Environmental exposures: how to counsel preconception and prenatal patients in the clinical setting

Redox mechanisms of environmental toxicants on male reproductive function

Humans and wildlife, including domesticated animals, are exposed to a myriad of environmental contaminants that are derived from various human activities, including agricultural, household, cosmetic, pharmaceutical, and industrial products. Excessive exposure to pesticides, heavy metals, and phthalates consequently causes the overproduction of reactive oxygen species. The equilibrium between reactive oxygen species and the antioxidant system is preserved to maintain cellular redox homeostasis. Mitochondria play a key role in cellular function and cell survival. Mitochondria are vulnerable to damage that can be provoked by environmental exposures. Once the mitochondrial metabolism is damaged, it interferes with energy metabolism and eventually causes the overproduction of free radicals. Furthermore, it also perceives inflammation signals to generate an inflammatory response, which is involved in pathophysiological mechanisms. A depleted antioxidant system provokes oxidative stress that triggers inflammation and regulates epigenetic function and apoptotic events. Apart from that, these chemicals influence steroidogenesis, deteriorate sperm quality, and damage male reproductive organs. It is strongly believed that redox signaling molecules are the key regulators that mediate reproductive toxicity. This review article aims to spotlight the redox toxicology of environmental chemicals on male reproduction function and its fertility prognosis. Furthermore, we shed light on the influence of redox signaling and metabolism in modulating the response of environmental toxins to reproductive function. Additionally, we emphasize the supporting evidence from diverse cellular and animal studies.

Synthetic Chemicals: What We Have Learned and Still Need to Learn About Their Associations with Childhood Allergy and Asthma

PURPOSE OF REVIEW

Prenatal and childhood exposure to synthetic chemicals, such as phenols and phthalates, have been linked to asthma and allergy, but the extent of this association and the underlying mechanisms are not fully understood. Here we provide an up-to-date review of the evidence linking phenol and phthalate exposure with childhood asthma and allergy and of proposed mechanistic pathways.

RECENT FINDINGS

Five experimental and 12 epidemiological studies that examined associations between exposures to synthetic chemicals to asthma and allergic diseases were included. An additional 14 studies provided mechanistic support for the importance of immune modification through epigenetic regulation, induction of pro-allergic T2 expression, and endocrine disruption. While recent studies have provided further experimental and epidemiological evidence for how these chemical exposures may induce childhood asthma and allergy, the recent literature remains limited. However, emerging mechanistic studies have identified chemical-induced alterations in DNA methylation of genes implicated in allergic inflammation and endocrine disruption as potential pathways. In addition, barriers to decrease exposure to synthetic chemicals at the individual level (facilitated through education) and areas for further action at the organizational and governmental levels are suggested. The latter includes transferring some of the onus from the individual to organizations and legislation to restrict marketing and access to products containing potentially harmful chemicals and provide alternative products. We also suggest future research that focuses on further elucidating pathways between exposure to disease development and identifying strategies to reduce exposure at the population level.

Optimizing preconception care and interventions for improved population health

There is growing literature indicating that optimal preconception health is associated with improved reproductive, perinatal, and pediatric outcomes. Given that preconception care is recommended for all individuals planning a pregnancy, medical providers and public health practitioners have a unique opportunity to optimize care and improve health outcomes for reproductive-aged individuals. Knowledge of the determinants of preconception health is important for all types of health professionals, including policy makers. Although some evidence-based recommendations have already been implemented, additional research is needed to identify factors associated with favorable health outcomes and to ensure that effective interventions are made in a timely fashion. Given the largely clinical readership of this journal, this piece is primarily focused on clinical care. However, we acknowledge that optimizing preconception health for the entire population at risk of pregnancy requires broadening our strategies to include population-health interventions that consider the larger social systems, structures, and policies that shape individual health outcomes.

Associations between Phthalate Exposure and Gestational Age at Delivery in a Diverse Pregnancy Cohort

The association between prenatal phthalate exposure and late preterm birth (LPTB) is unclear. We examined singleton pregnancies (2006-2011) from a racially and socioeconomically diverse sample of women in the CANDLE cohort of the ECHO-PATHWAYS Consortium. Urine collected in the second and third trimester was analyzed for 14 phthalate metabolites. Multivariate logistic and linear regressions were performed for LPTB, defined as delivery 34-37 weeks, and gestational week, respectively. Models were controlled for socio-demographics, behavioral factors, clinical measurements, medical history, and phthalates in the other trimester. Effect modification by race and pregnancy stress, indicated by intimate partner violence (IPV), was investigated. We conducted a secondary analysis in women with spontaneous preterm labor. The rate of LPTB among 1408 women (61% Black, 32% White) was 6.7%. There was no evidence of decreased gestational age (GA) in association with any phthalate metabolite. Each two-fold increase in third trimester mono-benzyl phthalate (MBzP) was associated with 0.08 weeks longer gestational age (95% CI: 0.03, 0.12). When restricting to women with spontaneous labor, second trimester mono-n-butyl phthalate (MBP) was associated with 54% higher odds (95% CI: 2%, 132%) of LPTB. Associations were not modified by maternal race or IPV exposure. In conclusion, we observed mixed evidence concerning our hypothesis that prenatal phthalate exposure increases risk of LPTB, though secondary analyses suggest increased risk of spontaneous LPTB associated with MBP, which is consistent with a recent pooled analysis of 16 cohorts.

Development and Validation of the Prevention of Toxic Chemicals in the Environment for Children Tool: A Questionnaire for Examining the Community's Knowledge of and Preferences Toward Toxic Chemicals and Children's Brain Development

Early-life exposures to toxic chemicals can adversely impact brain development. Understanding people's knowledge of the impact of toxic chemicals on brain development is critical to reduce widespread exposure to chemicals. Yet it is unknown what people know about risks of toxic chemicals and how to reduce exposures. We developed and validated the questionnaire, PRevention of Toxic chemicals in the Environment for Children Tool (PRoTECT), to examine people's knowledge and attitudes about the influence of toxic chemicals on child development. We used best practices for developing and validating scales. First, we drafted items to assess knowledge of the impact of toxic chemicals on brain development, levels of concern regarding exposures, and preferences for prevention of neurodevelopmental disorders. Second, we received feedback on item clarity from five focus groups consisting of 46 community participants. In addition, 17 experts completed a content validity scale for each item and provided qualitative feedback. We administered the revised 18-item questionnaire to 190 participants of child-bearing age for scale development, and using exploratory factor analysis, we found evidence for a four-factor model of PRoTECT, RMSR = 0.05, of which 16 of the 18 items had adequate content validity with loadings >0.40 on a derived factor. We discuss future directions and applications of PRoTECT.

What to Expect When Expecting in Lab: A Review of Unique Risks and Resources for Pregnant Researchers in the Chemical Laboratory

Pregnancy presents a unique risk to chemical researchers due to their occupational exposures to chemical, equipment, and physical hazards in chemical research laboratories across science, engineering, and technology disciplines. Understanding “risk” as a function of hazard, exposure, and vulnerability, this review aims to critically examine the state of the science for the risks and associated recommendations (or lack thereof) for pregnant researchers in chemical laboratories (labs). Commonly encountered hazards for pregnant lab workers include chemical hazards (organic solvents, heavy metals, engineered nanomaterials, and endocrine disruptors), radiation hazards (ionizing radiation producing equipment and materials and nonionizing radiation producing equipment), and other hazards related to the lab environment (excessive noise, excessive heat, psychosocial stress, strenuous physical work, and/or abnormal working hours). Lab relevant doses and routes of exposure in the chemical lab environment along with literature and governmental recommendations or resources for exposure mitigation are critically assessed. The specific windows of vulnerability based on stage of pregnancy are described for each hazard, if available. Finally, policy gaps for further scientific research are detailed to enhance future guidance to protect pregnant lab workers.

Praegnatio Perturbatio-Impact of Endocrine-Disrupting Chemicals

The burden of adverse pregnancy outcomes such as preterm birth and low birth weight is considerable across the world. Several risk factors for adverse pregnancy outcomes have been identified. One risk factor for adverse pregnancy outcomes receiving considerable attention in recent years is gestational exposure to endocrine-disrupting chemicals (EDCs). Humans are exposed to a multitude of environmental chemicals with known endocrine-disrupting properties, and evidence suggests exposure to these EDCs have the potential to disrupt the maternal-fetal environment culminating in adverse pregnancy and birth outcomes. This review addresses the impact of maternal and fetal exposure to environmental EDCs of natural and man-made chemicals in disrupting the maternal-fetal milieu in human leading to adverse pregnancy and birth outcomes-a risk factor for adult-onset noncommunicable diseases, the role lifestyle and environmental factors play in mitigating or amplifying the effects of EDCs, the underlying mechanisms and mediators involved, and the research directions on which to focus future investigations to help alleviate the adverse effects of EDC exposure.

Impact of gestational exposure to endocrine disrupting chemicals on pregnancy and birth outcomes

With the advent of industrialization, humans are exposed to a wide range of environmental chemicals, many with endocrine disrupting potential. As successful maintenance of pregnancy and fetal development are under tight hormonal control, the gestational exposure to environmental endocrine disrupting chemicals (EDC) have the potential to adversely affect the maternal milieu and support to the fetus, fetal developmental trajectory and birth outcomes. This chapter summarizes the impact of exposure to EDCs both individually and as mixtures during pregnancy, the immediate and long-term consequences of such exposures on the mother and fetus, the direct and indirect mechanisms through which they elicit their effects, factors that modify their action, and the research directions to focus future investigations.

Comparison of the Effect on Fetal Growth of a Mixture of Atrazine and Nitrates in Drinking Water and of Active Tobacco Exposure during Pregnancy

Active tobacco exposure during pregnancy is a known determinant of fetal growth. Nitrates and atrazine metabolites in drinking water may affect fetal growth as a mixture of endocrine disruptors (ED). We aimed to determine whether EDC have an additional effect on fetal growth compared to active tobacco exposure. A historic cohort study was carried out with a sample stratified with regard to the maternity unit, drinking water exposure, and year of birth. The women included were living in Deux-Sèvres, had given birth between 2005 and 2010 in three selected maternity units, and ultrasound data were available in their obstetrical records. Mixed linear models were used to analyze fetal weight evolution from the second trimester to the time of birth according to drinking water exposure to EDC mixture and active tobacco exposure. We included 558 mother-neonate couples, of whom 9% were exposed to high doses of the mixture and 21% to active tobacco smoking. There was no difference in fetal weight evolution according to drinking water mixture exposure (0.97 g; 95% CI [-3.01; 4.94]). We could not show a supplementary effect of mixture exposure in drinking-water on fetal growth as compared to active tobacco exposure. Further research is needed, using more precise methods to estimate EDC exposure.

How to Educate Pregnant Women about Endocrine Disruptors?

Background: Despite mediatization, only half of pregnant women are informed about endocrine disruptors (EDs). We wished to inquire about appropriate environmental health education procedures during pregnancy: Who, when, and how? Methods: The question stems from a comprehensive population health intervention research project. It includes qualitative studies aimed at constructing an educational program in environmental health and an accompanying assessment tool. The validation of a customized questionnaire (PREVED^© for Pregnancy Prevention Endocrine Disruptors) about the knowledge, attitudes, and practices (KAP) of pregnant women regarding exposure to EDs was carried out in a quantitative study. Results: Health education by a prenatal professional with communication skills should take place as early as possible, during the preconception period or early pregnancy, as part of individual consultation or group workshops. In order to customize the discourse and to develop women’s empowerment, concomitant presentation of the risks by the products used in each room and of previous solutions is recommended. Conclusion: Appropriate health education procedures on EDs should be done at every contact but taking the KAP of pregnant women into account first. We propose all educational actions should be accompanied by questioning of the KAP of pregnant women; for example, with questions from the PREVED^© questionnaire.

Timescales of developmental toxicity impacting on research and needs for intervention

Much progress has happened in understanding developmental vulnerability to preventable environmental hazards. Along with the improved insight, the perspective has widened, and developmental toxicity now involves latent effects that can result in delayed adverse effects in adults or at old age and additional effects that can be transgenerationally transferred to future generations. Although epidemiology and toxicology to an increasing degree are exploring the adverse effects from developmental exposures in human beings, the improved documentation has resulted in little progress in protection, and few environmental chemicals are currently regulated to protect against developmental toxicity, whether it be neurotoxicity, endocrine disruption or other adverse outcome. The desire to obtain a high degree of certainty and verification of the evidence used for decision-making must be weighed against the costs and necessary duration of research, as well as the long-term costs to human health because of delayed protection of vulnerable early-life stages of human development and, possibly, future generations. Although two-generation toxicology tests may be useful for initial test purposes, other rapidly emerging tools need to be seriously considered from computational chemistry and metabolomics to CLARITY-BPA-type designs, big data and population record linkage approaches that will allow efficient generation of new insight; epigenetic mechanisms may necessitate a set of additional regulatory tests to reveal such effects. As reflected by the Prenatal Programming and Toxicity (PPTOX) VI conference, the current scientific understanding and the timescales involved require an intensified approach to protect against preventable adverse health effects that can harm the next generation and generations to come. While further research is needed, the main emphasis should be on research translation and timely public health intervention to avoid serious, irreversible and perhaps transgenerational harm.

Environmental Health Knowledge, Attitudes, and Practices of French Prenatal Professionals Working with a Socially Underprivileged Population: A Qualitative Study

Introduction: As environmental health knowledge of population is associated with social economic status, the objective of this study was to determine environmental health knowledge, attitudes, and practices of French prenatal professionals working with a socially underprivileged population. Material and methods: A focus group with eleven prenatal professionals working with socially underprivileged population was carried out in France in 2015. Content analysis of verbatim explanation was conducted with choice-of-subject categories carried out according to the triangulation principle, and topic trees were generated and applied. Results: The professionals have non-specialized experimental knowledge of emergent risks and were essentially preoccupied by infectious biological risks. In practice, however, they became increasingly cognizant of emergent risks. Their educational practices take cultural context into account but educational tools with imagination and affectivity have to be developed in order to reach socially underprivileged population. Discussion: Professionals are often sensitized to the field of environmental health in their apprehension of polluted biological environments, which they associate with social contexts and behavioral factors. In this study, we recommend adapted training programs and updated professional guidelines in view of reducing prenatal emergent risk exposures and social inequalities of health.

Determinants of Risk Perception Related to Exposure to Endocrine Disruptors during Pregnancy: A Qualitative and Quantitative Study on French Women

Endocrine disruptors (EDCs) are known as environmental exposure factors. However, they are rarely reported by health professionals in clinical practice, particularly during pregnancy, even though they are associated with many deleterious consequences. The objectives of this study were to estimate the risk perception of pregnant women related to EDC exposure and to evaluate its determinants. A qualitative study based on the Health Belief Model was carried out through interviews of pregnant women and focus group with perinatal, environmental health and prevention professionals in 2015 in the city of Poitiers, France. Then, determinants of risk perception were included in a questionnaire administered to 300 women in the perinatal period through a quantitative study. Scores were subsequently calculated. Perception of EDC risk was defined as perceived severity for different stages of the infant’s development and perceived susceptibility to EDC exposure. The determinants reported in the qualitative study were: age, strong maternal figure, socio-professional category, level of knowledge, and involuntariness of exposure. Age and level of knowledge were confirmed in our statistical model as determinants. Mean score of EDC risk perception was 55.0 ± 18.3 on 100 points. Our study should guide healthcare providers when advising pregnant women about EDC and environmental exposure. Our score for perceived EDC risk and assessment of its known determinants may help to assess the impact and the relevance of prevention programs dedicated to reducing exposure to EDC during pregnancy.

The Prenatal Visit

A pediatric prenatal visit during the third trimester is recommended for all expectant families as an important first step in establishing a child's medical home, as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition As advocates for children and their families, pediatricians can support and guide expectant parents in the prenatal period. Prenatal visits allow general pediatricians to establish a supportive and trusting relationship with both parents, gather basic information from expectant parents, offer information and advice regarding the infant, and may identify psychosocial risks early and high-risk conditions that may require special care. There are several possible formats for this first visit. The one used depends on the experience and preference of the parents, the style of the pediatrician's practice, and pragmatic issues of payment.

Endocrine Disruptors and Pregnancy: Knowledge, Attitudes and Prevention Behaviors of French Women

Endocrine disrupting chemicals (EDC) are environmental exposure factors that are rarely reported in clinical practice, particularly during pregnancy. This study aimed to describe women's knowledge, attitudes and behaviors towards EDC exposure. A study was conducted in the French Department of Vienne between 2014 and 2016 and comprised semi-structured interviews with pregnant women, a focus group of professionals in perinatology and environmental health, and the administration of a psychosocial questionnaire comprising scores in 300 pregnant or in postpartum period women. The mean score of knowledge was 42.9 ± 9.8 out of 100 (from 13.5 to 75.7). Exposure attitude was determined by risk perception. Mean level of cues to action to reduce their EDC exposure was estimated at 56.9 ± 22.5 out of 100 (from 0 to 100). Anxiety was significantly increased after the questionnaire. Anxiety about EDC was associated with a high score of knowledge (OR = 2.30, 95% CI (1.12-4.71)) and with no pregnancy anxiety (OR = 0.57, 95% CI (0.34-0.95)). Our findings suggest that healthcare providers should consider pregnant women's knowledge and perceptions, possibilities of action, and be careful not to increase their anxiety when advising them about EDC and environmental exposure.

Association of reproductive disorders and male congenital anomalies with environmental exposure to endocrine active pesticides

There is growing evidence that environmental exposure to pesticides may increase the risk of developing reproductive and developmental disorders. This study determined the prevalence and risk of developing gestational disorders and male congenital genitourinary malformations in areas with distinct exposure to pesticides, many of them with potential endocrine disrupting properties. A population-based case-control study was carried out on pregnant women and male children living in ten health districts of Andalusia classified as areas of high and low environmental exposure to pesticides according to agronomic criteria. The study population included 45,050 cases and 950,620 controls matched for age and health district. Data were collected from computerized hospital records between 1998 and 2005. Prevalence rates and risk of miscarriage, low birth weight, hypospadias, cryptorchidism and micropenis were significantly greater in areas with higher use of pesticides in relation to those with lower use, thus supporting and extending previous information.

Exposures to Endocrine Disrupting Chemicals in Consumer Products-A Guide for Pediatricians

Endocrine disrupting chemicals, a group of exogenous chemicals that can interfere with hormone action in the body, have been implicated in disrupting endocrine function, which negatively affects human health and development. Endocrine disrupting chemicals are ubiquitously detected in consumer products, foods, beverages, personal care products, and household cleaning products. Due to concerns about their negative effects on human health, several professional health provider societies have recommended the reduction of common endocrine disrupting chemical exposures. The purpose of this review is to provide a brief overview of common endocrine disrupting chemicals (bisphenol A, phthalates, triclosan, polybrominated ethers, and parabens) and potential effects on child development and health. In addition, we aim to provide guidance and resources for pediatricians and other health care providers with counseling strategies to help patients to minimize exposures to common endocrine disrupting chemicals.

The Role of Healthcare Professionals in Environmental Health and Fertility Decision-Making

There is increasing evidence that raises specific concerns about prenatal exposures to toxic substances which makes it necessary to consider everyday exposures to industrial chemicals and toxic substances in consumer products, including endocrine disrupting chemicals. Pregnant women have measurable levels of numerous toxic substances from exposures in their everyday environments, including those which are associated with adverse developmental and reproductive health outcomes. As a result, environmental contexts have begun to influence the decisions women make related to fertility, as well as the formal guidelines and advice provided by healthcare professionals. This article provides an overview of the potential role for obstetricians and gynecologists in educating their patients about the role of toxic substances in fertility decision-making and pregnancy. It explores the emerging guidelines and recommendations from professional organizations and problematizes the limitations of these approaches.

Perception of Environmental Risks and Health Promotion Attitudes of French Perinatal Health Professionals

The exposure of pregnant women to environmental contaminants is a subject of international concern. However, the risk perception of these contaminants by health professionals (HP) has not been extensively investigated. The main objective of the PERI-HELPE study (Perception of Risk-HEaLth Professionals & Environment Study) was to assess the risk perception of environmental exposure of pregnant women by perinatal HPs. The secondary objectives were to describe the preventive attitudes of perinatal HPs concerning chemicals exposure of pregnant women and to identify the barriers to preventive attitude. A cross-sectional study was performed in 2015 in France. One hundred eighty-nine HPs (obstetricians, midwives, and general practitioners) replied to an online self-administered questionnaire (participation rate: 11%). Carbon monoxide, pesticides and lead were the contaminants most frequently perceived as a high risk for pregnant women. A minority of HPs asked women about their chemical exposure and advised them to reduce exposure. The lack of information, training and scientific evidence in environmental health were the main difficulties declared by the HPs to advise pregnant women. Despite the low response rate, our findings provide important information to encourage French health authorities to take into account the difficulties encountered by HPs and set up appropriate training programs in Environmental health.

Environmental Contaminants and Reproductive Bodies: Provider Perspectives on Risk, Gender, and Responsibility

Increasingly, leading health organizations recommend that women who are pregnant or considering pregnancy avoid certain toxic chemicals found in our products, homes, and communities in order to protect fetuses from developmental and future harm. In the contemporary United States, women's maternal bodies have been treated as sites of exceptional risk and individual responsibility. Many studies have examined this phenomenon through the lens of lifestyle behaviors like smoking, drinking, and exercise. However, we know little about how environmental hazards fit into the dominant framework of gendered, individual responsibility for risk regulation. I draw on in-depth interviews with 19 reproductive healthcare providers in the United States to explore how they think about their patients' exposure to environmental contaminants and sometimes subvert this gendered, individualized responsibility and adopt more collective frames for understanding risk.

Implications of Applying Minimal Risk Standards in Clinical Research to Information Provision in Prenatal and Pre-conception Care

BACKGROUND

There have long been minimal risk thresholds beneath which risks may not need to be discussed in clinical research. This threshold concept may be applied to clinical practice. Our research explored application of minimal risk standards in research regulations to providing information in prenatal and pre-conception care.

METHODS

A case study approach applied minimal risk standards in research regulations to prenatal and pre-conception care with respect to the risks of excess alcohol consumption, folic acid insufficiency, exposure to phthalate plasticizers, and exposure to brominated flame retardants (BFRs).

RESULTS

Excess alcohol consumption and folic acid insufficiency were found to be above the minimal risk standards as outlined in research regulations, while exposure to phthalates and BFRs requires more evidence to determine whether they are above minimal risk. However, applying the minimal risk standard based on the daily life of a healthy adult or a fetus in a healthy pregnant woman, phthalates and BFRs are at the minimal risk threshold regardless of their potential harm since all pregnant women may be exposed to these chemicals in their daily life. Nevertheless, if there is demonstration of sufficient evidence of harm, they may be above minimal risk if such harm can be reduced by individual choice to avoid exposure.

CONCLUSION

The minimal risk concept in research regulations as applied to clinical practice may be useful to help clinicians and professional organizations determine what risks need be discussed in prenatal and pre-conception care.

Obesogens: an emerging threat to public health

Endocrine disrupting chemicals (EDCs) are defined as exogenous chemicals, or mixtures of chemicals, that can interfere with any aspect of hormone action. The field of endocrine disruption is historically rooted in wildlife biology and reproductive endocrinology where EDCs are demonstrated contributors to infertility, premature puberty, endometriosis, and other disorders. Recently, EDCs have been implicated in metabolic syndrome and obesity. Adipose tissue is a true endocrine organ and, therefore, an organ that is highly susceptible to disturbance by EDCs. A subset of EDCs, called "obesogens," promote adiposity by altering programming of fat cell development, increasing energy storage in fat tissue, and interfering with neuroendocrine control of appetite and satiety. Obesity adds more than $200 billion to US healthcare costs and the number of obese individuals continues to increase. Hence, there is an urgent, unmet need to understand the mechanisms underlying how exposures to certain EDCs may predispose our population to be obese. In this review, we discuss the history of obesogen discovery from its origins in reproductive biology to its latest role in the transgenerational inheritance of obesity in mice. We discuss the development of adipose tissue in an embryo, maintenance of adipocyte number in adults, how EDC disruption programs stem cells to preferentially make more adipocytes, the mechanisms by which chemicals can permanently alter the germline epigenome, and whether there are barriers to EDCs in the gametes.

Obesogens: an emerging threat to public health

Endocrine disrupting chemicals (EDCs) are defined as exogenous chemicals, or mixtures of chemicals, that can interfere with any aspect of hormone action. The field of endocrine disruption is historically rooted in wildlife biology and reproductive endocrinology where EDCs are demonstrated contributors to infertility, premature puberty, endometriosis, and other disorders. Recently, EDCs have been implicated in metabolic syndrome and obesity. Adipose tissue is a true endocrine organ and, therefore, an organ that is highly susceptible to disturbance by EDCs. A subset of EDCs, called "obesogens," promote adiposity by altering programming of fat cell development, increasing energy storage in fat tissue, and interfering with neuroendocrine control of appetite and satiety. Obesity adds more than $200 billion to US healthcare costs and the number of obese individuals continues to increase. Hence, there is an urgent, unmet need to understand the mechanisms underlying how exposures to certain EDCs may predispose our population to be obese. In this review, we discuss the history of obesogen discovery from its origins in reproductive biology to its latest role in the transgenerational inheritance of obesity in mice. We discuss the development of adipose tissue in an embryo, maintenance of adipocyte number in adults, how EDC disruption programs stem cells to preferentially make more adipocytes, the mechanisms by which chemicals can permanently alter the germline epigenome, and whether there are barriers to EDCs in the gametes.

Preconception care and reproductive planning in primary care

Preconception care is designed to identify and reduce biomedical, behavioral, and social risks to the health of a woman or her baby before pregnancy occurs. Few women present requesting preconception care; however, 1 in 10 US women of childbearing age will become pregnant each year. As primary care physicians (PCPs) care for reproductive-aged women before, between, and after their pregnancies, they are ideally positioned to help women address health risks before conception, including optimizing chronic conditions, to prevent adverse pregnancy and longer-term health outcomes. PCPs can help women make informed decisions both about preparing for pregnancy and about using effective contraception when pregnancy is not desired.

Medical education for obstetricians and gynecologists should incorporate environmental health

Obstetricians-gynecologists can protect the reproductive health of women, men, and their offspring from environmental hazards through preconception and prenatal counseling and encouraging patients to take actions to reduce environmental exposures. Although obstetricians-gynecologists are well positioned to prevent hazardous exposures, education on environmental health in medical education is limited. The Mid-Atlantic Center for Children's Health and the Environment and the Department of Obstetrics and Gynecology of George Washington University convened a meeting to begin integration of environmental health topics into medical education for obstetricians-gynecologists. Several avenues were identified to incorporate environmental health topics into medical education including continuing education requirements, inclusion of environmental health questions on board certification examinations and the creation of a curriculum on environmental health specific to obstetrics-gynecology.

Counseling patients on preventing prenatal environmental exposures--a mixed-methods study of obstetricians

OBJECTIVE

Describe the attitudes, beliefs, and practices of U.S. obstetricians on the topic of prenatal environmental exposures.

STUDY DESIGN

A national online survey of American Congress of Obstetricians and Gynecologists (ACOG) fellows and 3 focus groups of obstetricians.

RESULTS

We received 2,514 eligible survey responses, for a response rate of 14%. The majority (78%) of obstetricians agreed that they can reduce patient exposures to environmental health hazards by counseling patients; but 50% reported that they rarely take an environmental health history; less than 20% reported routinely asking about environmental exposures commonly found in pregnant women in the U.S.; and only 1 in 15 reported any training on the topic. Barriers to counseling included: a lack of knowledge of and uncertainty about the evidence; concerns that patients lack the capacity to reduce harmful exposures; and fear of causing anxiety among patients.

CONCLUSION

U.S. obstetricians in our study recognized the potential impact of the environment on reproductive health, and the role that physicians could play in prevention, but reported numerous barriers to counseling patients. Medical education and training, evidence-based guidelines, and tools for communicating risks to patients are needed to support the clinical role in preventing environmental exposures that threaten patient health.

Views of pregnant women and clinicians regarding discussion of exposure to phthalate plasticizers

OBJECTIVE

This study explores the views of pregnant women and clinicians regarding discussion of exposure to phthalate plasticizers during pregnancy, subsequent to the 2011 Health Canada ban of certain phthalates at a concentration greater than 1000 mg/kg in baby toys. This occurred with no regulation of products to which pregnant women are exposed, such as food packaging and cosmetics.

METHODS

Pregnant women, physicians and midwives were recruited through posters and pamphlets in prenatal clinics in Southwestern Ontario for a semi-structured interview. All interviews were audiotaped, transcribed, and subjected to rigorous qualitative analysis through a grounded theory approach, supported by NVIVO™ software. Themes emerged from line by line, open, and axial coding in an iterative manner.

RESULTS

Theoretical sufficiency was reached after 23 pregnant women and 11 clinicians had been interviewed. The themes (and subthemes from which they arose) were: Theme I-Information Provision (IA-Sources of Information, IB-Standardization, IC-Constraints, ID-Role of Government); Theme II-Risk (IIA-Significant Risk, IIB-Perceived Relevance, IIC-Reconciliation); and Theme III- Factors Influencing Level of Concern (IIIA-Current Knowledge, IIIB-Demographic Factors).

CONCLUSION

To respond to the increasing media and research attention regarding risk of phthalates to women, and pregnant women in particular, national professional organizations should provide patient information. This could include pamphlets on what a pregnant woman should know about phthalates and how they can be avoided, as well as information to clinicians to facilitate this discussion.

Exposure to toxic environmental agents

Reducing exposure to toxic environmental agents is a critical area of intervention for obstetricians, gynecologists, and other reproductive health care professionals. Patient exposure to toxic environmental chemicals and other stressors is ubiquitous, and preconception and prenatal exposure to toxic environmental agents can have a profound and lasting effect on reproductive health across the life course.Prenatal exposure to certain chemicals has been documented to increase the risk of cancer in childhood; adult male exposure to pesticides is linked to altered semen quality, sterility, and prostate cancer; and postnatal exposure to some pesticides can interfere with all developmental stages of reproductive function in adult females, including puberty, menstruation and ovulation, fertility and fecundity, and menopause. Many environmental factors harmful to reproductive health disproportionately affect vulnerable and underserved populations,which leaves some populations, including underserved women, more vulnerable to adverse reproductive health effects than other populations. The evidence that links exposure to toxic environmental agents and adverse reproductive and developmental health outcomes is sufficiently robust, and the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine join leading scientists and other clinical practitioners in calling for timely action to identify and reduce exposure to toxic environmental agents while addressing the consequences of such exposure.

Exposure to toxic environmental agents

: Reducing exposure to toxic environmental agents is a critical area of intervention for obstetricians, gynecologists, and other reproductive health care professionals. Patient exposure to toxic environmental chemicals and other stressors is ubiquitous, and preconception and prenatal exposure to toxic environmental agents can have a profound and lasting effect on reproductive health across the life course. Prenatal exposure to certain chemicals has been documented to increase the risk of cancer in childhood; adult male exposure to pesticides is linked to altered semen quality, sterility, and prostate cancer; and postnatal exposure to some pesticides can interfere with all developmental stages of reproductive function in adult females, including puberty, menstruation and ovulation, fertility and fecundity, and menopause. Many environmental factors harmful to reproductive health disproportionately affect vulnerable and underserved populations, which leaves some populations, including underserved women, more vulnerable to adverse reproductive health effects than other populations. The evidence that links exposure to toxic environmental agents and adverse reproductive and developmental health outcomes is sufficiently robust, and the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine join leading scientists and other clinical practitioners in calling for timely action to identify and reduce exposure to toxic environmental agents while addressing the consequences of such exposure.

Exploring prenatal outdoor air pollution, birth outcomes and neonatal health care utilization in a nationally representative sample

The impact of air pollution on fetal growth remains controversial, in part, because studies have been limited to sub-regions of the United States with limited variability. No study has examined air pollution impacts on neonatal health care utilization. We performed descriptive, univariate and multivariable analyses on administrative hospital record data from 222,359 births in the 2000, 2003 and 2006 Kids Inpatient Database linked to air pollution data drawn from the US Environmental Protection Agency's Aerometric Information Retrieval System. In this study, air pollution exposure during the birth month was estimated based on birth hospital address. Although air pollutants were not individually associated with mean birth weight, a three-pollutant model controlling for hospital characteristics, demographics, and birth month identified 9.3% and 7.2% increases in odds of low birth weight and very low birth weight for each μg/m(3) increase in PM(2.5) (both P<0.0001). PM(2.5) and NO(2) were associated with -3.0% odds/p.p.m. and +2.5% odds/p.p.b. of preterm birth, respectively (both P<0.0001). A four-pollutant multivariable model indicated a 0.05 days/p.p.m. NO(2) decrease in length of the birth hospitalization (P=0.0061) and a 0.13 days increase/p.p.m. CO (P=0.0416). A $1166 increase in per child costs was estimated for the birth hospitalization per p.p.m. CO (P=0.0002) and $964 per unit increase in O(3) (P=0.0448). A reduction from the 75th to the 25th percentile in the highest CO quartile for births predicts annual savings of $134.7 million in direct health care costs. In a national, predominantly urban, sample, air pollutant exposures during the month of birth are associated with increased low birth weight and neonatal health care utilization. Further study of this database, with enhanced control for confounding, improved exposure assessment, examination of exposures across multiple time windows in pregnancy, and in the entire national sample, is supported by these initial investigations.