Web-based behavioral intervention to reduce exposure to phthalate metabolites, bisphenol A, triclosan, and parabens in mothers with young children: A randomized controlled trial

Reducing Exposures to Endocrine Disruptors (REED) study, a personalized at-home intervention program to reduce exposure to endocrine disrupting chemicals among a child-bearing age cohort: study protocol for a randomized controlled trial

BACKGROUND

Exposures to endocrine disrupting chemicals (EDCs) have been linked to chronic diseases including breast cancer, metabolic syndrome, diabetes, and infertility. Exposure during pregnancy may have a lifelong impact on the fetus. Services are needed to allow individuals to learn about their personal EDC exposures and how to reduce them. Million Marker (MM) aims to crowdsource and scale the biomonitoring of environmental chemicals and provide actionable results to empower individuals to proactively assess, track, and reduce their EDC exposures. In previous research, we developed and tested the first mobile EDC intervention service (mail-in urine testing and exposure report-back) for its efficacy in increasing EH literacy (EHL), willingness to reduce exposures (i.e., readiness to change, RtC), and system usability. After intervention, we found increased EHL, increased RtC in women (but not men), and decreased EDC exposure. However, some participants did not increase their RtC and had difficulty carrying out the intervention on their own. The reasons for these less optimal results were the difficulty in the EHL subject matter-participants still felt ill-prepared to apply their knowledge to making healthier lifestyle changes. Therefore, in this study, we will address these perceived limitations.

METHODS

We will test a self-directed online interactive curriculum with live counseling sessions and individualized support modeled after the highly effective Diabetes Prevention Program (DPP). Recruiting from the Healthy Nevada Project (HNP), one of the largest population health cohorts in the world, we test the effectiveness of our EDC-specific online intervention curriculum via EHL and RtC surveys and determine changes in EDC exposure before and after intervention in a randomized controlled trial. We will also test for common clinical biomarkers via a commercially available at-home test (Siphox). We will recruit and randomize 300 women and 300 men of reproductive age (total n=600) from HNP. Our target population is men and women of reproductive age (18-44 years old).

DISCUSSION

At the conclusion of this project, we will be well-positioned to scale our services to clinics and the general public, with the eventual aims of FDA approval, insurance coverage, and incorporation into routine clinical care.

Lifestyle and Chemicals: Exploring Behavioral Habits Related to Endocrine Disruptor Exposure Among the General Population of Saudi Arabia

BACKGROUND

Endocrine-disrupting chemicals (EDCs) interfere with hormonal systems, potentially causing metabolic, reproductive, and neurological issues, as well as hormone-related cancers. Found in everyday products, EDCs accumulate in body tissues over time, with adverse effects depending on the dose and duration of exposure. This study aims to explore behaviors related to EDC exposure among Saudi citizens to assess the need for further risk reduction interventions.

METHODOLOGY

This cross-sectional study employed a validated, self-administered online questionnaire to assess daily life behaviors associated with EDC exposure. A total of 563 participants were recruited using convenient sampling through online platforms.

RESULTS

The study revealed that a significant majority of participants were aged 18-25 years (48.67%, n=274). On average, participants scored 32.78 out of a maximum of 60 for potential EDC exposure, with scores ranging from 13 to 54 points. The majority (85.26%, n=480) fell into the moderate potential exposure category, while a small minority (4.26%, n=24) exhibited high potential risk based on their reported daily habits, predominantly among male participants (95.83%, n=23). A significant majority (72.65%, n=409) indicated a likelihood of adopting lifestyle changes to reduce exposure to harmful substances.

CONCLUSION

This study reveals diverse behavioral patterns linked to endocrine disruptor exposure among the general population in Saudi Arabia. Interestingly, the participants showed a positive attitude and willingness to change their risky behaviors. These findings underscore the necessity for educational programs and public health campaigns aimed at addressing gaps in knowledge. Encouraging the public to adopt behaviors that reduce exposure is essential to minimizing the potential long-term effects of EDCs.

Bisphenol A-What Do We Know? A Global or Local Approach at the Public Health Risk Level

BPA has demonstrated enormous multisystem and multi-organ toxicity shown mainly in animal models. Meanwhile, the effects of its exposure in humans still require years of observation, research, and answers to many questions. Even minimal and short-term exposure contributes to disorders or various types of dysfunction. It is released directly or indirectly into the environment at every stage of the product life cycle, demonstrating its ease of penetration into the body. The ubiquity and general prevalence of BPA influenced the main objective of the study, which was to assess the toxicity and health effects of BPA and its derivatives based on the available literature. In addition, the guidelines of various international institutions or regions of the world in terms of its reduction in individual products were checked. Bisphenol A is the most widely known chemical and perhaps even the most studied by virtually all international or national organizations, but nonetheless, it is still controversial. In general, the level of BPA biomonitoring is still too high and poses a potential threat to public health. It is beginning to be widely argued that future toxicity studies should focus on molecular biology and the assessment of human exposure to BPA, as well as its substitutes. The effects of its exposure still require years of observation, extensive research, and answers to many questions. It is necessary to continue to deepen the knowledge and interest of many organizations, companies, and consumers around the world in order to make rational purchases as well as future choices, not only consumer ones.

Phthalate exposure and lung disease: the epidemiological evidences, plausible mechanism and advocacy of interventions

Phthalates are a kind of synthetic plasticizers, which extensively used as plastic productions to improve their plasticity and flexibility. However, exposure to phthalates has been proved an increased risk of respiratory disease, because by they affect the development and functions of the lung and immune system. Here, we attempt to review respiratory health of phthalate exposure. Firstly, we describe the relationship between phthalates and lung function and airway inflammation. Then, the role of phthalates in asthma, lung cancer, rhinitis, and respiratory tract infections and the possible mechanisms of action are discussed. Finally, possible effective measures to reduce exposure to phthalates are proposed, and health care workers are called upon to provide educational resources and advocate for informed public health policies. Overall, the evidence for association between phthalate exposure and respiratory disease is weak and inconsistent. Therefore, thorough implementation in large populations is needed to produce more consistent and robust results and to enhance the overall understanding of the potential respiratory health risks of phthalate in long-term exposure.

Effects of Behavioral, Clinical, and Policy Interventions in Reducing Human Exposure to Bisphenols and Phthalates: A Scoping Review

BACKGROUND

There is growing interest in evidence-based interventions, programs, and policies to mitigate exposures to bisphenols and phthalates and in using implementation science frameworks to evaluate hypotheses regarding the importance of specific approaches to individual or household behavior change or institutions adopting interventions.

OBJECTIVES

This scoping review aimed to identify, categorize, and summarize the effects of behavioral, clinical, and policy interventions focused on exposure to the most widely used and studied bisphenols [bisphenol A (BPA), bisphenol S (BPS), and bisphenol F (BPF)] and phthalates with an implementation science lens.

METHODS

A comprehensive search of all individual behavior, clinical, and policy interventions to reduce exposure to bisphenols and phthalates was conducted using PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar. We included studies published between January 2000 and November 2022. Two reviewers screened references in CADIMA, then extracted data (population characteristics, intervention design, chemicals assessed, and outcomes) for studies meeting inclusion criteria for the present review.

RESULTS

A total of 58 interventions met the inclusion criteria. We classified interventions as dietary (n = 27 ), clinical (n = 13 ), policy (n = 14 ), and those falling outside of these three categories as "other" (n = 4 ). Most interventions (81%, 47/58) demonstrated a decrease in exposure to bisphenols and/or phthalates, with policy level interventions having the largest magnitude of effect.

DISCUSSION

Studies evaluating policy interventions that targeted the reduction of phthalates and BPA in goods and packaging showed widespread, long-term impact on decreasing exposure to bisphenols and phthalates. Clinical interventions removing bisphenol and phthalate materials from medical devices and equipment showed overall reductions in exposure biomarkers. Dietary interventions tended to lower exposure with the greatest magnitude of effect in trials where fresh foods were provided to participants. The lower exposure reductions observed in pragmatic nutrition education trials and the lack of diversity (sociodemographic backgrounds) present limitations for generalizability to all populations. https://doi.org/10.1289/EHP11760.

Urinary concentrations and elimination half-lives of parabens, benzophenones, bisphenol and triclosan in Japanese young adults

Environmental phenols are widely distributed in the environment and human samples, suggesting potential exposure to these chemicals. We designed an intervention trial with 30 participants over 6 days to assess the urinary concentrations and half-lives of environmental phenols in Japanese young people. The target environmental phenols include three parabens (methyl paraben, ethyl paraben, and propyl paraben), two benzophenones (benzophenone 1 and 3), two bisphenols (bisphenol F and bisphenol S), and triclosan. Throughout the intervention, the participants consumed the same food and drinks and used personal care products provided by the project. The target phenols were measured in urine from the participants using a liquid chromatography-tandem mass spectrometer. We compared the measured concentrations between the study periods to better understand the exposure tendency. Some statistically significant differences were observed. All target analytes were detected in more than 50% of samples collected on Day 0 (the day before the intervention). Methyl paraben was the dominant phenol detected in urine (1640 μg/g-creatinine), followed by ethyl paraben (119 μg/g-creatinine). Downward trends in creatinine-corrected concentrations were observed for all target analytes in some instances. Non-compartment analysis was performed to estimate urinary excretion parameters. The estimated half-lives ranged from 7.69 to 20.3 h. Use of paraben-free products during the intervention period reduced the body burden.

Prenatal Exposure to Nonpersistent Environmental Chemicals and Postpartum Depression

Importance

Postpartum depression (PPD) affects up to 20% of childbearing individuals, and a significant limitation in reducing its morbidity is the difficulty in modifying established risk factors. Exposure to synthetic environmental chemicals found in plastics and personal care products, such as phenols, phthalates, and parabens, are potentially modifiable and plausibly linked to PPD and have yet to be explored.

Objective

To evaluate associations of prenatal exposure to phenols, phthalates, parabens, and triclocarban with PPD symptoms.

Design, Setting, and Participants

This was a prospective cohort study from 5 US sites, conducted from 2006 to 2020, and included pooled data from 5 US birth cohorts from the National Institutes of Health Environmental Influences on Child Health Outcomes (ECHO) consortium. Participants were pregnant individuals with data on urinary chemical concentrations (phenols, phthalate metabolites, parabens, or triclocarban) from at least 1 time point in pregnancy and self-reported postnatal depression screening assessment collected between 2 weeks and 12 months after delivery. Data were analyzed from February to May 2022.

Exposures

Phenols (bisphenols and triclosan), phthalate metabolites, parabens, and triclocarban measured in prenatal urine samples.

Main Outcomes and Measures

Depression symptom scores were assessed using the Edinburgh Postnatal Depression Scale (EPDS) or the Center for Epidemiologic Studies Depression Scale (CES-D), harmonized to the Patient-Reported Measurement Information System (PROMIS) Depression scale. Measures of dichotomous PPD were created using both sensitive (EPDS scores ≥10 and CES-D scores ≥16) and specific (EPDS scores ≥13 and CES-D scores ≥20) definitions.

Results

Among the 2174 pregnant individuals eligible for analysis, nearly all (>99%) had detectable levels of several phthalate metabolites and parabens. PPD was assessed a mean (SD) of 3 (2.5) months after delivery, with 349 individuals (16.1%) and 170 individuals (7.8%) screening positive for PPD using the sensitive and specific definitions, respectively. Linear regression results of continuous PROMIS depression T scores showed no statistically significant associations with any chemical exposures. Models examining LMW and HMW phthalates and di (2-ethylhexyl) phthalate had estimates in the positive direction whereas all others were negative. A 1-unit increase in log-transformed LMW phthalates was associated with a 0.26-unit increase in the PROMIS depression T score (95% CI, -0.01 to 0.53; P = .06). This corresponded to an odds ratio (OR) of 1.08 (95% CI, 0.98-1.19) when modeling PPD as a dichotomous outcome and using the sensitive PPD definition. HMW phthalates were associated with increased odds of PPD (OR, 1.11; 95% CI, 1.00-1.23 and OR, 1.10; 95% CI, 0.96-1.27) for the sensitive and specific PPD definitions, respectively. Sensitivity analyses produced stronger results.

Conclusions and Relevance

Phthalates, ubiquitous chemicals in the environment, may be associated with PPD and could serve as important modifiable targets for preventive interventions. Future studies are needed to confirm these observations.

Effects of postnatal exposure to phthalate, bisphenol a, triclosan, parabens, and per- and poly-fluoroalkyl substances on maternal postpartum depression and infant neurodevelopment: a korean mother-infant pair cohort study

Exposure to endocrine-disrupting chemicals (EDCs) can promote infant neurodevelopmental impairment and maternal postpartum depression (PPD). However, the associations between lactation exposure to EDCs, maternal PPD, and infant neurodevelopment are unclear. Hence, we investigated these relationships in infants aged 36-42 months. We recruited 221 Korean mothers and analyzed 29 EDCs. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess maternal PPD. Bayley scales of infant development; the Swanson, Nolan, and Pelham rating scale (SNAP); and the Child Behavior Checklist (CBCL) were used to assess neurodevelopment in infants exposed to the top 30% of EDC over three years. Multiple regression analyses were adjusted for maternal age, pre-pregnancy body mass index, education, income, employment, residence, and infant age and sex. The rates of infants with clinically abnormal diagnoses on neurologic developmental tests (Balyey, SNAP, and CBCL scales) ranged from 7.7 to 38.5% in this study, with the motor and hyperactivity/impulsivity areas scoring the highest among 65 boys and girls. Mono-2-ethylhexyl phthalate (MEHP) and mono-isononyl phthalate (MiNP) levels in breast milk significantly correlated with infant inattention and hyperactivity. Perfluorononanoic acid (PFNA) and perfluorooctyl sulfonate (PFOS) levels correlated significantly with motor development of BSID-III and total CBCL score which mean infant might have lower developmental status. EDC concentrations in breast milk were not associated with maternal PPD. Overall, lactational exposure to EDCs during the postpartum period can exert a negative effect on maternal PPD and infant neurodevelopment.

Supporting legislative action: Urinary levels of phthalates and phenols among influencers in the 'Plastics in the spotlight' advocacy initiative

BACKGROUND

Society-wide initiatives to prevent human exposure to plastic residues include laws and policies. Such measures require citizens' support, which can be increased by honest advocacy and pedagogic projects. These efforts must have a scientific basis.

OBJECTIVE

To assist the 'Plastics in the spotlight' advocacy initiative raise awareness among the general public of the presence of plastic residues in the human body, and to increase citizens' support for legislation on plastic control in the European Union.

METHODS

Spot urine samples of 69 volunteers with cultural and political influence from Spain, Portugal, Latvia, Slovenia, Belgium, and Bulgaria were collected. Concentrations of 30 phthalate metabolites and phenols were determined through a high-performance liquid chromatography with tandem mass spectrometry and ultra-high-performance liquid chromatography with tandem mass spectrometry, respectively.

RESULTS

At least 18 compounds were detected in all urine samples. The maximum number of compounds detected per participant was 23, and the mean, 20.5. Phthalates were detected more frequently than phenols. Median concentrations were highest for monoethyl phthalate (41.6 ng/mL, adjusted for specific gravity), and maximum concentrations were highest for mono-iso-butyl phthalate (1345.1 ng/mL), oxybenzone (1915.1 ng/mL), and triclosan (949.6 ng/mL). Most reference values were not exceeded. Women had higher concentrations of the 14 phthalate metabolites and oxybenzone than men. Urinary concentrations were not correlated with age.

DISCUSSION

The study had three main limitations: method of subject selection (volunteers), small sample size, and limited data on determinants of exposure. Studies on volunteers do not pretend to be representative of the general population and are no substitute for biomonitoring studies in representative samples of the populations of interest. Studies as ours can only illustrate the existence and some aspects of the problem, and can raise awareness among citizens concerned by the evidence that the studies provide in a group of subjects who are humanly appealing.

CONCLUSIONS

The results illustrate that human exposure to phthalates and phenols is widespread. All countries appeared to be similarly exposed to these contaminants, with higher levels in females. Most concentrations did not exceed reference values. The effects of this study on the objectives of the 'Plastics in the spotlight' advocacy initiative deserve a specific analysis from policy science.

Interventions to Reduce Exposure to Synthetic Phenols and Phthalates from Dietary Intake and Personal Care Products: a Scoping Review

PURPOSE OF REVIEW

A scoping review was conducted to identify interventions that successfully alter biomarker concentrations of phenols, glycol ethers, and phthalates resulting from dietary intake and personal care product (PCPs) use.

RECENT FINDINGS

Twenty-six interventions in populations ranging from children to older adults were identified; 11 actively removed or replaced products, 9 provided products containing the chemicals being studied, and 6 were education-only based interventions. Twelve interventions manipulated only dietary intake with a focus on bisphenol A (BPA) and phthalates, 8 studies intervened only on PCPs use and focused on a wider range of chemicals including BPA, phthalates, triclosan, parabens, and ultraviolet absorbers, while 6 studies intervened on both diet and PCPs and focused on phthalates, parabens, and BPA and its alternatives. No studies assessed glycol ethers. All but five studies reported results in the expected direction, with interventions removing potential sources of exposures lowering EDC concentrations and interventions providing exposures increasing EDC concentrations. Short interventions lasting a few days were successful. Barriers to intervention success included participant compliance and unintentional contamination of products. The identified interventions were generally successful but illustrated the influence of participant motivation, compliance, ease of intervention adherence, and the difficulty of fully removing exposures due their ubiquity and the difficulties of identifying "safer" replacement products. Policy which reduces or removes EDC in manufacturing and processing across multiple sectors, rather than individual behavior change, may have the greatest impact on population exposure.

Time-course trend and influencing factors for per- and polyfluoroalkyl substances in the breast milk of Korean mothers

Many studies have reported that neonates and infants are exposed to several per- and polyfluoroalkyl substances (PFASs) via breastfeeding; however, these studies have had small sample sizes. This study aimed to determine the concentrations and time-course trend of PFASs in breast milk and identify influencing factors governing PFAS concentrations. Between July and September (2018), 207 low-risk primiparous women were recruited from a lactation counseling clinic in Korea and their breast milk samples were tested for 14 PFASs, including four perfluoroalkyl sulfonic acids. A questionnaire survey, comprising 84 questions covering the women's demographic, obstetrical, dietary, lifestyle, behavioral, and neonatal information, was conducted to investigate associations. Twelve of the 14 PFASs were detectable in breast milk samples. Perfluorooctanesulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and perfluorodecanoic acid were detected in 100% of the samples, followed by perfluorohexanesulfonic acid (detection rate: 87%), perfluorononanoic acid (87%), and perfluorohexanoic acid (73%); the median concentrations were 0.05, 0.10, 0.031, 0.007, and 0.033 ng/mL, respectively. The PFAS concentrations in breast milk measured in our study were higher than those reported in other studies or countries. In 12 years, from 2007 to 18, the mean concentration of PFOA in breast milk increased by approximately three times (278%). The major factors associated with PFAS concentrations in the bivariate association analysis were body mass index; living area (non-metropolitan); neonatal age; and frequency of fish, ice cream, and canned food consumption. In the multiple regression model, fish consumption significantly influenced the PFOS concentrations in breast milk (β = 0.88, p = 0.033). Frequently, fish consumption has been analyzed as the main dietary factor related to PFOS concentration. Our findings suggest the need for a comprehensive cohort study on PFAS exposure and its association with infant health.

Lifestyle interventions to reduce endocrine-disrupting phthalate and phenol exposures among reproductive age men and women: A review and future steps

Non-persistent endocrine-disrupting chemicals (EDCs), including phthalates and phenols, are ubiquitous in both the environment and human body. A growing body of epidemiologic studies have identified concerning links between EDCs and adverse reproductive and developmental health effects. Despite consistent evidence, risk assessments and policy interventions often arrive late. This presents an urgent need to identify evidence-based interventions for implementation at both clinical and community levels to reduce EDC exposure, especially in susceptible populations. The reproductive life cycle (menarche to menopause for females and after pubertal onset for males) includes some of the most vulnerable periods to environmental exposures, such as the preconception and perinatal stages, representing a key window of opportunity to intervene and prevent unfavorable health outcomes. This review aims to synthesize and assess behavioral, dietary, and residential EDC-driven interventions to develop recommendations for subsequent, larger-scale studies that address knowledge-gaps in current interventions during the reproductive life cycle. We selected 21 primary interventions for evaluation, in addition to four supplemental interventions. Among these, accessible (web-based) educational resources, targeted replacement of (known) toxic products, and personalization of the intervention through meetings and support groups, were the most promising strategies for reducing EDC concentrations. However, we document a paucity of interventions to prevent phthalate and phenol exposures during the reproductive years, especially among men. Accordingly, we recommend additional, larger clinical and community-based intervention studies to reduce EDC exposure. Specifically, future intervention studies should focus on short-term, mid-, and long-term exposure reduction to phthalates and phenols. The latter, especially, is required for the development of clinical and public health guidelines to promote reproductive and developmental health globally.

Interventions on Reducing Exposure to Endocrine Disrupting Chemicals in Human Health Care Context: A Scoping Review

Purpose

Inevitability of exposure to endocrine disrupting chemicals (EDCs) in daily lives of modern society is increasing interests in developing and implementing interventions to prevent or reduce harmful health effects of EDCs in various academic areas. This is a scoping review of intervention studies aimed at reducing exposure to EDCs in the text of human health care.

Methods

Scoping review methodology was used to explore the extent, range, and nature of current literature. A comprehensive systematic search of PubMed, CINAHL, Cochrane, PcycINFO, EMBASE, and RISS was performed for studies published to date. The authors followed Arksey and O'Malley's stages; 1) identification of research questions; 2) identification of relevant studies using a total of six electronic databases; 3) study selection; 4) charting the data; and 5) collation, summarization and reporting of the data.

Results

A total of 2114 articles were retrieved, from which 13 articles were included in the final review. Among the 13 studies, 12 conducted interventions regarding dietary modification or replacement of household or personal goods. The duration of interventions ranged from at least three days to a maximum of six months, including six studies with a period of less than ten days. The participants were all healthy populations, eight of which were for adults, three for children or adolescents, and two for families. Outcome of the interventions were measured through concentration of EDCs in urine or/and house air. The effects of the interventions were inconsistent, with 11 studies showing significant changes of EDC concentration while no significant change was found in two studies.

Conclusion

The results indicate a need for randomized controlled trials, participant-centered studies promoting active participation and practices of subjects, studies specifying subgroups of participants, and studies including families as units in interventions.