Conflict of Interest Disclosure

Harvey P. Katz, MD The commercial entities with which I have relationships do not produce healthcare-related products or services relevant to the content I am planning, developing, or presenting for this activity.

Hormones, Food, and Our Environment

Harvey P. Katz, M.D.
Associate Clinical Professor Department of Population Medicine Harvard Medical School Boston, MA

Current Clinical Issues in Primary Care

How much do we know about the foods we eat?

What commonly prescribed food : Can lead to MR in infants Can cause hypothyroidism in adults Can possibly protect against breast cancer
danger contains food

Twin A-B.G.
35 wk gestation C/S breech & oligohydramnios g Birth wt. 2.2 kg. Hypothermia-10 days in isolette Mild jaundice (bilirubin T/D 8/4/0.7) Abnormal thyroid screen
Courtesy, Rosalind Brown, M.D.

Exam-11 days
Wt. 21.kg (25th %ile) Mild jaundice Skin slightly dry ? Umbillical hernia Normal general exam Feeding problem-formula changed

Twin A: congenital hypothyroidism*

Age T4 ug/dl Free T4 ng/dl TSH mU/L Comments Rx

How do you explain?

Age 4 days 11 days 2 wks T4 ug/dl <2 2.5 3.5 <2 Free T4 ng/dl 0.4 0.8 QNS TSH mU/L >150 >150 >100 676 83 10.4 7.3 Comments Rx L-T4 25 ug 37.5 ug 50 ug Soy Formula 75 ug D/C Soy

4 days 11 days 2 wks 4 wks

<2 2.5 3.5 <2

0.4 0.8 QNS

>150 >150 >100 676

L-T4 25 ug 37.5 ug 50 ug 75 ug

4 wks 6 wks 10 wks 12 wks

*Courtesy of Dr. Rosalind Brown

SOY
? The Miracle Food* ? The Poison Seed* An Endocrine Disruptor
*Endocrine News; Mixed Messages on Soy, April 2011

Clinical Importance
Soy is an endocrine disruptor Soy can interfere with absorption of thyroid Pts on L-T4 should not be on soy if possible If soy is necessary, monitor TSH may need more TSH-may L-T4 Soy can interfere with thyroid biosynthesis (thyroid peroxidase) & cause hypothyroidism High index of suspicion for hypothyroid sx if patient is on soy Importance of the environmental history

Another Cause of Prepubertal Gynecomastia

Prepubertal = always investigate and include an environmental histrory-why?

lavender

Tea tree oil

Aids to Identify Cause

Any medication; OTCs? Any herbals or homeopathics? Soy? Lotions? Lavendar soaps, shampoos, conditioners? Left anything out?
CA Bloch

Hormones, Food, and Our Environment: Goals

Definition of endocrine disruptors (EDCs) Potential adverse clinical effects of EDCs Systems and hormones most involved Importance of the environmental history Anticipatory guidance for patients Data surrounding the 6 most common EDCs Increased awareness, research, and regulation

What are Endocrine Disruptors?

Endocrine disruptors are exogenous substances-natural or synthetic- that can mimic or modify the action of endogenous hormones.
Pediatric Environmental Health-3rd edition AAP Health 3 edition,

Why the Recent Resurgence of Interest:

Some Unexplained, Troubling Observations
Trend towards earlier puberty Increase in newborns with cryptorchidism I i b ith t hidi Increasing trends-testicular cancer Increasing infertility rates Increased Type 1 diabetes and thyroid disease

An exogenous substance or mixture that alters function(s) of the endocrine system and consequently causes adverse health effects in an intact orgnism, or its progeny, or populations
World Heath Organiztion

HEADLINES
Exposure of fetuses & children to endocrine disruptors: A ESPE & PES call to action

Pioneer in Environmental Health: Herbicides, Pesticides, Insecticides as Poisons

Gender-bender chemicals puttng everyone at risk

Thyroid action disrupted by BPA

Silent Spring Dedication To Albert Schweitzer

Who said: Man has lost the Man capacity to foresee and to forestall. He will end by destroying the earth.

Examples of Other Endocrine Disruptors

Bisphenol A Phthalates DDT PCBs Bovine GH PCBs Dioxins

Man can hardly even recognize the devils of his own creation
Over 80,000 chemicals are in use in the United States 1000-2000 new chemicals are introduce into commerce/yr.

Hormones, Food, and Our Environment: Goals

Definition of endocrine disruptors (EDCs) Potential adverse clinical effects of EDCs Systems and hormones most involved Importance of the environmental history Anticipatory guidance for patients Data surrounding the 6 most common EDCs Increased awareness, research, and regulation

No routine assessment of safety by the EPA

Vandenberg et al., BPA & the Great Divide: Controverises in field of EDCs.End Reviews 2009

6 Other Major Endocrine Disruptors Part 2

Foods Beef Non persistent Non-persistent BPA and Phthalates Persistent PCB and Dioxin Drugs DES

What is your beef?

Hamburger thyrotoxicosis Bovine GH Steroids

Is Milk from GH Rx Cows Harmful

HGH-How does it work?

From the GH no: Protein, vitamins,minerals, Lipids-same

From IGH: maybe link to future malignancy??

From sex steroids: ? Cause of early puberty and premenopausal breast ca. Linos et al. Cancer
epidemiol. biomarkers, 2008

Plasticizers
BPA Makes l ti M k plastic more rigid Phthalates Makes l ti M k plastic more flexible

BPA-Unanswered Questions
Are dental sealants harmful Is IV tubing safe How can I reduce exposure Is it a cause of autism

Estrogenicity of BPA
An estrogen receptor agonist Possible link to PCOAS Possible cause of early puberty Induced proliferation of breast cancer cells

BPA-Everywhere Present in >95% of Population

50 million metric tons / yr Toys Baby bottles Water b ttl W t bottles Cans Dental sealants Eye lenses IV tubing Sports helmets

Tips to Avoid Exposure BPA and Phthalates

Look at codes Avoid 3,6, & 7 N plastic in No l ti i microwaves to warm food/formula No plastic in dishwasher

Tips to Avoid Exposure BPA and Phthalates

Use glass wherever possible Store fruits/vegtables in glass jars y y p Buy only BPA/Phthalate free products

BPA-Bisphenol A Plasticizers
BPA Makes l ti M k plastics more rigid Phthalates Makes l ti M k plastics more flexible

Phthalates-Ubiqitous
Toys Solvents and Lubricating oils Soap, cosmetics, hairspray Nail polish p IV tubing Vinyl flooring Garden hoses Enteric coated medication

U.S. Scientists to EPA: Phthalates Are a Health Concern Concern

Phthalates, a class of hormone-mimicking chemicals found in toys, cosmetics, air fresheners, plastics and other common household products, need urgent study, according to the National Research Council.

Phthalates:Anti-Androgens Prevention
Leach out of products easily Inhaled, ingested, dermally In breast milk Decreased fertility Cryptorchidism Hypospadius Testicular cancer

Organochlorines
Highly Toxic Carcinogen & EDC
Victor Uchenko, Ukraine-Poisoned

Organochlorines-Endocrine Disruptor
-Decreased sperm concentration & motility -An anti-estrogen -Link to type 2 diabetes -Decreased t4, Incrased TSH in animal studies -Effect on puberty and growth being investigated

PCBs -Derivative of DDT -In pesticides -Flame retardant -Electric insulator -Banned in 1977

Dioxin -Enters food supply via animal feed -Long half life -No regulatory standards -Multiple mass poionings

DES
Synthetic estrogen used to prevent miscarriage that causes: -vaginal cancer in daughters i l i d ht -testicular cancer in sons -urogenital anomalies in sons -infertility

Eight American Research Socities Letter to Science

Although chemical testing has been in the domain of toxicologists, it is clear that the development of improved testing guidelines and better methods of assessing risks posed by common chemicals to which all Americans are exposed requires the expertise of a broad range of scientific and clinical disciplines.

Recommended Reference AAP

THANK YOU

References
Pediatric Environmental Health, 3rd ed. AAP Endocrine News; Mixed Messages on Soy, April 2011 Science 2011. Assessing chemical risk 331:1136 Vandenberg et al. A review of controversies in the Field of EDCs. 2009. 30:75-95 Chorazy, P. et al. Persistent hypothyroidism on soy formual. Pediatrics. 1995, 148-150.

Henley, D. et al. Gynecomastia and lavender.NEJM 2007, 356:479-85 Exposure of fetuses and children to EDC: Call to Action Statement. JCEM 2011,96:3056-3058.