Recommending calcium to reduce lead toxicity in children: a critical review

Male zebra finches exposed to lead (Pb) during development have reduced volume of song nuclei, altered sexual traits, and received less attention from females as adults

Lead (Pb) is a pervasive global contaminant that interferes with sensitive windows for neurological development and causes oxidative damage to tissues. The effects of moderate and high exposure to Pb have been well-studied in birds, but whether low-level early-life exposure to Pb influences adult phenotype remains unclear. Female songbirds use a male's song and coloration to discriminate between high- and low-quality males. Therefore, if early-life exposure to Pb disrupts song learning ability or shifts the allocation of antioxidant pigments away from colorful secondary sexual traits, male birds exposed to Pb may be less attractive to females. We exposed developing zebra finches (Taeniopygia guttata) to Pb-contaminated drinking water (100 or 1000 parts per billion [ppb]) after hatching (days 0-100). Once male finches reached adulthood (120-150 days post hatch), we measured song learning ability, coloration of bill and cheek patches, and volume of song nuclei in the brain. We also measured female preference for Pb-exposed males relative to control males. Finally, we measured motoric and spatial cognitive performance in male and female finches to assess whether cognitive traits differed in their sensitivity to Pb exposure. Male zebra finches exposed to 1000 ppb Pb had impaired song learning ability, reduced volume of song nuclei, bills with less redness and received less attention from females. Additionally, Pb exposure impaired motoric performance in both male and female finches but did not affect performance in a spatial cognitive task. Adult finches exposed to Pb-contaminated water had higher blood-Pb levels, though in all cases blood-Pb levels were below 7.0 µg dL^-1. This study suggests that low-level exposure to Pb contributes to cognitive deficits that persist into adulthood and may indirectly influence fitness by altering secondary sexual traits and reducing male attractiveness.

Dietary zinc, calcium and nickel are associated with lower childhood blood lead levels

The potential mitigation of elevated blood lead (PbB) levels with nutrient intake remains debatable. A comprehensive review by Kordas (2017) concluded that careful examination of the links between nutrition (nutritional status, nutrients, diet) and lead (Pb) exposure revealed limited and tenuous evidence. We have measured 20 elements including calcium (Ca), chromium (Cr), copper (Cu), iron (Fe), magnesium (Mg), manganese (Mn), nickel (Ni), zinc (Zn), and Pb from 6-day duplicate diets of 108 young children over a 5-year period and expressed these as intakes per body weight. Bivariate analyses showed a weak positive association between the Pb content in the diets of the participants and the level of Pb in their blood, as might be expected. Weak, but negative, associations occurred between the other elements in the diet and PbB. The associations for Ca, Mg, Ni and Zn were statistically significant for both subject-based (between subjects) and within-subject effects: that is, as the levels of elements in diet increased, the PbB level decreased. The largest percentage of variance of PbB in the context of the bivariate model accounted for was 4.23% for Zn, followed by Ca (3.91%) and Fe (2.20%). Supplementary analyses indicated that the between- and within-subject effects did not vary with the age at which participants entered the study, or with the levels of elements at their first measurement. A multivariable analysis using Weighted Quantile Sum Regressions showed that a weighted composite comprised of all the dietary elements had a significant association with PbB when adjusted for Pb in the diet and other covariates and also when adjusted for Pb in house dust; the latter was found to have the strongest association with PbB in earlier analyses. The highest weights were for Ca (0.29), Ni (0.27) and Zn (0.22); these results are generally consistent with those from the mixed model analyses.

The effect of lead (Pb) exposure and iron (Fe) deficiency on intestinal lactobacilli, E. coli and yeast: A study in experimental rats

OBJECTIVE

The current study investigated the additive effect of oral lead (Pb) exposure and dietary iron (Fe) deficiency on intestinal lactobacilli, E. coli, and yeast in SD rats.

METHODS

Weanling rats were fed on control diet (CD) or iron deficient diet (ID) for 4 weeks, followed by oral Pb exposure for another 4 weeks. Lead exposure was withdrawn for 2 weeks, and then resumed after 2 weeks. Blood samples were collected to determine haemoglobin (Hb), serum iron, blood Pb and δ-Aminolevulenic acid dehydratase (ALAD) activity. Fecal samples were collected to enumerate the lactobacilli, E. coli and yeast population on selective agar media and determine Pb levels.

RESULTS

Hb and serum Fe levels decreased significantly in iron deficient rats. Pb exposed rats had a significant increase in blood Pb levels and decreased ALAD activity. The lactobacilli population was significantly decreased (p<0.05) in ID rats compared to the CD group. Further, a significant decrease in the lactobacilli population was observed in Pb exposed rats irrespective of the dietary regimen. Upon withdrawal of Pb exposure, lactobacilli increased significantly in both the CD+Pb and ID+Pb groups, whereas re-exposure to Pb decreased lactobacilli population. The E. coli and yeast populations were inconsistent among both the ID and Pb exposed rats compared to controls. Fecal Pb levels increased significantly in Pb exposed rats irrespective of diet.

CONCLUSION

An additive effect of dietary Fe deficiency and oral Pb exposure resulted in greater reductions in the intestinal lactobacilli population compared to either treatment alone. In addition, transient withdrawal of Pb exposure led to improved lactobacilli population irrespective of Fe status.

Nutritional status and diet as predictors of children's lead concentrations in blood and urine

Lead exposure remains an important public health problem. Contaminated foods may act as a source of lead exposure, while certain nutrients may reduce lead absorption. We examined the cross-sectional associations of dietary patterns and the intake of several nutrients and foods with blood (Pb-B) and urinary (Pb-U) lead concentrations in children (5-8y) from Montevideo, Uruguay. From two 24-hour recalls completed by caregivers, we derived the mean daily intake of select nutrients and food groups (dairy, milk, fruit, root vegetables, foods rich in heme and non-heme iron), as well as "nutrient dense" and "processed" food patterns. Pb-B (n=315) was measured using atomic absorption spectrometry; Pb-U (n=321) using ICP-MS. Pb-U was adjusted for specific gravity and log-transformed to approximate a normal distribution. Iron deficiency (ID) and dietary variables were tested as predictors of Pb-B and log-Pb-U in covariate-adjusted regressions. Median [5%, 95%] Pb-B and Pb-U were 3.8 [0.8-7.8] μg/dL and 1.9 [0.6-5.1] μg/L, respectively; ~25% of Pb-B above current U.S. CDC reference concentration of 5μg/dL. ID was associated with 0.75μg/dL higher Pb-B, compared to non-ID (p<0.05). Consumption of root vegetables was not associated with Pb-B or log-Pb-U. Higher scores on the nutrient-dense pattern were related with higher Pb-Bs, possibly due to consumption of green leafy vegetables. Dietary intake of iron or iron-rich foods was not associated with biomarkers of lead. Conversely, children consuming more calcium, dairy, milk and yogurt had lower Pb-B and log-Pb-U. Our findings appear consistent with existing recommendations on including calcium-rich, but not iron- or vitamin-C-rich foods in the diets of lead-exposed children, especially where the consumption of these foods is low.

Blood Lead and Other Metal Biomarkers as Risk Factors for Cardiovascular Disease Mortality

Analyses of the Third National Health and Nutrition Examination Survey (NHANES III) in 1988 to 1994 found an association of increasing blood lead levels < 10 μg/dL with a higher risk of cardiovascular disease (CVD) mortality. The potential need to correct blood lead for hematocrit/hemoglobin and adjust for biomarkers for other metals, for example, cadmium and iron, had not been addressed in the previous NHANES III-based studies on blood lead-CVD mortality association. We analyzed 1999 to 2010 NHANES data for 18,602 participants who had a blood lead measurement, were ≥ 40 years of age at the baseline examination and were followed for mortality through 2011. We calculated the relative risk for CVD mortality as a function of hemoglobin- or hematocrit-corrected log-transformed blood lead through Cox proportional hazard regression analysis with adjustment for serum iron, blood cadmium, serum C-reactive protein, serum calcium, smoking, alcohol intake, race/Hispanic origin, and sex. The adjusted relative risk for CVD mortality was 1.44 (95% confidence interval = 1.05, 1.98) per 10-fold increase in hematocrit-corrected blood lead with little evidence of nonlinearity. Similar results were obtained with hemoglobin-corrected blood lead. Not correcting blood lead for hematocrit/hemoglobin resulted in underestimation of the lead-CVD mortality association while not adjusting for iron status and blood cadmium resulted in overestimation of the lead-CVD mortality association. In a nationally representative sample of U.S. adults, log-transformed blood lead was linearly associated with increased CVD mortality. Correcting blood lead for hematocrit/hemoglobin and adjustments for some biomarkers affected the association.

Risk factors for lead exposure in adult population in southern Brazil

In Brazil there is no systematic evaluation to access blood lead levels (BLL) in the general population and few studies with adults have been published. The aim of this study was to examine the socioeconomic, environmental, and lifestyle determinants of BLL in the adult Brazilian population. In total, 959 adults, aged 40 years or more, were randomly selected in a city in southern Brazil. Information on socioeconomic, dietary, lifestyle, and occupational background was obtained by interviews. A spatial analysis was conducted to discern whether there were any identifiable sources of exposure. BLL were measured by inductively coupled plasma-mass spectrometry. There was an adjustment for gender, age, race, education, income class, smoking status, alcohol consumption, occupation, and red meat or cow milk consumption (Model 1), and for occupation and gender (Model 2). The geometric mean of BLL was 1.97 μg/dl (95% CI: 1.9-2.04 μg/dl). In Model 1, BLL were positively associated with male gender, older age, and drinking and smoking habits, and less frequently with milk consumption. In Model 2, data showed higher BLL in non-white than white participants, in former smokers and individuals with current or former employment in lead (Pb) industries. The participants living in the area with more Pb industries had higher BLL (3.3 μg/dl) compared with those residing in other areas with no or fewer Pb industries (1.95 μg/dl). Despite the low BLL found in adults living in an urban area, Pb industries need to be monitored and regulatory laws implemented to prevent metal contamination in urban settings.

Contribution of dietary patterns to blood heavy metal concentrations in Korean adults: findings from the Fifth Korea National Health and Nutrition Examination Survey 2010

The aim of the present study was to evaluate the associations between dietary patterns and blood levels of lead and mercury in Korean adults. A total of 858 Korean adults (≥20 years) who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) V-1 2010 were included in this study. Data of biochemical measurements including blood lead and mercury levels, nutrients intakes and anthropometric measurements were acquired. 'Balanced diet', 'Grain and kimchi', and 'Alcohol and noodle' dietary patterns were derived from a factor analysis, and the subjects were divided into tertiles by each dietary pattern score. A logistic multiple regression analysis showed that the balanced diet pattern was negatively associated with blood levels of lead before and after adjustment. On the other hand, the alcohol and noodle pattern was positively associated with blood lead and mercury levels. These results indicate that the alcohol and noodle dietary pattern characterized by high alcohol consumption and lack of various foods, and the balanced dietary pattern, including vegetable, fish, meat and milk intake, was associated with the blood concentrations of heavy metals in Korean adults.

The effect of calcium supplementation on blood lead levels in Nigerian children

OBJECTIVE

To determine whether calcium supplementation alters the risk of lead toxicity.

STUDY DESIGN

Children aged 12-18 months from 3 communities in Nigeria were assigned to receive daily calcium supplementation, as either calcium carbonate (400 mg) or ground dried fish (529 ± 109 mg), or placebo. All children received 2500 IU of vitamin A. Levels of blood lead, calcium, and vitamin D metabolites were measured at baseline and after 12-18 months (n = 358).

RESULTS

The mean (± SD) baseline lead level was 11.1 ± 7.8 μg/dL (range, 1-43 μg/dL; median, 9 μg/dL); 44.7% of subjects had a lead level >10 μg/dL. After 12-18 months, the mean lead level was 8.1 ± 6.3 μg/dL (range, 1-48 μg/dL; median, 6 μg/dL), with 22.6% with a level >10 μg/dL. Lead levels at baseline varied among communities (P = .01) and were higher in children who used eye cosmetics or lived near a lead-acid battery melter (both P < .001). In a multiple regression model, the decrease in blood lead level was predicted by age, baseline lead level, and time of final lead value at 12-18 months (R(2) = 31%), but not by calcium supplementation (P = .98).

CONCLUSIONS

Lead toxicity is common in Nigerian children, but calcium supplementation does not affect blood lead levels.

Lead and essential trace element levels in school children: a cross-sectional study

BACKGROUND

Nutritional status is thought to modulate susceptibility to lead (Pb) toxicity. The type and nature of these interactions needs to be investigated.

AIM

To assess the prevalence of sub-clinical Pb toxicity (defined by ≥ 10 μ_rm;g/dL blood levels) and trace element deficiencies (Iron (Fe), Zinc (Zn), Copper (Cu) and Magnesium (Mg)) and to find out their possible relationship, if any.

SUBJECTS AND METHODS

A cross-sectional survey was carried out in a total of 195 school children residing in urban (n = 65), urban heavy traffic (n = 65) and urban industrial (n = 65) zones of Hyderabad, India. Blood Pb, trace element levels, haemoglobin and δ-aminolevulinate dehydratase (δ-ALAD) activity was measured.

RESULTS

High blood lead levels ( ≥ 10 μ_rm;g/dL) were observed in 54.3% of children while percentage prevalence of trace element deficiencies such as Fe (16.2%), Zn (68.6%), Mg (41.7%) and Cu (25%) were also high in children included in the study. Higher blood Pb levels and reduced δ-ALAD activity was observed in children residing in heavy traffic and industrial areas. Blood Pb levels but not δ-ALAD activity correlated inversely with serum Fe in heavy traffic and industrial children, respectively. Interestingly, δ-ALAD activity but not blood Pb levels correlated inversely with trace element levels only in urban children.

CONCLUSIONS

These results suggest higher prevalence of sub-clinical Pb toxicity and trace element deficiencies in urban children. Further, high blood Pb levels appear to be correlated with reduced δ-ALAD activity and iron status in Pb exposed children.

Effect of calcium supplementation on blood lead levels in pregnancy: a randomized placebo-controlled trial

BACKGROUND

Prenatal lead exposure is associated with deficits in fetal growth and neurodevelopment. Calcium supplementation may attenuate fetal exposure by inhibiting mobilization of maternal bone lead and/or intestinal absorption of ingested lead.

OBJECTIVE

Our goal was to evaluate the effect of 1,200 mg dietary calcium supplementation on maternal blood lead levels during pregnancy.

METHODS

In a double-blind, randomized, placebo-controlled trial conducted from 2001 through 2003 in Mexico City, we randomly assigned 670 women in their first trimester of pregnancy to ingest calcium (n = 334) or placebo (n = 336). We followed subjects through pregnancy and evaluated the effect of supplementation on maternal blood lead, using an intent-to-treat analysis by a mixed-effects regression model with random intercept, in 557 participants (83%) who completed follow-up. We then conducted as-treated analyses using similar models stratified by treatment compliance.

RESULTS

Adjusting for baseline lead level, age, trimester of pregnancy, and dietary energy and calcium intake, calcium was associated with an average 11% reduction (0.4 microg/dL) in blood lead level relative to placebo (p = 0.004). This reduction was more evident in the second trimester (-14%, p < 0.001) than in the third (-8%, p = 0.107) and was strongest in women who were most compliant (those who consumed > or = 75% calcium pills; -24%, p < 0.001), had baseline blood lead > 5 microg/dL (-17%, p < 0.01), or reported use of lead-glazed ceramics and high bone lead (-31%, p < 0.01).

CONCLUSION

Calcium supplementation was associated with modest reductions in blood lead when administered during pregnancy and may constitute an important secondary prevention effort to reduce circulating maternal lead and, consequently, fetal exposure.

Interactions between nutrition and environmental exposures: effects on health outcomes in women and children

Exposure to environmental chemicals is increasing globally. Nutritional status may modify susceptibility to chemical exposures. However, there are a large number of toxicants, and malnutrition takes many forms including deficiency and excess. Thus, the relation between environmental exposures and nutritional status is complex. The symposium on "Heavy Metal Exposures in Women and Children, the Role of Nutrients," presented at Experimental Biology 2007 examined interactions among nutritional status, nutrients, and heavy metals in vulnerable populations. The aim was to encourage nutritionists to consider environmental exposures in nutrition research. This introductory article highlights examples of nutrient-toxicant interactions.

Environmental lead toxicity and nutritional factors

Environmental lead toxicity is an old but persistent public health problem throughout the world and children are more susceptible to lead than adults because of their hand to mouth activity, increased respiratory rates and higher gastrointestinal absorption per unit body weight. In the last decade children's blood lead levels have fallen significantly in a number of countries. Despite this reduction, childhood lead toxicity continues to be a major public health problem for certain at-risk groups of children, and concern remains over the effects of lead on intellectual development. The currently approved clinical intervention method is to give chelating agents, which bind and removed lead from lead burdened tissues. Studies indicate, however, that there is a lack of safety and efficacy when conventional chelating agents are used. Several studies are underway to determine the beneficial effect of nutrients supplementation following exposure to lead. Data suggest that nutrients may play an important role in abating some toxic effects of lead. To explain the importance of using exogenous nutrients in treating environmental lead toxicity the following topics are addressed: (i) different sources of lead exposure/current blood lead levels and (ii) protective effects of nutrients supplementation (some essential elements and vitamins) in lead toxicity.

Dietary calcium supplementation to lower blood lead levels in pregnancy and lactation

Pregnancy and lactation are states known to be accompanied by physiologically up regulated bone resorption in response to the calcium demands of the developing fetus and nursing infant. The role of calcium supplements in altering maternal responses to fetal demand for calcium is not fully understood. Exposure to the toxicant lead is known to pose a major hazard to fetal neurodevelopment and growth. Since >95% of maternal lead is stored in the bone, mobilization of cumulative maternal lead stores into the circulation represents an endogenous source of exposure, which may pose a significant hazard for the fetus and infant. Maternal dietary calcium supplementation has been associated with reductions in lead levels in both animal and human studies when administered during pregnancy and lactation. Therefore, supplementation of the maternal diet with calcium may represent an important secondary prevention strategy aimed not only at reducing circulating levels of lead in the mother but also at reducing lead exposure to the developing fetus and nursing infant.

The challenge posed to children's health by mixtures of toxic waste: the Tar Creek superfund site as a case-study

In the United States, many of the millions of tons of hazardous wastes that have been produced since World War II have accumulated in sites throughout the nation. Citizen concern about the extent of this problem led Congress to establish the Superfund Program in 1980 to locate, investigate, and clean up the worst sites nationwide. Most such waste exists as a complex mixture of many substances. This article discusses the issue of toxic mixtures and children's health by focusing on the specific example of mining waste at the Tar Creek Superfund Site in Northeast Oklahoma.

Early (in uterus and infant) exposure to mercury and lead

Mercury and lead are toxic metals widely spread in the environment with bio-accumulative features that raises public health concerns. Both metals are equally dispersed in the human food chain but exposure and risk of toxicity during early human development are modulated by the diet and nutritional status. Understanding how Hg and Pb occur and interact with nutrients is fundamental to establish guidelines for diminishing exposure and the risk of toxicity. The risk of fetal and infant exposure to Hg can be influenced by maternal amalgam filling (inorganic Hg) and fish consumption (monomethyl Hg), whereas the risk of exposure to Pb is complex: maternal absorption depends on nutrient interactions (Ca and P); and maternal body Pb accumulation responds to all factors known to interact with bone and calcium metabolism. Maternal exposure to Hg and Pb is more important during fetal development than during breastfeeding. Moreover, these metals (especially Pb) are frequently higher in infant formulas which do not carry the nutritional and psychological advantages and protection of breastfeeding. Infant's reference dose is lower for Hg than for Pb, but risk of Pb contamination for fetuses and infant (breast- or formula-fed) is higher and lasts longer than Hg. Breastfeeding is essential to complete infant development. Interruption or suppression of breast-feeding with cow's milk-based formulas is not an option to environmental pollution.

Efficacy of iron and/or zinc supplementation on cognitive performance of lead-exposed Mexican schoolchildren: a randomized, placebo-controlled trial

OBJECTIVE

Lead exposure in children has been associated with both global and specific cognitive deficits. Although chelation therapy is advised for children with blood lead concentrations of >44 microg/dL, treatment options for children with lower blood lead values are limited. Because lead absorption is related to children's nutritional status, micronutrient supplements may be 1 strategy for combating low-level, chronic lead exposure. This study was designed to test the efficacy of iron and zinc supplementation for lowering blood lead concentrations and improving cognitive performance in schoolchildren who live in a lead-contaminated city.

METHODS

This randomized, double-blind, placebo-controlled field trial was conducted in public elementary schools in Torreón, an industrialized city in northern Mexico. A metal foundry, located close to the city center and within 3.5 km of 9 schools, was the main source of lead exposure. A total of 602 children who were aged 6 to 8 years and regularly attending first grade in the study schools were enrolled. Children were given 30 mg of iron, 30 mg of zinc, both, or a placebo daily for 6 months. A total of 527 completed the treatment, and 515 were available for long-term follow-up, after another 6 months without supplementation. Eleven cognitive tests of memory, attention, visual-spatial abilities, and learning were administered at baseline and each follow-up.

RESULTS

There were no consistent or lasting differences in cognitive performance among treatment groups.

CONCLUSIONS

Daily supplementation with iron and/or zinc may be of limited usefulness for improving cognition in lead-exposed schoolchildren. However, these treatments may be effective in settings with higher prevalence of nutritional deficiencies or in younger children.

Mercury, cadmium and arsenic contents of calcium dietary supplements

The cadmium (Cd) and arsenic (As) contents of calcium (Ca) supplements available on the Korean market were determined by a graphite furnace atomic absorption spectrometer using Zeeman background correction and peak area mode after microwave digestion. The mercury (Hg) content of the supplements was measured using an Hg analyser. Recoveries ranged from 92 to 98% for Hg, Cd and As analyses. Fifty-five brands of Ca supplements were classified into seven categories based on the major composite: bone, milk, oyster/clam shell, egg shell, algae, shark cartilage and chelated. The means of Hg, Cd and As in Ca supplements were 0.01, 0.02, and 0.48 mg kg(-1), respectively. Ca supplements made of shark cartilage had the highest means of Hg (0.06 mg kg(-1)) and Cd (0.13 mg kg(-1)). The mean daily intakes of Hg and Cd from the supplement were estimated as about 0.1-0.2 microg, with both contributing less than 0.4% of provisional tolerable daily intakes set by the Food and Agricultural Organization/World Health Organization Joint Food Additive and Contaminants Committee.

Lead poisoning in pregnancy: a case study with implications for midwives

Lead poisoning remains a significant problem in the United States affecting the health of women and children. Although the damage is greatest at higher levels of accumulation, no level of lead has been found to be safe. Over the last 25 years, the blood level of lead thought to be associated with toxicity has dropped dramatically, from to 60 mcg/dL in 1960 to 10 mcg/dL today. Studies confirm that exposure to lead causes kidney damage, encephalopathy, and impaired cognitive function in children and in adults. Recent evidence indicates children with levels less than 10 mcg/dL may suffer from compromised development and intellectual performance later in life. This article discusses the case of a woman found to have lead poisoning during pregnancy. Environmental sources of lead, implications for the immediate and future health of the fetus and mother, and techniques clinicians can use in their practice to minimize the adverse effect of lead on their clients are reviewed.