The Clinical Practice of

Stephen J. GenuisMD FRCSC DABOG DABEM FAAEM

Clinical ProfessorFaculty of Medicine

University of Alberta

Betty Ann & Wade Heggie Lecture in Integrative Medicine

Highlights in Medicine Conference 2017 University of Saskatchewan

June 23, 2017

Faculty Disclosure

Dr. Stephen J Genuis• Relationship with commercial interests – None• Disclosure of Commercial Support – None• Mitigating Potential Bias – None• Conflict of interest – None• Consulting Fees – None• Grants/Research Support – None• Speakers Bureau - None

Learning Objectives:

1) Participants will be apprised of the neglected epidemic of chronic disease

2) Participants will learn about environmental factors contributing to the challenge of chronic disease.

3) Participants will be introduced to the clinical practice of environmental medicine.

The Clinical Practice of Environmental Medicine (EM)

Section I - Background

• The challenge of chronic disease

• The origins of chronic illness

Section II - Clinical

• Approach to the clinical practice of EM

Section I. The Challenge of Chronic Disease

Canadian Healthcare System:A fundamental pillar of our national identity

Conference Board of Canada study:• 90% Canadians: health care should be main priority for decision-makers

• Preserving healthcare system more important than any other issue including the economy and the environment

Conference Board of Canada. The inconvenient truths about Canadian Health Care. http://www.conferenceboard.ca/cashc/research/2012/inconvenient_truths.aspx

major challenge…

219.1 Billion (2015 estimate)

‘Healthcare in Canada is heading toward a fiscal cliff’

^

Rise in costs far exceed • population growth• economic growth

• inflation

No signs of slowingConsidered unsustainable

Healthcare in Canada

Despite

– Unprecedented resources expended• single biggest expenditure of each province

(near 1/2 of total program spending)

– More MDs/population working in Canada than ever before (1/439)…

Canadian Institute for Health Information , Aug 2016

… availability of services appears to be declining

• Close to 1 in 5 Canadians unable to find a family doctor

• Longer waiting lists to see health providers

• Difficulty with access to care in many regions

• Extended waits for some investigations and for surgery

• Prolonged waits in emergency departments

• Bailey T. Waiting for a family doctor Can Fam Phys 2007;• Canadian views on health care quality Results from the 2013 Commonwealth Fund International Health Policy Survey of the General Public.

http://healthcouncilcanada.ca/content_lm.php?mnu=2&mnu1=48&mnu2=30&mnu3=56• Canada ranked last among OECD countries in health care wait times. http://www.ctvnews.ca/health/canada-ranked-last-among-oecd-countries-in-health-care-wait-times-1.1647061• Health Care in Canada, 2012. https://secure.cihi.ca/free_products/HCIC2012-FullReport-ENweb.pdf

Ongoing calls for action from many sources

• e.g. President of Canadian Medical Association 2011 Dr. Jeff Turnbull:

“Moral imperative to fix the Healthcare system …. the time for action is now!”

Extensive efforts re healthcare dilemma:

– Round tables, commissions, task forces, advisory panels, reports,• Romanow Commission, Mazankoski Report, Building on Values: the

Future of Health Care in Canada, Advisory Panel on Healthcare Innovation, etc, etc,

– Attempts by federal and provincial ministers to fix national health care

• e.g. Paul Martin “fix for a generation”

Yet, i) unsustainable costs? ii) availability of services?

Consider:

A primary determinant of the escalating

healthcare challenge has not been

adequately explored & addressed…

Medical Literature – rapidly escalating problem

• “The neglected epidemic of chronic disease”Article by Richard Horton*, The Lancet 2005, doi: 10.1016/S0140-6736(05)67454-5

*Editor in chief of The Lancet, one of the top three medical journals

The Problem: North America

• Chronic diseases accounts for >85% of health care costs

• ½ all American adults have at least one chronic condition;

• More than ¼ have multiple chronic conditions e.g. 3D’s• Diabetes• Depression• Dementia• etc

• Centers for Disease Control and Prevention. Saving Lives, Protecting People. http//www.cdc.gov/chronicdisease/• US Department of Health & Human Services. Prevention makes common cents. https://aspe.hhs.gov/pdf-report/prevention-makes-common-cents• http://www.fightchronicdisease.org/sites/default/files/docs/GrowingCrisisof ChronicDiseaseintheUSfactssheet 81009.pdf

Diabetes

Available https://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf

DIABETES

DEPRESSION

• No. 1 Cause of Illness and Disability Worldwide

• When I was in Medical School: ‘5% will experience a mental illness’

• Currently:An estimated 26.2 percent of Americans ages 18 and older — about one in four adults — suffer from a diagnosable mental disorder in a given year

• WHO, more than 300 million people living with depression, an increase of more than 18% between 2005 and 2015.

DEMENTIA

"The number of people affected by Alzheimer's and dementia is growing at an epidemic pace, and the skyrocketing financial and personal costs will devastate the world's economies and healthcare systems.“William Thies, Ph.D., Chief Medical & Scientific Officer Alzheimer's Association.

Pritchard C, Rosenorn-Lanng E. Neurological deaths of American adults (55-74) and the over 75's by sex compared with 20 Western countries 1989-2010: Cause for concern. Surg Neurol Int. 2015;6:123

These problems expected in aging population?

Pediatric chronic illness

“Health and social welfare systems are unprepared for the rapid growth in demands that will arise

from these epidemics.”

Perrin JM, Bloom SR, Gortmaker SL JAMA 2007;297:2755-2759. The increase in childhood chronic conditions in the United States.

Weintraub Karen, The prevalence puzzle: Autism counts . Nature 479, 22-24 (2011) | doi:10.1038/479022a Hertz-Picciotto I, Delwiche L. The Rise in Autism and the Role of Age at Diagnosis. Epidemiology. 2009;20(1):84-91.

Better diagnosis?

Expanded criteria?

Epidemiology – comparing apples to apples

.

Autism

Pediatric Mental Health

Canada:

• Child and youth emergency visits for mental health issues increased 45% (2007 to 2014)

• Half of pediatric hospital beds filled to treat mental health problems

USA:• Visits for American youth with bipolar disorder increased >40 fold

(1994-2003)

Canadian Broadcasting Corporation. The Current. Half of all hospital beds in Canada for kids and youth filled to treat mental health. Thurs March 3rd 2016Moreno C et al. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64(9):1032-9.

‘Children with Cancer UK’ – Sept. 2016

• Pediatric cancer up 40% in 16 years (1998-2014)• The rise is most apparent in teenagers and young

adults aged between 15 and 24

Children with Cancer UK. Fourth international scientific conference. London, UK. Sept 5-7, 2016. http://childhoodcancer2016.org.uk/

Escalating Rates of Cancer• Life time cancer rates in the United States*

• 1 in 3 women• 1 in 2 men

• Anticipate 50% increase in rates of cancer over the next 15 years

• “Nearly half of all Canadians are expected to be diagnosed with some form of cancer in their lifetime” Canadian Cancer Society

*2010 rates

Chronic Pain

• Increasing number of people living with inexplicable chronic pain

• Waiting lists often >1 year for consultation at pain clinics

• 70 Million Americans live with chronic pain

• Escalating problem with adolescents living with chronic pain

Olorunto WA, Galandruk S. Managing the spectrum of surgical pain: acute management of the chronic pain patient. J Am Coll Surg 2006;202:160-75.Canadian Pain Society, Canadian Pain Coalition; Canadian Pain Foundation

Unexplained environmental illnesses

• Clinical picture frequently: sensitivities to chemical exposures, food intolerances, fatigue, multimorbidity

• Many become compromised in daily life activities or disabled

• Increasing prevalence in Canada, the United States and around the worlde.g. one Canadian province: 570,000

Pall ML: Multiple Chemical Sensitivity: Toxicological Questions and Mechanisms Chapter XX In 'General and Applied Toxicology', 3rd Edition. Ballantyne B, Marrs TC, and Syversen T (Eds) . John Wiley & Sons, London. (2009)Genuis, SJ. Sensitivity-related illness: the escalating pandemic of allergy, food intolerance and chemical sensitivity. Science of the Total Environment 408.24 (2010): 6047-6061

Not just statistics…

Human reality:• Personal suffering• Decreased quality of life• Functional decline - Crisis of Disability• Family hardships: financial, emotional etc

Social reality:• Greater demand for health services• Escalating health care costs

But are people healthier andliving longer than ever before?

Life expectancy?

Year Female Male

19001 48.3 46.3

19501 71.1 65.6

20142 81.2 76.4

1. http://www.cdc.gov/nchs/fastats/life-expectancy.htm (Centers for Disease Control)2. http://u.demog.berkeley.edu/~andrew/1918/figure2.html. “Life expectancy in the USA, 1900-98.”

Life expectancy (L/E)? (con’t)

• L/E statistics based on average age of death in a population

• 90 + 80 = 170 L/E = 85 years• 90 + 0 (neonatal death) = 90 L/E = 45 years

• Impact of infant mortality? • 1921: 98.7 infant deaths / 1000 live births• 2016: 4.3 infant deaths / 1000 live births

• Decline in premature death primarily responsible for L/E improvement– >90% decline in infant mortality in last century

Life expectancy (L/E)? (con’t)

• More realistic picture: consider L/E at age 60

• L/E affected by advances in acute care, e.g.

• Trauma• Cardiac events• Infectious disease

Management of acute illness is unprecedented. The challenge lies with “the neglected epidemic of chronic disease”

.

The origins of chronic illness

How do we manage chronic health problems?

1. Assess the Patient

2. Assign ‘Diagnosis’

3. Treat with Medicine or Surgery

4. Many spend the rest of their life coping with chronic illness

Common Algorithm for Clinical Management of Chronic Illness

Common algorithm for approach to illness

Osteoporosis

Bipolar Illness

Assessment Diagnosis Treatment

Assessment Diagnosis Treatment

What about the etiology?

Etiology often not explored

If there was a correctable causation, one would explore & treat the cause to resolve the problem?

Fundamental Assumption…

Frequent Assumption

The general algorithm ofAssessment Diagnosis Treatment

• Common presumption: cause of chronic illness is not readily explainable… assumed genetic & non-correctable

Is the genetic predestination paradigm consistent with recent science?

Identical twin studiesExamples:

• Parkinson’s Disease: 49 pairs of identical twins – one of the pair developed Parkinson’s and the other twin did not.

• Autoimmune Diseases: Growing number of studies support the role of both genetic and environmental factors leading to autoimmunity

Goldman SM, et al. Solvent exposures and Parkinson's disease. Ann Neurol. 2011 Nov 14.Selmi C et al Heritability versus the role of the environment in autoimmunity. J Autoimmun. 2012;39(4):249-52.

Genetics: Family history

• Why do so many have chronic health afflictions in the absence of family history?

Weintraub Karen, The prevalence puzzle: Autism counts . Nature 479, 22-24 (2011) doi:10.1038/479022a

Genomic Constancy but Rise in illness

1. Socioeconomic: Thyroid cancer incidence in Canada is increased in high SEC groups

2. Nationality: Multiple sclerosis afflicts Canadians at a rate that outpaces anyplace else in the world

3. Location of Residence: Thyroid cancer in Canada is highest in Metro Toronto (controlled for SEC factors)

Genetics: Demographics

Corsten MJ, et al. Incidence of differentiated thyroid cancer in Canada by City of residence. J Otolaryngol Head Neck Surg. 2015;44:36.

Migration & chronic disease

2011: Somali Minnesota children 1:28 have ASD

Cancers of the prostate and breast among Japanese and white immigrants in Los Angeles County. Br J Cancer. 1991;63(6):963-6

Cancer of the gastrointestinal tract among Japanese and white immigrants in Los Angeles County. J Natl Cancer Inst. 1987;78(2):223-8

Genetic Pre-Destinational Model: Incomplete

There must be other factors along with genetics that are contributing to health & illness

What might they be?

Centers of Disease Control

“Virtually all human diseases result from the interaction of genetic susceptibility and modifiable

environmental factors.”

Office of Genomics and Disease Prevention: Centers for Disease Control and Prevention. Department of Health and Human Services. Gene-Environment Interaction Fact Sheet. 2000.

National Institutes of Health

“Nearly all diseases result from a complex interaction between an individual’s genetic make-up and the environmental agents that he or she is exposed to.”

70-90% of chronic disease is primarily related to environmental determinants

Rappaport SM, Smith MT. Epidemiology. Environment and disease risks. Science. 2010;330(6003):460-1.

• Exceedingly few question their patients about adverse exposures.

• Main challenge: over 90% claim they have had no training in the field of environmental health sciences and toxic exposures.

Physician study

Stotland NE,, et al. Counseling patients on preventing prenatal environmental exposures—a mixed-methods study of obstetricians. PLoS One. 2014;9(6):e98771

Environmental Health Sciences

• Some universities have recently instituted

• Objective: Assess the health risks associated with biological, chemical and physical hazards in natural and built environments

Review: Section 1

• Increasing chronic disease

• Significant impact on individuals & society

• Environmental factors identified as a primary determinant of chronic illness epidemic

• Medical trainees lack education in environmental determinants of disease

Section II. EM Approach to clinical practice

Genome Environment(modifiable)(fixed)

What are the clinically significant environmental factors?

CDC: “Virtually all human diseases result from the interaction of

genetic susceptibility and modifiable environmental

factors.”

Genome Environment(modifiable)(fixed)

Environmental Medicine

EM Approach to Clinical Practice

Environmental Medicine:Investigating and managing modifiable determinants within the environmental realm to prevent health problems & promote recovery.

Environmental determinants of Illness

• What are all these factors:– e.g. includes adverse exposures including chemicals, pathogens, radiation, etc

• To introduce: will focus on one aspect for today’s discussion– Chemical toxins

• Info available for further study

Cigarette Smoking…

• Increased exposure = increased risk

• Bioaccumulation of toxic agents, e.g. cadmium, benzene, etc

• Associated with various cancers, respiratory disease, heart disease, maternal-fetal issues, stroke, etc.

Chemical revolution in last 60 years

• More than 90,000 anthropogenic compounds have been created and many released into the environment

• Many chemicals people are breathing, part of daily life:– Bioaccumulate– just as bad or worse than cigarettes– e.g. various pesticides, perfluorinated compounds (PFCs),

brominated flame retardants (PBDEs), etc.

Centers for Disease Control

• Largest and most comprehensive analysis of toxicant exposure ever performed on humans

• Most American adults and children have bioaccumulated numerous potentially toxic chemicals

• Health Canada (same findings)

Centers for Disease Control and Prevention: Department of Health and Human Services. https://www.cdc.gov/exposurereport/index.html

• Physiological functioning, governed by biochemical reactions, involving levels in ppb & ppt

• Endogenous free estradiol adult women (serum)e.g. 0.0006-0.0071 ppb

Question: Are levels insignificant?

Welshons WV, et al. (2003) Large effects from small exposures. Environ Health Perspect 111,994–1006.2016.

The Chemical Disruption of Human Metabolism

CELLULAR TOXICITY PATHOPHYSIOLOGY

Damage to Cell Structures -e.g. DNA, mitochondria* Endocrine Disruption *

Oxidative Stress* Inflammation

Receptor and Transporter Dysregulation Immune Dysregulation *

Epigenetic Change Pathway Impairment

Cellular Detoxification Impairment Biome Alteration

Dysregulation of Signalling ANS Dysregulation

Plaque Formation Neurotransmission Dysfunction *

Displacement Nutritional Compromise

Other Mechanisms of Cellular Toxicity Other Pathophysiological Mechanisms

Genuis SJ, Kyrillos E. The Chemical Disruption of Human metabolism. Toxicology Mechanisms and Methods 2017

Polybrominated Diphenyl Ethers (PBDEs)

Type of Fire Retardant Common in North America:

• Polyurethane foam

• Children’s clothing (e.g. pajamas)

• Electronics

• Insulation in Buildings

Federal Mattress Flammability Standard (e.g. CFR 1633 & TB 117)

• Fire Regulations – responding to smoking in beds

• (until recently) Requires 12-second open flame testing for polyurethane inside furniture

• Necessitate up to 25-30% BFRs by weight to meet regulations

Characteristics of PBDEs

Properties

• EHC recycling

• Bioaccumulate

• Lipophilic

• Persistent

Schecter et al 2005; J Occup Environ Med. 2005 Mar;47(3):199-211. Ikonomou et al 2002; 2006; Rayne et al 2003; Johnson-Restrepo et al 2005; Elliot et al 2005Lebeuf et al 2004; She et al 2002; Shaw et al 2008. Shaw and Kannan 2009. PBDEs: Blood levels 1973 – 2005

Polybrominated Diphenyl Ethers: Sequelae

• Diabetes• Dementia• Neurodevelopmental Deficits – e.g. diminished IQ• Pediatric Mental Health Disorders – e.g. ADD• Estrogenic endocrine disruptor• Infertility• Some cancers• Thyroid disease …• Quality

• etc., etc.

Main KM et al. Flame retardants in placenta and breast milk and cryptorchidism in newborn boys. Env Health Perspect 2007 Oct;115(10):1519-26. Harley KG et al. PBDE concentrations in women’s serum and fecundability.. Environ Health Perspect. 2010 May;118(5):699-704Polybrominated diphenyl ethers in human serum and sperm quality. Akutsu K, et al. Bull Environ Contam Toxicol. 2008 Apr;80(4):345-50. Turyk ME et al. Hormone disruption by PBDEs in adult male sport fish consumers. Environ Health Perspect. 2008 Dec;116(12):1635-41. Stapleton et al. Associations between PBDE flame retardants, phenolic metabolites, and thyroid hormones during pregnancy. Environ Health Perspect. 2011 Oct;119(10):1454-9. Hurley S et al. Adipose levels of polybrominated diphenyl ethers and risk of breast cancer. Breast Cancer Res Treat. 2011 Sep;129(2):505-11.

Endocrine Disruption: Etiology of widespread hormonal dysfunction

• Many toxicant compounds distort endocrine function

• Agents interfere with synthesis, transport, action, or excretion of hormones

• May mimic hormones, block hormone receptors, act synergistically with hormones, have anti-hormonal action, etc.

• Can affect fertility, thyroid function, pubertal development, sexual development, and hormone sensitive organs such as prostate, breast, endometrium, etc.

The Prague Declaration on Endocrine Disruption -126 Signatories. Meeting for international group of scientists convened in Prague. May 1-12, 2005Mnif et al. Effect of Endocrine Disruptor Pesticides: A Review. Int J Environ Res Public Health. 2011 June; 8(6): 2265–2303.

Thyroid Disruption - Small sample of the literature.

BPA , other plasticizers DDT & PCBs, etcTriclosan, PBDEs, etcPhthalates, etcPCBs,etcFungicide (Mancozeb) etcMetals (Pb, Hg, Cd, etc)Organochlorines, etc

etc…

Binds thyroid hormone receptorsBind TSH receptorInduction of thyroid autoantibodiesBlocks Iodide uptakeBinds thyroid transport proteinImpairs thyroid hormone productionInhibition of DeodinasesDirect Thyrotoxicity

• Brent GA. Environmental Exposures and Autoimmune Thyroid Disease.Thyroid. 2010 Jul; 20(7): 755–761. • Takser L et al.. Thyroid hormones in pregnancy in relation to environmental exposure to organochlorine compounds and mercury. Env Health Perspect. 2005;113(8):1039-45• Crofton KM. Thyroid disrupting chemicals: mechanisms and mixtures. Int J Androl. 2008 Apr;31(2):209-23• Shen O, Comparison of in vitro hormone activities of selected phthalates using reporter gene assays. Toxicol Lett. 2009 Dec 1;191(1):9-14.• etc. etc.

Etiology

Disease(label for the S&S)

Biochemistrydisrupted with

altered function

EM approach to clinical practicePathway to illness (Pathogenesis)

Abnormal Process(what is actually going on)

Effect(manifestation)

Cause

HealthyPerson

Etiology DiseaseDisorderedBiochemical

Process

Ways of Approaching Intervention

Health

Option 1Option 2

Option 3

Etiology DiseaseBut less symptomsRelieves sufferingMitigate damage

Biochemistryimproved with

intervention(e.g. meds, some

supplements)

Pathway to feeling better

HealthyPerson

If assume genetic & thus fixed – only option

Etiology Disease(label for the S&S)

Altered Biochemistry &

Physiology

EM: How to restore health – Interrupting pathway to illness

Intervene to improve

EffectAddress cause if possible-genetic (fixed)-environmental (modifiable)

HealthyPerson

Example I: Male 60 y/o Multimorbidity• Insulin dependent diabetic• Insulin Dependent Diabetes – Rx Insulin• Chronic severe headaches and other

neurological issues: numbness• Recurrent skin problems • Symptoms unresolved arious treatments in the

past

Toxicological testing: Arachlor 1254 (mixture of PCB congeners)

Redgrave et al. (2005)Treatment with a dietary fat substitute decreased Arochlor 1254 contamination in an obese diabetic male. J Nutr Biochem ;16(6):383-4.Jandacek RJ, et al. (2014) Reduction of the body burden of PCBs and DDE by dietary intervention in a randomized trial. J Nutr Biochem 25: 483-488.

Intervention: Male 60 y/o Multimorbidity• Insulin dependent diabeticRx with non-absorbable fat Olestra Rx- Lipophilic “sink” x 2 years.

Result: – PCBs dropped markedly (3200 mg/kg to 56

mg/kg)– Normoglycemic, off insulin– Resolution of other symptoms – Marked clinical improvement

Redgrave et al. (2005)Treatment with a dietary fat substitute decreased Arochlor 1254 contamination in an obese diabetic male. J Nutr Biochem ;16(6):383-4.Jandacek RJ, et al. (2014) Reduction of the body burden of PCBs and DDE by dietary intervention in a randomized trial. J Nutr Biochem 25: 483-488.

Prevention – Alzheimer’s

• Has reached epidemic proportions• Between 1999 and 2014, the death rate

from Alzheimer’s increased by 55 percent, killing more than 93,500 Americans in 2014

U.S. Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report May 26, 2017 / 66(20);521–526

Sauna bathing is inversely associated with dementia and Alzheimer's disease in middle-aged Finnish men.

• Prospective cohort study of 2,315 apparently healthy men aged 42-60 years at baseline,

• Median follow-up of 20.7 years

Compared to 1 sauna/weekHR (hazard ratio) for dementia was 0.78 for 2-3 sauna sessions per week HR for dementia was 0.34 for 4-7 sauna sessions per week.

Laukkanen T, Kunutsor S, Kauhanen J, Laukkanen JA. Sauna bathing is inversely associated with dementia and Alzheimer's disease in middle-aged Finnish men. Age Ageing. 2016

SPECIAL COMMUNICATIONInternational Federation of Gynecology and Obstetrics opinion onreproductive health impacts of exposure to toxic environmental chemicals

From abstract (doi: 10.1016/j.ijgo.2015.09.002):

• “Exposure to toxic environmental chemicals during pregnancy and breastfeeding is ubiquitous and is a threat to healthy human reproduction”

• “There are tens of thousands of chemicals in global commerce, and even small exposures to toxic chemicals during pregnancy can trigger adverse health consequences”

Obstetric: FIGO Oct 2015

American Red Cross - Cord Blood Samples

Environmental Working Group. Body burden - the pollution in newborns A benchmark investigation of industrial chemicals, pollutants and pesticides in umbilical cord blood. (Executive Summary) July 14, 2005. [Accessed Sept 16, 2005] http//ewg.org/reports/bodyburden2/execsumm.php .

Many toxic chemicals pass vertically from mother to child –adverse sequelae reported

Organic Solvents in Pregnancy

Women exposed to solvents in their occupations• factory workers, lab techs, cleaning

industry, cosmetic industry, printing companies, etc

Increased risk of major fetal malformation – major CNS, CVS defects, etc

• 13-fold increased risk of anomalies• Higher rates of pregnancy loss• Reduced fertility among women

Khattak S, Moghtader GK, McMartin K, Barrera M, Kennedy D, Koren G. Pregnancy outcome following gestational exposure to organic solvents: a prospective controlled study. JAMA 1999; 281:1106-9

Pediatric Cancer and Toxic Exposure

Linked (1) birth addresses of children who died from childhood malignancy over a 15 year period, with (2) sites of toxic emissions from

industrial sites

Almost all childhood malignancies, a leading cause of mortality by disease in children 1-15 years of age, were directly associated with

maternal exposure to certain environmental toxins.

Knox, E. G. Childhood cancers and atmospheric carcinogens. J Epidemiol Community Health. 2005 Feb; 59(2)101-5.

Challenge: Knowledge translation

• Dr. Norm Delarue , thoracic surgeon at TGH: in 1947 recognized the relationship between smoking and lung cancer.

• Info on smoking & mortality published in 1954 BMJ & still ignored • Took the usual 30-40 years before widely accepted• Now: accrual of various toxic chemicals in cigarettes recognized as

a determinant of many illnesses

• Many other examples – e.g. H Pylori

Doll R, Hill AB. (1954). The mortality of doctors in relation to their smoking habits. BMJ 328.

Now we have a plethora of other chemical exposures that people are routinely exposed to.

(some of which are at least as toxic as smoking)

I. Knowledge Translation among Health Professionals

ResearchPublications

SuccessfulImplementation

WidespreadPractitionerExposure to

New Information

Where are we?

Clinical Implementation – lethargic process

Impact on healthcare

Are environmental determinants contributing to the global epidemic of chronic disease that are challenging healthcare systems?

Diabetes Mellitus II

Production of Synthetic Organic Chemicals.The Paradox of Progress: Environmental Disruption of Metabolism and the Diabetes Epidemic. http://diabetes.diabetesjournals.org/content/60/7/1838.full#ref-72. Updated from: Neel BA & Sargis RM. Diabetes 2011;60:1838-48

Many persistent pollutants linked to DM II

Autism

• Rossignol D et al. Environmental toxicants and autism spectrum disorders: A systematic review. 2013. In Press• CDC figures. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6103a1.htm?s_cid=ss6103a1_w• Prevalence of Autism Spectrum Disorders --- Autism and Developmental Disabilities Monitoring Network, United States, 2006. MMWR 2009; 58(SS10);:1-20.• Geier MR, Geier DA. Thimerosal in childhood vaccines, neurodevelopment disorders, and heart disease in the United

States. J Am Phys Surg. 2003;8(1):6-11.• Production of Synthetic Organic Chemicals.The Paradox of Progress: Environmental Disruption of Metabolism and the Diabetes Epidemic.

http://diabetes.diabetesjournals.org/content/60/7/1838.full#ref-72. Updated from: Neel BA & Sargis RM. Diabetes 2011;60:1838-48.

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Prostate Cancer

• Derouiche et al. 2013 Dec;2(1):54. Springerplus. Bisphenol A stimulates human prostate cancer cell migration via remodelling of calcium signalling..• Prostate Cancer. Canadian Cancer Society/National Cancer Institute of Canada (2006, April) Table 7.1

http://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2006-EN.pdf• Production of Synthetic Organic Chemicals.The Paradox of Progress: Environmental Disruption of Metabolism and the Diabetes Epidemic.

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Bushnik et al. Estimating the prevalence of infertility in Canada. Hum Reprod. 2012 Mar;27(3):738-46.Production of Synthetic Organic Chemicals.The Paradox of Progress: Environmental Disruption of Metabolism and the Diabetes Epidemic. http://diabetes.diabetesjournals.org/content/60/7/1838.full#ref-72.

Endocrine disrupting compounds may be linked to unexplained infertility –disruption of sperm production & ovulation

Review

• The epidemic of chronic physical and mental disease has been linked to environmental determinants (e.g. CDC, NIH, WHO, extensive med lit)

• Most MDs have not been trained to investigate and manage environmental determinants of illness

• Incorporation of EM into medical education could have profound impact

Opportunity - The TENDR Consensus Statement

• “We call on health professionals to integrate knowledge about environmental toxicants into patient care and public health practice.”

• Education in med school, residency & practitioner CME to address pandemic of chronic disease by integrating EM knowledge and approach

• What might this look like? …half dozen lectures and PBL sessions – could provide foundation to the field

Endorsed by• American College of Obstetricians and Gynecologists

• Child Neurology Society

• Endocrine Society

• International Neurotoxicology Association

• International Society for Children’s Health and the

Environment

• And others

Project TENDR: Targeting Environmental Neuro-Developmental Risks. The TENDR Consensus Statement. Environmental Health Perspectives (2016) DOI:10.1289/EHP358

www.stephengenuis.com- videos, references, and medical papers

MD FRCSC DABOG DABEM FAAEMClinical Professor – Faculty of Medicine

University of Alberta