cycle of replacing one bad chemical with another bad chemical has a long history in the United States and elsewhere.

Some large and small hospital systems in the United States have successfully reduced their use of DEHP-plasticized medical equipment, including Kaiser Permanente in California and Hawaii, Miller Children’s Hospital in California, Lucille Packard NICU in California, Evergreen Hospital NICU in Washington State, and John Muir Medical Center in California.

Hospitals can also limit exposure of harmful chemicals for employees and staff by making simple changes. Hand sanitizers, for instance, often contain the antibacterial, endocrine-disrupting chemical triclosan, and can easily be switched out for safer products containing ethanol and ethyl alcohol. Hand sanitizers contain dermal penetration-enhancing chemicals and touching thermal paper after use of a hand sanitizer will result in very high absorption of BPA from the paper.67 Vinyl (PVC) examination gloves can be exchanged for unpowdered, nitrile gloves.

For ways in which you can facilitate change in your hospital or healthcare center, contact Health Care Without Harm (https://noharm-uscanada.org/issues/us-canada/alternatives-pvc-and-dehp).

Testing for Toxins

The desire to connect symptoms to a causative agent can be very appealing for both clinicians and patients. However, special care must be taken when testing for toxins because of the vast array of environmental agents with varying physiologic effects, testing expense, variable quality of tests, questionable validity, and unknown clinical significance that may create more questions than answers. Humans can be exposed to dozens, if not hundreds, of industrial chemicals every day, making the timing of testing an additional confounder depending on the persistence of the parent compound or known metabolites. Experimental testing for toxins remains largely unfunded with few exceptions. Only a few hundred chemicals have been tested by the CDC as part of the ongoing National Health and Nutrition Examination Survey (NHANES), at considerable expense; laboratories with this expertise are not available to clinicians or the general public.

Given that screening for chemicals is costly and not routinely available, it is advisable for clinicians to obtain a full environmental health history to ascertain the potential for specific environmental chemicals (e.g., heavy metals, solvents, plasticizers) as a cause for patient’s symptoms. Choosing laboratory tests for patients in a thoughtful, methodical manner will better direct resources toward the most appropriate medical recommendations and management.

Detox Protocols

There is a growing body of evidence that reducing exposure and actively eliminating various chemicals from the body can reduce clinical symptoms of disease. Detoxification programs range from juicing, cleanses, and fasts to binding protocols such as chelation therapy, activated charcoal, and bentonite clay ingestion. Given their variable protocols, often unsupervised use, and relative risks, clinicians should discuss these modalities in detail with their patients who employ them.

Cleanses And Fasting

Weight loss and even intermittent fasting has many benefits for overall health and longevity. One mechanism that is promoted by intermittent energetic challenges is improved cellular bioenergetics, repair or removal of molecules damaged by oxidative stress, and reduced inflammation.89,93,94,148 However, because adipose tissue provides storage of toxic lipophilic chemicals, weight loss is associated with increased serum levels as these chemicals are released. In one study, researchers measured levels of chlorinated pesticides in adults undergoing either a calorie-restricted diet or stomach-stapling surgery; they found that the greater the weight loss, the greater the increase in serum pesticide levels.69 Numerous studies have documented an obesity paradox in which the overweight and obese elderly have a better prognosis than those with ideal body weight. Good prognosis among these elderly persons may reflect the relative safety of storing the harmful lipophilic chemicals, known as persistent organic pollutants (POPs), in adipose tissue rather than in other critical organs. Weight loss in obese elderly patients with higher serum concentrations of POPs may carry some risk.66 CYP450 enzymes are reliant on adequate precursors as substrate for phase 2 liver detoxification.55 Complete fasting, juice fasts, and marginally nutrient fasting regimens may result in reduced precursors, leading to highly toxic bioactive intermediates and free radicals, with resulting decrease in phase 2 detoxification activity. Therefore, it is not recommended that patients, particularly those who are chronically ill, follow these types of detoxification methods, especially for prolonged periods.111

Chelation Therapy

In chelation therapy, a chelator such as ethylenediaminetetraacetic acid (EDTA) or dimercaptosuccinic acid (DMSA) is used to bind with a metal (e.g., mercury, lead, iron) and eliminate it from the body. Heavy metals, similar to many lipophilic environmental chemicals, reside in fat tissue but can be released with rapid weight loss or with chelation therapy. Use of this therapy by medical practitioners for patients with acute, high-dose metal poisoning has proved invaluable, but for the treatment of chronic health disorders (e.g., complications from atherosclerosis), its use has been controversial.

Lead, arsenic, mercury, and cadmium rank among the top 10 substances on the Agency for Toxic Substances and Disease Registry (ATSDR) Priority List of Hazardous Substances.143 Exposure to metals comes from many sources. Lead is found in residential paint (before 1978), adulterated herbal medicines, gasoline (before the mid-1980s), outdated plumbing, and cigarette smoke; arsenic is found in well water, rice (both organic and conventional), and apple juice; mercury is found in many fish; and cadmium can be found in toys, jewelry, and products from overseas, as well as rechargeable batteries.

Given the pervasiveness of metals in our environment and the known relationships between heavy metal exposure and hypertension, dyslipidemia, atherosclerosis, cardiovascular disease, and kidney disease, interest in chelation therapy has gained traction. Results from the large, double-blinded, placebo-controlled Trial to Assess Chelation Therapy (TACT) study showed that patients who were stable after myocardial infarction (MI) and were taking established evidence-based medical therapy (i.e., statins and aspirin) had a statistically significant reduction in cardiovascular events when treated with a combination of high-dose vitamins and chelation therapy.84 Even more striking was the finding that post-MI diabetic patients age 50 years or older demonstrated a marked reduction in cardiovascular events with EDTA chelation. There was a 41% reduction in clinical events, including a 43% reduction in deaths over 5 years. The researchers stated that further studies are still needed before routine use of chelation therapy is initiated for all post-MI diabetic patients.47 Newer studies using TACT data have argued that xenobiotic metal contamination is a modifiable risk factor for atherosclerotic disease and that “prudent public health measures should be taken to fully assess, then minimize the public’s exposure to xenobiotic metals.”135 According to some cardiologists, post-MI diabetic patients seeking chelation therapy should not be discouraged from doing so, and high-risk patients in hospitals that offer chelation as a therapeutic choice can be encouraged to undergo therapy.83 The National Center for Complementary and Integrative Health (NCCIH), run by the NIH, suggests that patients choose an appropriate practitioner if they decide to partake in chelation therapy.102

Chelation therapy is not a benign process, however. Side effects include dehydration, hypocalcemia, kidney damage, elevated transaminases, allergic reactions, lowered levels of dietary elements, and even death.7 Chelation has been studied in small pilot trials for cancer treatment, but no definitive or suggestive data are yet available that would form the basis of treatment for cancer. Chelation therapy has been used to treat autism and behavioral disorders with limited results. As of 2008, 7% of children with autism had undergone chelation therapy32; however, a 2015 review and a determination by the NCCIH both concluded that, given its health risks, cost, and lack of clinical evidence for effectiveness, the use of chelation as a treatment for autism spectrum disorders is not supported.72,78,101

At this time, evidence does not support the widespread use of chelation therapy for prevention of chronic health diseases or treatment of developmental disorders such as autism spectrum disorder. Certain populations, such as post-MI diabetics, may gain benefit from chelation therapy, but more research is needed before this becomes the standard of care. In cases of acute or chronic poisoning, such as those seen with widespread drinking water contamination, chelation therapy determination and management should be performed under the guidance of a trained medical toxicologist or environmental health physician.

Radiofrequency Radiation

For more information on the health effects of radio frequency radiation, see Chapter 10. Following are some safe cell phone use recommendations.

  • Keep devices away from the body, particularly the head, reproductive organs, heart, and pregnant abdomen; choose either wired phone lines, wireless headphones, or speaker phones whenever possible, and keep calls short.

  • Do not attach a cell phone to your belt, put it in a pocket, or carry it in your bra. The amount of radiation absorbed by the body decreases dramatically even with a small distance of separation.

  • Keep cell phones at least 8 inches from a cardiac pacemaker.

  • Turn the device onto airplane mode or turn it off when carrying it next to the body and at night while sleeping.

  • Text rather than talk; phones emit less radiation when sending texts than during phone communications, and texting keeps radiation away from the head area.

  • Call only when the signal is strong (i.e., more signal bars on screen); fewer signal bars means that the phone must try harder to broadcast its signal to the tower, raising radiation levels.

  • Limit children’s cell phone use whenever possible. Turn devices to airplane mode when children play with games already downloaded to the phone or tablet.

  • Avoid so-called radiation shields such as antenna caps and keyboard covers; they reduce the connection quality and force the phone to transmit greater energy, generating more radiation.

  • If looking at computer screens for extended periods, use orange-tinted glasses (“blue-blockers”) to protect the retina and reduce blue light exposure and symptoms of extended screen time.

  • Adjust phone and computer screen using a blue light filter downloadable smartphone app (e.g. f.lux, Midnight, Night Screen, Twilight). These programs adjust blue spectrum light emitted from digital devices which can effect circadian rythyms and the sleep/wake cycle.

  • Clinicians should screen patients for device use and degree of exposure to radiofrequency radiation (RFR); in schools, in the workplace and in homes, given the wide use of WiFi and the addition of smart meters to monitor water and electricity usage.

Resources

BabySafe Project: a group of more than 150 physicians and experts advising practical means to protect pregnancy www.babysafeproject.org

Environmental Health Trust: www.ehtrust.org/resources-to-share/printable-resources/

Summary

As the number of potentially toxic chemicals and radiation sources in the environment continues to increase and government oversight remains limited, patients and clinicians need access to information that could help limit adverse effects from exposures. This chapter offers some best practices and resources for limiting such exposures based on the latest research and use of the precautionary principle. Empowered clinicians are in the best position to guide patients with environmental medicine information, which can greatly impact their health, as well as the health of their children and future generations.

Online Resources

Environmental Working Group www.ewg.org

EWG’s Skin Deep Database www.ewg.org/skindeep

The Smart Human http://thesmarthuman.com/

The Endocrine Disruption Exchange www.endocrinedisruption.com

Green Science Policy Institute http://greensciencepolicy.org/

Environmental Defence http://environmentaldefence.ca/

Natural Resources Defense Council www.nrdc.org

U.S. Environmental Protection Agency www.epa.gov

Centers for Disease Control and Prevention www.cdc.gov

Consumer Reports Greener Choices www.greenerchoices.org

U.S. EPA Air Quality: www.AirNow.gov

Association of Occupational and Environmental Clinics (AOEC), Pediatric Environmental Health Specialty Units (PEHSU): http://www.pehsu.net/.

Health Care Without Harm: https://noharm-uscanada.org

American College of Medical Toxicology: www.acmt.net

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