Medscape Medical News...

What's the Disease Burden From Plastic Exposure?

Liam Davenport | January 11, 2024

Exposure to endocrine-disrupting chemicals (EDCs) via daily use of plastics is a major contributor to the overall disease burden in the United States and the associated costs to society amount to more than 1% of the gross domestic product, revealed a large-scale analysis.

The research, published in the Journal of the Endocrine Society on January 11, 2024 indicated that taken together, the disease burden attributable to EDCs used in the manufacture of plastics added up to almost $250 billion in 2018 alone.

"The diseases due to plastics run the entire life course from preterm birth to obesity, heart disease, and cancers," commented lead author Leonardo Trasande, MD, MPP, Jim G. Hendrick, MD Professor of Pediatrics, Department of Pediatrics, NYU Langone Medical Center, New York, in a release.

"Our study drives home the need to address chemicals used in plastic materials" through global treaties and other policy initiatives, he said, so as to "reduce these costs" in line with reductions in exposure to the chemicals.

Co-author Michael Belliveau, Executive Director at Defend Our Health in Portland, ME, agreed, saying: "We can reduce these health costs and the prevalence of chronic endocrine diseases such as diabetes and obesity if governments and companies enact policies that minimize exposure to EDCs to protect public health and the environment."

Plastics may contain any one of a number of EDCs, such as polybrominated diphenylethers in flame retardant additives, phthalates in food packaging, bisphenols in can linings, and perfluoroalkyl and polyfluoroalkyl substances (PFAS) in nonstick cooking utensils.

These chemicals have been shown to leach and disturb the body's hormone systems, increasing the risk for cancer, diabetes, reproductive disorders, neurological impairments in developing fetuses and children, and even death.

In March 2022, the United Nations Environment Assembly committed to a global plastics treaty to "end plastic pollution and forge an international legally binding agreement by 2024" that "addresses the full lifecycle of plastic, including its production, design and disposal."

Minimizing EDC Exposure

But what can doctors tell their patients today to help them reduce their exposure to EDCs?

"There are safe and simple steps that people can take to limit their exposure to the chemicals of greatest concern," Trasande told Medscape Medical News.

This can be partly achieved by reducing plastic use down to its essentials. "To use an example, when you are flying, fill up a stainless steel container after clearing security. At home, use glass or stainless steel" rather than plastic bottles or containers.

In particular, "avoiding microwaving plastic is important," Trasande said, "even if a container says it's microwave-safe."

He warned that "many chemicals used in plastic are not covalently bound, and heat facilitates leaching into food. Microscopic contaminants can also get into food when you microwave plastic."

Trasande also suggests limiting canned food consumption and avoiding cleaning plastic food containers in machine dishwashers.

Calculating the Disease Burden

To accurately assess the "the tradeoffs involved in the ongoing reliance on plastic production as a source of economic productivity," the current researchers calculated the attributable disease burden and cost related to EDCs used in plastic materials in the United States in 2018.

Building on previously published analyses, they used industry reports, publications by national and international governing bodies, and peer-reviewed publications to determine the usage of each type of EDC and its attributable disease and disability burden.

This plastic-related fraction (PRF) of disease burden was then used to calculate an updated cost estimate for each EDC, based on the assumption that the disease burden is directly proportional to its exposure.

They found that for bisphenol A, 97.5% of its use, and therefore its estimated PRF of disease burden, was related to the manufacture of plastics, while this figure was 98%-100% for phthalates. For PDBE, 98% of its use was in plastics vs 93% for PFAS.

The researchers then estimated that the total plastic-attributable disease burden in the United States in 2018 cost the nation $249 billion, or 1.22% of the gross domestic product. Of this, $159 billion was linked to PDBE exposure, which is associated with diseases such as cancer.

Moreover, $1.02 billion plastic-attributable disease burden was associated with bisphenol A exposure, which can have potentially harmful health effects on the immune system; followed by $66.7 billion due to phthalates, which are linked to preterm birth, reduced sperm count, and childhood obesity; and $22.4 billion due to PFAS, which are associated with kidney failure and gestational diabetes.

The study was supported by the National Institutes of Health and the Passport Foundation.

Trasande declared relationships with Audible, Houghton Mifflin, Paidos, and Kobunsha, none of which relate to the present manuscript.

No other financial relationships were declared.

Obesity and our children

 Majority of US Children Today Will Be Obese by Age 35

Over half of today's children in the United States will be obese at the age of 35 if existing trends continue, despite the fact that currently, less than 20% of them are obese, a new simulated growth trajectory model indicates.

"Right now, about 17% of children between the ages of 2 and 19 have obesity," lead author of the new research, Zachary Ward, MPH, Harvard TH Chan School of Public Health, Boston, Massachusetts, explained in an email to Medscape Medical News.

"But we project that the majority of them — 57% — will have obesity when they turn 35," he added.

In fact, only those children with a current healthy weight have less than a 50% chance of becoming obese by the age of 35 years, the researchers say in their paper, published in the November 30, 2017 issue of the New England Journal of Medicine.

And perhaps not surprisingly, early development of obesity predicted obesity in adulthood, especially for children who were severely obese.

"Our findings highlight the importance of prevention efforts for all children as they grow up and of providing early interventions for children with obesity to minimize their risk of serious illness in the future," Dr Ward noted in a statement from his institution.

Obesity Is a Trajectory That Is Difficult to Change 

In the United States, obesity has declined recently among children between the ages of 2 and 5 years and has stabilized among those between the ages of 6 and 11 years of age but continues to rise among adolescents and adults, say Dr Ward and colleagues.

And although the obesity epidemic has been well characterized at a population level, less is known about the individual-level risk of adult obesity for a given child on the basis of current weight and age, they explain.

For their estimates, the researchers pooled five nationally representative data sets involving 41,567 children and adults who had repeated measures of height and weight over time, and they developed a simulation model to predict individual growth trajectories. They then created 1000 virtual populations of 1 million children through the age of 19 years that were representative of the 2016 US population and projected their trajectories in height and weight up to the age of 35 years.

"Among obese children, we found that the probability that they will still be obese at the age of 35 years increased with age," they report — that risk being almost 75% at the age of 35 if children are obese at the age of 2 and over 88% if they are obese at the age of 19.

Excess weight gained during childhood can therefore put children on a trajectory that is difficult to change, the authors say.

And this is particularly true when it comes to those with severe obesity — a condition that currently affects 4.5 million children in the United States. This was defined as 120% or more of the 95th percentile in children or BMI 35 mg/kg² or greater in adults.

At age 2, these children have only a one in five chance of not having obesity at age 35; at age 5, that chance drops to just one in 10.

Maintaining Healthy Weight Throughout Childhood Cuts Risk of Adult Obesity 

In contrast, children who are not obese at the age of 2 have a lower risk of becoming obese by the time they reach 35, provided they maintain a healthy weight through to the age of 19.

For example, if children are not obese at the age of 2, they have a 57.8% probability of being obese at the age of 35, but if they are still at a healthy weight at the age of 19, that risk drops down to 44.4%, the researchers point out.

But despite these figures, "we also found that the majority of obese 35-year-olds were not obese as children," the authors say.

In other words, approximately half of the prevalence of obesity seen in adulthood begins in childhood, while the remainder is explained by adult-onset obesity.

"It is critically important to implement policies and programs to prevent excess weight gain, starting at an early age," stressed senior author Steven Gortmaker, PhD, also of the Harvard TH Chan School of Public Health.

The research was supported in part by grants from the JPB Foundation, the Robert Wood Johnson Foundation, the Donald and Sue Pritzker Nutrition and Fitness Initiative, and the Centers for Disease Control and Prevention, including the Nutrition and Obesity Policy Research and Evaluation Network.The authors had no relevant financial relationships.

N Engl J Med. 2017;377:2145-2153.

ORIGINAL ARTICLE

Simulation of Growth Trajectories of Childhood Obesity into Adulthood

Zachary J. Ward, M.P.H., Michael W. Long, Sc.D., Stephen C. Resch, Ph.D., Catherine M. Giles, M.P.H., Angie L. Cradock, Sc.D., and Steven L. Gortmaker, Ph.D.

N Engl J Med 2017; 377:2145-2153November 30, 2017DOI: 10.1056/NEJMoa1703860

BACKGROUND

Although the current obesity epidemic has been well documented in children and adults, less is known about long-term risks of adult obesity for a given child at his or her present age and weight. We developed a simulation model to estimate the risk of adult obesity at the age of 35 years for the current population of children in the United States.

METHODS

We pooled height and weight data from five nationally representative longitudinal studies totaling 176,720 observations from 41,567 children and adults. We simulated growth trajectories across the life course and adjusted for secular trends. We created 1000 virtual populations of 1 million children through the age of 19 years that were representative of the 2016 population of the United States and projected their trajectories in height and weight up to the age of 35 years. Severe obesity was defined as a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of 35 or higher in adults and 120% or more of the 95th percentile in children.

RESULTS

Given the current level of childhood obesity, the models predicted that a majority of today’s children (57.3%; 95% uncertainly interval [UI], 55.2 to 60.0) will be obese at the age of 35 years, and roughly half of the projected prevalence will occur during childhood. Our simulations indicated that the relative risk of adult obesity increased with age and BMI, from 1.17 (95% UI, 1.09 to 1.29) for overweight 2-year-olds to 3.10 (95% UI, 2.43 to 3.65) for 19-year-olds with severe obesity. For children with severe obesity, the chance they will no longer be obese at the age of 35 years fell from 21.0% (95% UI, 7.3 to 47.3) at the age of 2 years to 6.1% (95% UI, 2.1 to 9.9) at the age of 19 years.

CONCLUSIONS

On the basis of our simulation models, childhood obesity and overweight will continue to be a major health problem in the United States. Early development of obesity predicted obesity in adulthood, especially for children who were severely obese. (Funded by the JPB Foundation and others.)

Artificial sweetener may not be what you desire if you're trying to lose weight....

 

Artificial Sweetener Ups Appetite in Women, People With Obesity

A new study (September 28, 2021), suggests that replacing sugar (sucrose) with the nonnutritive sweetener sucralose may not have the desired weight-loss effect, and in fact, it appears to increase appetite in women and people with obesity.

These are novel insights and further studies are needed, experts say.

After consuming a drink sweetened with sucralose versus sucrose, women and people with obesity had increased activity in the reward center of the brain and women ate more food at a post-fasting buffet.

"We were able to show that females and people with obesity may be more sensitive to artificial sweeteners," senior author Kathleen Page, MD, an associate professor of medicine at the Keck School of Medicine, University of Southern California, Los Angeles, summarized in a press release from the university.

"For these groups, drinking artificially sweetened drinks may trick the brain into feeling hungry, which may in turn result in more calories being consumed," she added.

Although many people use artificial sweeteners to try to lose weight, Page noted their place in a healthy diet is controversial. Some studies suggest they may be helpful, while others show they may contribute to weight gain, type 2 diabetes, and other metabolic disorders.

The new findings may partly explain these previous differences, she said.

The results also highlight the need to consider gender and body mass index in future research of nonnutritive sweeteners.

The study, by Alexandra G. Yunker, an MPH candidate in nutrition at Harvard University, Boston, Massachusetts, and colleagues, was published onlineSeptember 28 in JAMA Network Open.

Novel Findings, Need to Consider Sex, Adiposity in Future Research 

The current study "is of great importance as it provides novel insights into how adiposity and sex are associated with neural and behavioral outcomes of [nonnutritive sweetener] ingestion," Stephanie Kullmann, PhD, writes in an accompanying invited commentary.

Invited to comment, John L. Sievenpiper, MD, PhD, associate professor in the Department of Nutritional Sciences and Medicine at the University of Toronto, Ontario, Canada, agreed that the data need to be reproduced.

Several questions remain, he stressed in an email to Medscape Medical News: "Was it the sucralose per se or the absence of calories that explains these findings? And the bigger question is, do these differences by adiposity and sex translate into weight gain?"

Systematic reviews and meta-analyses of the available randomized controlled trials of low and no calorie sweeteners including sucralose show the expected decrease in caloric intake and downstream weight loss in both males and females who are overweight or obese, he noted.

"It would be useful to understand if there are important interactions by adiposity and sex in future trials," Sievenpiper added.

Young Men and Women of Diverse Weight

Nonnutritive sweeteners are now used by more than 40% of US adults, the researchers write, but studies have reported mixed results on appetite, glucose metabolism, and body weight, and it is not clear whether these sweeteners are beneficial or harmful to health.

Prior research that was mainly in men and lean participants showed that brain areas involved in the regulation of taste, reward, and homeostasis may respond differently to nonnutritive versus nutritive sugars.

The researchers aimed to investigate this using initial data from the Brain Response to Sugar study (clinicaltrials.gov).  

They analyzed data from 74 healthy 18- to 35-year-olds (58% women) with a mean age of 23. Overall, 37% had a healthy weight, 32% were overweight, and 31% had obesity.

Participants made three separate visits to the study center after a 12-hour overnight fast.

At each visit they drank 300 mL of water, a sucralose-sweetened drink, or a sucrose-sweetened drink.

They had blood drawn at baseline and at 10, 35, and 120 minutes after ingesting the drink.

At 20 minutes after consuming the drink, they had a functional MRI, during which they were shown 12 pictures of high-calorie, low-calorie, sweet, or savory foods and four pictures that were not foods and were asked to rank their appetite.

At 125 minutes after they ingested the drink, participants had access to a buffet meal.

"As expected, endocrine responses" — blood levels of glucose, insulin, and glucagon-like peptide-1 — "were greater after sucrose than sucralose ingestion," Kullmann noted, "but there were no significant differences based on sex and adiposity."  

However, "the most prominent and novel findings were observed on a neurobehavioral level," according to Kullmann.

That is, individuals with obesity (but not those with overweight or a healthy weight), had greater neural activity in the prefrontal reward-related areas of the brain, in response to savory food images, after ingesting a drink containing sucralose versus sucrose.

Similarly, after consuming a sucralose-sweetened drink as opposed to a sucrose-sweetened drink, female participants had greater activity in reward areas of the brain in response to food cues, especially high-calorie and sweet foods.

Women also consumed more calories at the buffet meal after they had ingested a sucralose-sweetened drink than after a sucrose-sweetened drink.

The study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH). The Research Electronic Data Capture (REDCap) database used is supported by the Southern California Clinical and Translational Science Institute through an NIH grant. The researchers and editorialist have reported no relevant financial relationships.

JAMA Netw Open. 2021;4:e2126313, e2128047. Article, Editorial