Letter to Michelle Obama

March 25, 2010 

First Lady Michelle Obama
The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500

Dear Mrs. Obama:
We, the undersigned, are partners in the Collaborative on Health and the Environment, an international network of scientists, health professionals and advocates committed to using the best available science to improve the health of our families and our communities. We are deeply grateful for your leadership in facing the challenge of the obesity epidemic, which has concerned many of us for years. We also strongly support the initiatives that you are undertaking to address this major public health issue, which is having such a devastating effect on the health of American families.

We would like to underscore in this letter that the obesity epidemic is the result of many interacting factors and not just a lifestyle challenge—something that you acknowledge, but is rarely highlighted in the media or understood by the general public. The Institute of Medicine (IOM), for example, has publicly stated the importance of access to healthy food to help curb the increasing prevalence of obesity.[1] Along these lines, it is clear the federal government, given its ability to influence food production through subsidies, needs to incorporate strategies to promote more healthful and less calorie-dense, nutrient-poor food.

Other factors contributing to obesity include socioeconomic status and genetic predisposition, as well as poorly designed communities that discourage walking and biking.

In addition to these issues, the prestigious international Endocrine Society published a seminal report last year stating that, “scientific research implies the impact of environmental substances in the generative roots of obesity.”[2] The rapidly growing body of scientific evidence suggests that chemicals known as endocrine disruptors may be associated with a range of health concerns, including various cancers, developmental disabilities and infertility. In addition, some of these chemicals may also act as “obesogens” – that is, substances that trigger the propensity to develop obesity. Of critical importance, these obesogens appear to reprogram metabolism starting before birth, thereby increasing a child’s predisposition for obesity before he/she is even born. In addition, research shows that these chemicals may also promote the development and maturation of fat cells throughout life. In other words, we cannot ignore the evidence that these chemicals, found in everyday products and in our food and water, may also contribute to this epidemic.

The science on obesogens is very clear in animal studies (please see the attached article in press for the San Francisco Medical Society Journal [available on CHE’s website]). Although we have little information yet about how obesogens impact humans, there is some initial research in humans suggesting the urgent need for further study.[3]

The truth is that we as a society need to recognize all the interacting factors that can contribute to obesity—including the risk that exposures to obesogens can pose. Any campaign that does not take into account the role of these chemicals in the obesity epidemic will run counter to President Obama’s promise that this administration will be guided by the best available science. Given this, the emerging science clearly indicates that national chemical policy reform is an essential ingredient of your campaign against childhood obesity.

We congratulate you on your foresightedness in choosing obesity as one of your signature issues as First Lady. Please know we would also be happy to discuss ways to address the full range of concerns associated with obesity and to work with you and your colleagues to champion prevention as essential to real health care reform for all Americans.

Thank you again for your leadership and consideration.

With best wishes,

Bruce Blumberg, PhD, Professor, Departments of Developmental and Cell Biology and Pharmaceutical Sciences, University of California, Irvine

Susan Braun, Executive Director, Commonweal

Linda C. Guidice, MD, PhD, MSc, Professor and Chair, Department of Obstetrics, Gynecology and Reproductive Science, The Robert B. Jaffe, MD Endowed Professor in the Reproductive Sciences, Director, Center for Research on Origins and Biological Consequences of Human Infertility, Director UCSF Women’s Reproductive Health Research Career Development Center, University of California, San Francisco

Andrea Gore, PhD, Gustavus and Louise Pfeiffer Professor, Division of Pharmacology and Toxicology, The University of Texas, Austin

Richard J. Jackson, MD, MPH, Chair and Professor, Environmental Health Sciences, School of Public Health, University of California, Los Angeles

Phil Landrigan, MD, MSc, Ethel H. Wise Professor and Chairman, Department of Preventive Medicine, Professor of Pediatrics and Director of the Center for Children’s Health and the Environment, Mount Sinai School of Medicine

Philip R. Lee, MD, Former United States Assistant Secretary of Health, Chancellor of the University of California at San Francisco, Professor at Stanford University

Michael Lerner, PhD, President, Commonweal

Elise Miller, MEd, Director, Collaborative on Health and the Environment

John Peterson Myers, PhD, Founder, CEO and Chief Scientist of Environmental Health Sciences

Ted Schettler, MD, MPH, Science Director, Science and Environmental Health Network

Carlos Sonnenschein, MD, Professor, Department of Anatomy and Cellular Biology, Tufts University School of Medicine

Ana Soto, MD, Professor, Department of Anatomy and Cellular Biology, Tufts University School of Medicine

R. Thomas Zoeller, PhD, Chair and Professor, Biology Department, Morrill Science Center

[1] Institute of Medicine reports: The Public Health Effects of Food Deserts. Workshop Summary, Local Government Actions to Prevent Childhood Obesity and Progress in Preventing Childhood Obesity: Focus on Industry—Brief Summary: Institute of Medicine Regional Symposium. Available on the IOM website, http://www.iom.edu/Reports.aspx?search=obesity, viewed March 11, 2010.

[2] Diamanti-Kandarakis E et al. Endocrine-disrupting chemicals: An Endocrine Society Scientific Statement. Endocr Rev. 2009 Jun;30(4):293-342. Available online at http://www.endo-society.org/journals/scientificstatements/, viewed March 11, 2010.

[3] Grün F, Blumberg B. Endocrine disrupters as obesogens. Mol Cell Endocrinol. 2009 May 25;304(1-2):19-29. Heindel JJ, vom Saal FS. Role of nutrition and environmental endocrine disrupting chemicals during the perinatal period on the aetiology of obesity. Mol Cell Endocrinol. 2009 May 25;304(1-2):90-6.

Gaining Ground

Julia Varshavsky
Program Associate and Coordinator of the
Ferility/Reproductive Health Working Group

Are we gaining ground on translating environmental health science into clinical practice and public policy? You bet, but we still have a ways to go.

In a recent online article published by The Pump Handle called “Systematising the evidence base: a key strategy for bringing more environmental health science into clinical practice and public health policy,” Paul Whaley correctly describes the gap between environmental health science and clinical practice as a conflict between animal and human observational studies and randomized control trials (RCTs). The healthcare service industry relies on RCTs, a type of scientific experiment that tests the efficacy or effectiveness of pharmaceuticals and other technologies on patients. But as Whaley writes, “it is unethical to expose humans for research purposes to a substance suspected of causing harm, so the RCT is almost always off-limits for environmental health researchers.”

Instead, environmental health scientists rely on laboratory experiments, in addition to wildlife and human observational studies to understand the potential health impacts of a variety of chemicals. These studies have proven reliable in predicting harm in several cases, but many feel that in order for health professionals to trust environmental health science, a systematic and transparent methodology to weight the scientific evidence needs to be created. As Paul Whaley writes, an effort to do just that has been put in motion by Dr. Tracey Woodruff, Director of the Program on Reproductive Health and the Environment at the University of California, San Francisco. CHE-Fertility has been an instrumental partner in this effort, along with other leading organizations, and we continue to move this work forward.

In August 2009, our collaborative team hosted the Workshop on Navigating the Scientific Evidence to Ensure Prevention. We recapped this workshop for CHE partners who were not in attendance during a CHE Partnership Call that took place on November 11, 2009, and was recorded for those of you interested in hearing more about this project. We hope the conversation around how to incorporate environmental health science into clinical practice and public health policy will continue and broaden to include more voices, and were pleased to see this coverage by The Pump Handle.

The Complexities of Measuring Health and Its Determinants

Ted Schettler, MD, MPH
CHE Science Director, and Science Director of the Science and Environmental Health Network; Coordinator of CHE’s Science Working Group

What is health? How do we measure it? What determines it?  A new report from the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute takes a turn at answering these questions.  “County Health Rankings: Mobilizing action toward community health” combines weighted measures of health outcomes and health determinants to define and rank the health of individual counties throughout the US.

Premature mortality and morbidity, estimated by a combination of how healthy people feel and the percent of low birth weight babies, were given equal weight as measures of health outcomes. Various measures of health behaviors, clinical care, social and economic factors, and the physical environment were weighted as measures of health determinants and expressed as composite scores. The website also provides comparative rankings of health outcomes and measures of health determinants at the county level. The authors describe their methods of data collection and analysis in some detail, including a justification of their final choices for weighting individual variables in the composite score. This remarkable effort is worth exploring.

At the outset, the authors had to choose among many candidate health outcomes and determinants. How did they do? Are these the right measures of health or just available statistics? What other health determinants could reveal important insights? Several limits are notable.  Among them: This is a cross-sectional analysis and cannot determine causal relationships.  Genetics, gender, race, and ethnicity are left out. The relative contribution of each group of health determinants always adds up to 100%, regardless of context. (Health behaviors were assigned a weight of 40%, health care 10%, socioeconomic factors 40%, and the physical environment 10% for the final composite score. The justification for these relative weights and alternative opinions are available on the website.) Thus, potential interactions among health determinants are not considered.

For example, the report uses air pollution as a measure of environmental quality, yet it doesn’t acknowledge that people who are socioeconomically disadvantaged are more susceptible to the health effects of air pollution than people who are better off. It’s increasingly clear that air pollution causes more asthma and asthma attacks in children lower on the socioeconomic ladder, independent of other environmental exposures. How should we think about this? Is the problem air pollution, socioeconomic stressors, or both? How does our answer influence what we propose to do? If we ignore interactions, we not only underestimate the impacts of combined eco-social variables in vulnerable groups but also set ourselves up to fail to identify interventions that can have multiple, cross-cutting benefits.  

Despite its inevitable simplifications and assumptions, this detailed report deserves attention and discussion, especially among those of us embracing an ecological model of health. It raises many interesting questions. Is this the right mix of individual and county-wide variables? Are there other measures of health at the county level worth identifying? Are there other measures of environmental quality and integrity that should be added? 
Maybe the report’s biggest contribution will be to set the stage for soliciting ideas about what to do with the information.  Should high-ranking counties be complacent? Should they compete with themselves to improve? Counties struggling with poor health outcomes and multiple adverse health determinants will need something more than disconnected, poorly-coordinated activities. They must understand that risk factors don’t exist in isolation but rather in a complex, interactive web of causation. In those counties, the entire web needs fundamental transformation, achieved through creative, strategic interventions. This is no small task. I think of Donella Meadows’ Places to Intervene in a System in which she says: “There are no cheap tickets to systems change.  The higher the leverage point, the more the system resists changing it.”  Perhaps this is where collaborations like CHE come in…strength in numbers, ideas, and mutual support.