Commentary: 25 Years of Endocrine Disruptor Research – Great Strides, But Still a Long Way to Go

written by Laura N. Vandenberg, PhD
Assistant Professor and Graduate Program Director of Environmental Health Sciences, University of Massachusetts Amherst School of Public Health and Health Sciences

Laura Vandenberg (Credit: umass.edu)

Reprinted with permission from Environmental Health News

Cancer. Diabetes. Autism. Infertility. ADHD. Asthma. As the rates of these diseases increase over time, the public and researchers alike have focused on the role the environment might play in their cause and progression. Scientists in the field of environmental health sciences are not satisfied just to know that the environment contributes to human disease – they want to know how.

This week [ScienceSeptember 18-20], researchers, public health advocates, government officials, and industry spokespersons will meet at National Institutes of Health (NIH) to celebrate 25 years of scientific research on one aspect of environmental health: endocrine disrupting chemicals (EDCs). These are compounds that alter the way hormones act in the body, often by mimicking or blocking their actions. Just a few examples of widely used consumer products that contain EDCs are plastics, electronics, flooring, some personal care products, and furniture treated with some flame retardants.

A Story of Health Wins CDC Communications Award

The NCEH/ATSDR award given to A Story of Health

The National Center for Environmental Health (NCEH) and the Agency for Toxic Substances and Disease Registry (ATSDR) have honored A Story of Health multimedia eBook/continuing education course with an “Excellence in Communications” award.

NCEH and ATSDR are agencies of the Centers for Disease Control and Prevention (CDC). The award was given at the annual NCEH/ATSDR Honor Awards on February 3, 2016, to A Story of Health Team for excellence in communication for the development of a medical education product that highlights the importance of environmental health.

A Story of Health: Something for Everyone

written by Elise Miller, MEd
Director 

We all know there are multiple contributors to health and disease, but let’s say you want to figure out what the latest science says on environmental links to, say, asthma? Or learning disabilities? Or childhood leukemia? Pretty daunting, isn’t it? Which websites have the most evidence-based science? Which articles are accessible without paying a subscription or membership fee? What do those research findings mean for your patients, your family, and community? And many other pressing questions. Most health care professionals can’t begin to keep up with the emerging scientific literature, much less the rest of us.

Fortunately, A Story of Health is a brilliant, innovative new resource that can help you find out how various environments interact with our genes to influence health across the lifespan. Based on the latest peer-reviewed research, it’s more than a bunch of scientific facts thrown together with fancy graphics. It’s a story, or really—multiple, interactive, and interconnected stories that touch us and teach us not only about risk factors for disease, but how to prevent disease and promote health and resilience.

Chronic Stress and Health

written by Nancy Hepp, MS
Research and Communications Specialist

Nathan Seppa at ScienceNews published a summary of the state of knowledge about the effects of chronic stress on health. The summary draws from research on the effects of stress on heart attacks, stroke, cancer, premature childbirth, type 2 diabetes, telomere length, asthma and even the common cold. Seppa writes:

Chronic stress is the kind that comes from recurring pain, post-traumatic memories, unemployment, family tension, poverty, childhood abuse, caring for a sick spouse or just living in a sketchy neighborhood. Nonstop, low-grade stress contributes directly to physical deterioration, adding to the risk of heart attack, stroke, infection and asthma. Even recovery from cancer becomes harder.

Scientists have now identified many of the biological factors linking stress to these medical problems. The evidence centers on nagging inflammation and genetic twists that steer cells off a healthy course, resulting in immune changes that allow ailments to take hold or worsen.

Read the full article on the ScienceNews site.

Another Victory for Cleaner Air

written by Ted Schetter, MD, MPH
Science Director for CHE and the Science and Environmental Health Network

This month the US Court of Appeals in Washington, DC, upheld EPA’s 2012 decision to tighten air quality standards for fine particulate air pollution (PM 2.5) by lowering the annual average limit from 15 to 12 microgm/m³.[1] The EPA selected the new standard because it is slightly below the lowest long-term average concentration known to cause adverse health effects, including damage to the lungs and cardiovascular system and premature death in people with heart and lung disease.[2] The National Association of Manufacturers, the US Chamber of Commerce, and other industry groups had challenged the scientific basis of this decision, also objecting to EPA’s plan to eliminate the use of spatial averaging in determining compliance and to require near-road monitoring in certain heavily populated urban areas. The court’s affirmation of each of EPA’s decisions was timely since each year the Asthma and Allergy Foundation of America declares May to be “National Asthma and Allergy Awareness Month.”

The Primary Prevention of Asthma

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

Asthma is a complex disorder made up of different subtypes with differing causes, underlying pathology, treatment responses, and natural histories. According to the Centers for Disease Control, about 1 in 12 people in the US have asthma, and the numbers are growing every year. The disorder costs over $56 billion in medical costs, lost school and work days, and early deaths annually.

In 2005, CHE’s Asthma and the Environment Working Group convened a series of conversations to explore our interests in this complex disease and to see if we could identify some aspect of asthma around which we could focus our efforts. We began to wonder about the allocation of asthma research dollars. How much is invested in understanding the origins of asthma and opportunities for primary prevention versus how to reduce the frequency and severity of asthmatic episodes in people who already have the disease?

With that question in mind, we reviewed the research portfolio of the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health and concluded that less than 10 percent of asthma-related research was devoted to understanding the causes and primary prevention of the disease. Even though this was a rough estimate, based on a review of project descriptions in the NIH database, it seemed to indicate that primary prevention of asthma was underfunded.

Following that review, the working group concluded that convening a workshop to address the causes and primary prevention of asthma would be worthwhile. Published proceedings might attract more funding and help to raise awareness of the urgent need. However, we were initially unable to secure support for the proposed undertaking and the idea languished.

In 2009, CHE partner Polly Hoppin, Research Professor and Program Director of the environmental health program at the Lowell Center for Sustainable Production at the University of Massachusetts, Lowell, seized an opportunity to incorporate the primary prevention of asthma into the first Strategic Plan for Asthma in Massachusetts.

Polly worked with partner organizations in the Massachusetts Asthma Advocacy Partnership to draft a goal in the plan to “develop a Roadmap for better understanding the causes of asthma and the role of primary prevention in Massachusetts.” Its objective was to “develop agreement—’a roadmap’—among experts and other groups on the current evidence on primary prevention, research needed to increase our understanding of prevention of asthma, and evidenced-based strategies that can be currently implemented in Massachusetts.” With the goal of primary prevention of asthma clearly spelled out in the state’s strategic plan, Polly and her colleagues successfully undertook new efforts to find resources to convene a meeting addressing the state of the science, research needs, and capacity to reduce new onset asthma over time.

Polly and Molly Jacobs from UMass Lowell organized and led a planning committee that put considerable effort into preparing for the conference, “The Primary Prevention of Asthma: A Symposium on Current Evidence, Research Needs, and Opportunities for Action”, held at the Massachusetts Medical Society in Waltham, Massachusetts, in April, 2013. See http://www.sustainableproduction.org/proj.envh.AsthmaSymp.php for a description, the agenda, and links to presentations. Participants included invited researchers, clinicians, labor and community representatives, public health professionals, and government leaders from a range of sectors, including housing, education, health, transportation and environment. The symposium was co-sponsored by the Massachusetts Department of Public Health, the National Institute for Environmental Health Sciences, the US Department of Health & Human Services, Region I (New England), the Boston Public Health Commission, the American Lung Association of the Northeast, and Neighborhood Health Plan, with in-kind support from a range of collaborating organizations.

Opening presentations helped to frame the multifactorial, multilevel complexity of asthma, its public health impacts, and the structural and cultural underpinnings of asthma disparities. They were followed by experts who had been asked to review the state of the science linking specific risk factors to asthma onset, for example obesity, air pollution (in particular, traffic proximity), indoor allergens (i.e. dust mites and mold), dietary factors, chemicals, and stress, among others. These experts provided a summary of the literature, their analysis, and concluded with a recommended classification of each risk factor under discussion as known, probably, possibly, or known not to be associated with asthma onset. As necessary, risk factors were considered unclassifiable when data were inconsistent or sparse.

Following presentations of the evidence, conference attendees broke out into subgroups to discuss the various risk factors and decide which were “ready for action” based on the state of the science and considering additional factors such as: (a) the magnitude of the potential public health impact given the strength of the association and/or the scale of potential exposure, (b) additional benefits that could be reasonably expected to come with taking action, (c) the likelihood that taking action would result in serious unintended consequences. For those interested in more detail about the risk factors and conclusions reached at the conference see the conference link (above) and a  CHE partner call summarizing the symposium.

At the conclusion of the symposium attendees concurred that the primary prevention of asthma will require multiple, multilevel interventions. Attendees developed a shared understanding of the relevant science and created components of a 10-12 year roadmap as called for in the state’s Strategic Plan for Asthma. Polly is chairing a new primary prevention committee of the Massachusetts Asthma Advocacy Partnership, which is now working with the Department of Public Health to determine which of the symposium recommendations will be included in the next state strategic plan, currently in the planning stages.

Existing evidence supports the importance of avoiding exposure to tobacco smoke and chemicals that are respiratory tract sensitizers or irritants. Living in close proximity to traffic independently increases risk of developing asthma. Chronic stress is also an independent risk factor for asthma and nearly doubles the risk of asthma onset associated with proximity to traffic-related air pollution. Given the state of the evidence, asthma leaders in Massachusetts are committed to ongoing discussion about opportunities for primary prevention, developing policies to reduce exposure to risk factors, and implementing pilot programs with rigorous evaluation to develop effective interventions. Some actions are achievable within the five-year timeframe of the next strategic plan; others will unfold over the longer term as research on effective interventions strengthens. Finding resources to support an implementation research agenda continues to be a pressing need.

Since the Massachusetts symposium, leaders in other states have expressed interest in pursuing a similar strategy to reduce the burden of asthma over time. Our hope is that the primary prevention of asthma will become a more widely shared goal and ultimate reality.

Massachusetts Pursues the Primary Prevention of Asthma

Polly Hoppin
Co-coordinator of CHE’s Asthma Working Group

Massachusetts communities have high asthma rates, resulting in a substantial societal burden of human suffering, lost capacity and productivity, and direct fiscal costs. In 2010, 10.4% of adults in Massachusetts had asthma—one of the highest prevalence estimates in the nation. Current asthma prevalence among adults increased by 22.4% between 2000 and 2010. In 2009, 9.3% of Massachusetts children had current asthma [1]. And Massachusetts is not alone: asthma rates are increasing in states across the US.

As with other chronic diseases, far more resources focus on managing asthma in people who have it than on preventing the disease. Better compliance with medications, behavior modifications resulting from asthma education, and environmental interventions that reduce a person’s exposure to allergens and irritants are essential secondary prevention strategies that can reduce asthma attacks and keep people out of the doctor’s office, emergency room or hospital, often cost-effectively. Yet, there remains an urgent need to better understand the root causes of asthma and to develop strategies for reducing the rate of new cases.

A growing body of research documents associations between asthma onset and a range of risk factors, many of which are modifiable, such as exposure to contaminants and allergens in indoor air [2]; lack of breast feeding [3]; maternal health (including stress associated with poverty and racism, as well as obesity, and other factors [4]; and outdoor air pollution [5]. Evidence is also emerging that both adults and children living in close proximity to air pollution sources—for example traffic on busy roadways—are at higher risk than those living at greater distance [6]. Even higher rates of asthma onset are observed among children exposed to traffic who also experience significant stress in their lives [7]. Hundreds of specific chemicals have been associated with the onset of asthma in workers [8], and recent studies suggest that many of these same chemicals are found in household settings and may be associated with the onset of asthma in both children and adults [9]. A small but growing body of research has examined the impacts on asthma onset of specific interventions to reduce modifiable risk factors such as exposure to dust mites and other indoor allergens [10] as well as vitamin D deficits [11]. Several studies have demonstrated reduced rates of new onset asthma among recipients of an intervention to address multiple risk factors as compared to a control group [12]. A review of these studies suggests that a more systemic, multifactorial approach may be effective [13].

What could a state concerned about asthma prevalence do to reverse rates over time? For which risk factors is the weight of the evidence strong, indicating a known association between exposure and asthma onset? Where there remain uncertainties about the strength of the science, what other considerations might justify action to modify one or more risk factors? What kinds of interventions would align best with an understanding of asthma development as a complex, multifactorial process?

A two-day symposium on April 23-24, 2013, at the Massachusetts Medical Society will pursue these questions and feed recommendations into the next statewide strategic plan for asthma, which is in the early planning stages. Polly Hoppin and Molly Jacobs of the Lowell Center for Sustainable Production at the University of Massachusetts, Lowell, are convening the symposium, pursuing a goal they and others helped install in the current state strategic plan: “to develop….[with input from] a diverse group of professionals and individuals… a roadmap for better understanding the causes of asthma and the role of primary prevention in Massachusetts” [14]. The Symposium planning committee includes representatives of the Massachusetts Asthma Advocacy Partnership, a statewide asthma coalition; the regional offices of the American Lung Association; the US Department of Health and Human Services and EPA; the state Department of Public Health; the Asthma Regional Council of New England; the Boston Public Health Commission; hospitals and universities. CHE Science Director Ted Schettler has been instrumental in helping shape the agenda and is giving the opening presentation.

Ten years ago, research on the cost-effectiveness of home-based programs in reducing asthma symptoms was just emerging. New England organizations were leaders in synthesizing the research and convening public and private payers to discuss how to provide people with severe asthma home-based environmental interventions and asthma education to help bring their asthma under control. These activities played an important role in generating federal support for the delivery and financing of home visits for asthma. Organizers of the primary prevention symposium intend the April meeting to break comparably new ground in both the meeting processes used and its outcomes. A decade from now, we hope to be able to point to this gathering as an important first step in advancing understanding of the primary causes of asthma and action to address them.

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[1] Massachusetts Behavioral Risk Factor Surveillance System, Massachusetts Department of Public Health, and US Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention, multiple years.

[2] e.g., Mendell MJ. Indoor residential chemical emissions as risk factors for respiratory and allergic effects in children: a review.  Indoor Air. 2007; 17(4):259-77; Jaakkola JJ, Knight TL. The role of exposure to phthalates from polyvinyl chloride products in the development of asthma and allergies: A Systematic Review and Meta-analysis. Environ Health Perspect 116(7):845-853; Chen YC, Tsai CH, Lee YL, et al. Early-life indoor environmental exposures increase the risk of childhood asthma. International Journal of Hygiene and Environmental Health. 2011;215:19-25.

[3] Kull I, Wickman M, Lilja G, et al. Breast feeding and allergic diseases in infants—a prospective birth cohort study. Archives of Disease in Childhood. 2002;87:478-481; Oddy WH, Hold PG, Sly PD, et al. Associations between breast feeding and asthma in 6 year old children: Findings of a prospective birth cohort study.  British Medical Journal. 1999;319:815-819.

[4] Wright RJ, Cohen S, Carey V, Weiss ST, Gold DR. Parental stress as a predictor of wheezing in infancy: A prospective birth-cohort study. American Journal of Respiratory & Critical Care Medicine. 2002;165:358–365; Mrazek DA, Klinnert M, Mrazek PJ, Brower A, McCormick D, Rubin B, Ikle D, Kastner W, Larsen G, Harbeck R, et al. Prediction of early-onset asthma in genetically at-risk children. Pediatric Pulmonology. 1999;27:85–94; Sternthal MJ, Coull BA, Chiu YH, et al. Associations among maternal childhood socioeconomic status, cord blood IgE levels, and repeated wheeze in urban children. Journal of Allergy and Clinical Immunology. 2011;128(2):337-345; Scholtens S, Wija AH, Brunekreef B, et al. Maternal overweight before pregnancy and asthma in offspring followed for 8 years. International Journal of Obesity. 2009 Sep 29. [Epub ahead of print]

[5] Künzli N, Bridevaux P-O, Liu L-J S, et al. Traffic-related air pollution correlates with adult-onset asthma among never-smokers. Thorax. 2009;64:664-670; Jerrett M, Shankardass K, Berhane K, et al. Traffic-Related Air Pollution and Asthma Onset in Children: A Prospective Cohort Study with Individual Exposure Measurement. Environmental Health Perspectives. 2008;116:1433-1438; McConnell R, Islam T, Shankardass K, et al. Childhood incident asthma and traffic-related air pollution at home and school. Environmental Health Perspectives. 2010 Jul;118(7):1021-6; Clark NA, Demers PA, Karr CJ, et al. Effect of early life exposure to air pollution on development  of childhood asthma. Environmental Health Perspectives. 2009;118(2):284-290; Shankardass K, McConnell R, Jerrett M, et al.  Parental stress increases the effect of traffic-related air pollution on childhood asthma incidence. Proceedings of the National Academies of Science USA. 2009;106:12406-11.

[6] McConnell R, Islam T, Shankardass K, et al. Childhood incident asthma and traffic-related air pollution at home and school. Environmental Health Perspectives. 2010 Jul;118(7):1021-6.

[7] Shankardass K, McConnell R, Jerrett M, et al. Parental stress increases the effect of traffic-related air pollution on childhood asthma incidence. Proceedings of the National Academies of Science USA. 2009;106:12406-11.

[8] Malo J-L, Chan-Yeung M. Appendix: Agents Causing Occupational Asthma with Key References. In: Bernstein LI, Chan-Yeung M, Malo J-L, Bernstein DI (eds). Asthma in the Workplace. 3rd Ed. New York: Taylor & Francis, 2006.

[9] Mendell MJ. Indoor residential chemical emissions as risk factors for respiratory and allergic effects in children: a review. Indoor Air. 2007; 17(4):259-77.

[10] Maas T, Kaper J, Sheikh A, et al. Mono and multifaceted inhalant and/or food allergen reduction interventions for preventing asthma in children at high risk of developing asthma. Cochrane Database of Systematic Reviews. 2009; Jul 8;(3):CD006480.

[11] Litonjua AA. Vitamin D deficiency as a risk factor for childhood allergic disease and asthma.
Current Opinions in Allergy and Clinical Immunology. 2012 Jan 19. [Epub ahead of print]

[12] see Chan-Yeung M, Ferguson A, Watson W, et al.  The Canadian Childhood Asthma Primary Prevention Study: Outcomes at 7 Years of Age. Journal of Allergy and  Clinical Immunology. 2005 Jul;116(1):49-55.

[13] Maas T, Kaper J, Sheikh A, et al. Mono and multifaceted inhalant and/or food allergen reduction interventions for preventing asthma in children at high risk of developing asthma. Cochrane Database of Systematic Reviews. 2009; Jul 8;(3):CD006480.

[14] Strategic Plan for Asthma in Massachusetts, 2009-2014. Department of Public Health, Commonwealth of Massachusetts, 2009.

What’s really behind the increase in autism rates.

CHE partner Alice Shabecoff,  co-author with her husband Philip of the book Poisoned for Profit: How Toxins Are Making Our Children Chronically Ill.

The just-released data on autism shows a count of one in 88 children, up from a rate of one in 100 three years ago, and one in 150 five years ago.  With each change, the response remains the same: Oh, that’s because of better detection and broader definitions.

How, then, to account for the sharp increase in childhood asthma—15.7 percent higher today than ten years ago? Or an increase of the same magnitude in preterm births? Or the indisputable fact that childhood cancer has climbed an inexorable one percent, year after year, over the past thirty years?  As has Down Syndrome. And among rarer illnesses, too, the rates keep going up and up—from the increase in malformations of the penis among newborn boys, to the doubling in a generation of endometriosis, a deformity of the uterus, among girls.

There is no way that these wildly different childhood illnesses can be chalked up to, and written off as, an increase in detection and/or diagnosis.

Changing the Landscape

Elise Miller, MEd
Director

The American Medical Association (AMA) took an unprecedented action yesterday: It unanimously passed a resolution calling for new policies to decrease public exposure to endocrine disrupting chemicals (EDCs) [read more] based on the Endocrine Society’s seminal scientific statement on EDCs published last summer [read the statement]. Both The Endocrine Society Statement and the AMA’s resolution mark an historical turning point for mainstream medical associations. For the first time, tens of thousands of prestigious health professionals are saying in no uncertain terms:

Exposures to many industrial chemicals are contributing to the epidemic of chronic diseases and disabilities, including diabetes, obesity, learning and developmental disorders, infertility and other reproductive health problems. 

• We have enough science to undertake proactive health measures.
• The risk to public health is too great to wait any longer. 
• We need to act now to implement health protective policies and regulations.

Many CHE partners were involved in catalyzing this remarkable action. We now would like to encourage other health-related professional societies to adopt similar resolutons to signal to national leaders and policymakers that fundamental chemical policy reform can no longer be side-lined. In fact, chemical policy reform is not only integral to health care reform, as I suggested in last month’s CHE e-newsletter, but to climate change as well. EPA Administrator Jackson made this point on Monday in her remarks at the American Public Health Association conference. She announced greenhouse gas emission standards for automobiles, a first for the EPA, saying the limits would mean “less harmful pollution that sends people to the hospital with asthma, heart disease, and any number of other conditions.”

In this context, what if we prioritized these same health-focused principles in climate change decisions across the board? That is, in essence, what CHE organizational partners, the Health and Environmental Alliance (HEAL) and Health Care Without Harm (HCWH), are calling for in a new campaign entitled “Prescription for a Healthy Planet.” To date, protecting public health has been essentially left out of the conversation in international talks on climate change. At the upcoming Copenhagen summit in December, however, we have an opportunity to ensure that children’s health and that of other vulnerable populations are prioritized. As stated in the “Prescription”, “a fair and binding international agreement in Copenhagen means: less global warming, less illness, lower healthcare costs, better health for the world population and a healthier planet.” This sounds promising. But right now very little research and discussion has focused on climate change and health.

What we do know is that children will be the most impacted by climate change. Nine percent of American children already suffer from asthma and those attacks will become more numerous and severe with increased air pollution and ozone levels – and of course, the number of children affected in developing countries, where there may be even less regulation on pollutants, will likely be far higher. In addition, we will be faced with increased exposures to industrial chemicals as recently outlined by the World Health Organization. For example, with more extreme storms and floods, there will be greater runoff of chemicals used in urban and agricultural areas into surface and ground waters. With increased drought, non-volatile chemicals and toxic metals will concentrate and rapidly enter groundwater supplies through parched soil when rain finally comes. In addition, global warming will release chemicals currently trapped in glacial ice, and changing weather patterns will move persistent chemicals through water and air streams in ways previously unanticipated. And this doesn’t even begin to describe other concerns about increased infectious diseases and the challenges of whole populations migrating elsewhere because of rising sea water and less fertile land.

All of this is to say that the AMA and myriad other health professional societies in the US and abroad are essential to figuring out solutions to this thorny nexus of pressing public health issues, namely: chemical policy reform, health care reform and the impact of climate change on human health. Through ongoing efforts to translate the best available science for lay audiences and to incubate strategic health-focused initiatives, I have no doubt CHE partners can continue to change the landscape in which these major decisions – decisions affecting all of us and future generations – are made.

Our Health and the Health of the Environment: How Are They Connected? What Can We Do to Improve Both?

The CHE Public Policy Primer

Webster’s defines a primer as a book of elementary principles or a book for teaching children how to read. The new CHE primer Our Health and the Health of the Environment: How Are They Connected? What Can We Do To Improve Both? aims at providing its readers with some elemental principles of environmental health.

Through the examples of asthma, learning disabilities and breast cancer, the primer explains what we are learning about the links between chronic illness, toxic chemicals and other environmental contaminants. The primer also gives examples of legislative and corporate policies aimed at improving our health and the health of the environment.

CHE Partners are encouraged to use the primer as part of discussions with elected officials or those running for public office. Printed copies are available free from CHE or a PDF version of primer may be downloaded.

The Cases of Asthma, Learning Disabilities and Breast Cancer

Policies That Phase Out and Replace Chemicals With Safer Alternatives

Policies to Expand the Use of Health Tracking and Biomonitoring

Policies that Use Precaution to Make Decisions

Purchasing for Environmental Health

Creating a Chemicals Policy

Policies Championed by CHE Partners