Showing posts with label risk factors. Show all posts
Showing posts with label risk factors. Show all posts

Friday, December 2, 2011

It Ain't Easy Raising a Family on a Farm These Days...

If you were raised in a city or in suburbia, farm life must seem serene, bucolic, and wholesome. Sure, it means hard work, but it's honest and lets you escape to simpler times in human history...


Fields Near Greenfield, CA


In some ways, you'd be right. In most ways...


The Salinas Valley in California is known as the "Salad Bowl of the World" with its large production of lettuce, spinach, tomatoes and more. This title was not awarded simply by having small subsistence farms. Agriculture in the United States is big business, with heavy machinery, large acres of land, huge water needs, fertilizers, and pesticides. As such, farm life is complicated, scientific, and dangerous.


In 2007, organophosphate (OP) pesticides accounted for 36% of all pesticides used in the United States. This class of pesticides, whose membership includes chlorpyrifos, malathion, and phosmet, is greatly important to agriculture and the Californian economy.


Pesticides in the organophosphate class work by inhibiting the enzyme acetylcholinesterase. The targeted enzyme is important for proper neuron to neuron signalling in insect as well as human nervous systems, which makes it an excellent target for a pesticide.


However, many studies have shown associations with poorer neurobehavioral development in very young children who have been exposed to OP pesticides while in the womb or as an infant. Usually, this exposure to the pesticide is due to dietary consumption by the pregnant mother or infant. A recent study published in August of 2011 sought to examine whether these biological effects were long lasting, and at whether prenatal or postnatal exposure was a larger contributor to the observed neurobehavioral deficiencies.


The study examined data from a cohort of largely Latino pregnant mothers and children living in an agricultural community in the Salinas Valley. Their exposures to OP pesticides are, by and large, very high compared to other populations around the country, but are still within possible levels for the general population. They found, by measuring biological samples, that OP pesticide exposure to a pregnant mother is associated with lower IQ scores in her children even at the age of 7. Those children that had the highest exposure through their mothers had  an average deficit of 7 points! On the other hand, exposure during childhood was not associated with this outcome.


Now what do we do? We've been told to eat well and eat our veggies, especially when someone is pregnant. Are we simply poisoning our children with good intentions? No. Certainly not, agrees Elizabeth Marder, a University of California-trained toxicologist. "It is important to recognize that determining an exposure has occurred does not necessarily mean that a harmful exposure has occurred." But, there are clear indications for actions that can be taken for at risk people.


MINIMIZE EXPOSURE:
1) Pregnant mothers have many things to worry about during their pregnancies. If a pregnant mother is associated with or lives in a farming community, she should also be vigilant about possible ways to be exposed to these pesticides and avoiding them. For example, staying indoors on a crop dusting day, and making sure that any relatives that visit who work on the farm change into clean clothes before entering your home.


2) Always eat well--whether you're pregnant or not! This also means making sure any ingredients that are being used in a meal are cleaned thoroughly before being transformed into a healthy salad, casserole, or curry. Avoiding nutritionally healthy products based on a possible exposure is NOT the solution!


WAYS TO ACHIEVE:
1) For the population of women involved in this presented study, starting strong educational programs for avoiding or minimizing pesticide exposure while pregnant may be helpful. After all, knowledge is power. In this case, it's the power to know what other precautions a new mother can take as early as possible in pregnancy. Community outreach programs targeting agricultural populations in the languages they speak would seem to be the way to go.


2) A broader campaign may include television or radio ads encouraging the proper cleaning of fruits and vegetables before consumption. Reminders of good practices in common media can improve the chance the general population is maximally reducing their exposure to pesticides through their diets in ways they can afford.


DONE AND DUSTED (Wait, wait, not really):
Unfortunately, any opportunity to advocate good practices runs the risk of unintentionally alienating a population. The ability for persons to avoid exposures is also limited by their economic abilities. Migrant workers, for example, are a vital source of labor in California's agriculture infrastructure. They do not necessarily have the means to "avoid" pesticide exposures if a family depends upon the income generated by a working person. In this scenario, even a pregnant woman may insist on working in the fields during her pregnancy. Also, don't even bother thinking that she could use her maternity leave.


It is, indeed, difficult to raise a family, let alone raising one in an area where certain vulnerabilities are compounded by our environments. However, steps can be made to reduce our exposures to OP pesticides while still providing ourselves with food and an economy.


Citations:
Bouchard, MF, Chevrier, J, et al. Prenatal Exposure to Organophosphate Pesticides and IQ in 7-Year-Old Children. Environmental Health Perspectives, Vol 119, No 8, Aug 2011. 
Photos sourced through the Creative Commons Licenses.


Chandresh Ladva filled his lungs with pesticides and oil refinery fumes for 18 years while living in the San Joaquin Valley before he moved eastward to study philosophy and epidemiology at the University of Pennsylvania and Yale, respectively. He longs to return to California someday, but not before finding solutions to problems associated with development and environmental toxins. He is currently a pre-doctoral candidate in environmental health sciences at Emory University.


chandresh.ladva@emory.edu

Thursday, November 17, 2011

Over-the-counter and under-the-radar: use of NSAIDs among people with kidney disease is common and could be harmful

NSAIDs, or non-steroidal anti-inflammatory drugs, are widely available over-the-counter, including ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Anaprox™), and aspirin. These medications are primarily used as pain relievers (“analgesics”) and fever reducers. Additionally, many multi-drug formulations, like medicines for colds and menstrual symptoms, also contain NSAIDs.

Many NSAIDs are sold over-the-counter.
It is easy to forget that medications available over-the-counter are not without side effects and that they may not be safe for everyone. A recent community-based study (1) showed that NSAID use was common and that those with kidney disease were twice as likely to use NSAIDs frequently than those without kidney disease. This is despite the recommendation of the National Kidney Foundation (NKF) that people with kidney disease avoid NSAIDs because the effects of renal clearance of these drugs may be associated with kidney injury and progression of kidney disease. [Note that acetaminophen (Tylenol™) does not have the same type of clearance and is not considered risky in those with kidney disease.]


NSAIDs interact with several prescription drugs.
Additionally, NSAIDs may lessen the effectiveness of prescription drugs frequently taken by those with kidney disease, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and diuretics, all of which are taken to control blood pressure and prevent progression of disease. According to Vanessa Grubbs, MD, a nephrologist with the University of California, San Francisco, and co-author on the paper, “Primary care clinicians and doctors who prescribe medicine for pain management need to be aware of the potential interactions of NSAIDs with ACE inhibitors, ARBs, and loop diuretics.”

About 26 million people in the United States have early stages of kidney disease and >500,000 are currently treated with dialysis or have a kidney transplant because their kidneys have failed. Costs for kidney disease care make up about one-third of the Medicare budget. Thus, preventing and slowing the progression of CKD in the United States is essential, and educating patients and providers about the potential risks of NSAIDs is a way to improve patient outcomes.

What can you, as a patient, do about this potential risk?
First, know your risk for kidney disease. Other studies (2) have shown that most people with kidney disease are unaware of their disease. Kidney disease is often “silent” (=no symptoms) until it has progressed to late stages. Thus, knowing your risk allows you to ask your doctor for simple tests (serum creatinine and urine protein) that can assess possible damage to or reduced function of the kidneys. The most common risk factors for kidney disease are:

1. Diabetes
2. Hypertension
3. African-American, Hispanic, Pacific Islander, or Native American race/ethnicity
4. Family history
5. Older age
6. Inherited and autoimmune conditions such as glomerulonephritis and lupus

Second, if you have, or at high risk for, kidney disease, don’t assume that a drug is safe for you because it is available over-the-counter. There are explicit warnings on NSAIDs bottles about the increased risk of stomach ulcers/bleeding and cardiovascular events, but no such warnings regarding risk for kidney injury and disease progression appear on the bottle, despite calls for this labeling from the NKF >10 years ago. For any over-the-counter drug, read the entire label, including that insert inside the box that most of us throw away. You should consider asking your doctor about any drug or supplement you take over-the-counter, but specifically any that contain warnings about kidney or “renal” risks or describe the drug as having “renal clearance.”

What can health care providers do?
First, health care providers should test their high-risk patients regularly for kidney disease and talk to their patients about their risk. NSAIDs should be prescribed only as needed in those with or at high risk and after careful weighing of the risks and benefits. For example, a patient with debilitating arthritis may need pain relief for an acceptable quality of life, despite the potential risks.

Second, providers should carefully assess the use of over-the-counter NSAIDs in their patients. While patients often list the drugs they are taking as part of their visit, they may not consider over-the-counter NSAIDs as “drugs” or may forget about drug formulations that they take intermittently, such as cold medications. Also, some patients with low health literacy or problems with their vision may not be able to recall names of medications, which could lead to an ethical issue, if such vulnerable patients receive less-than-optimal advice. Providers may want to consider instead presenting a series of photos of various types of medication packaging that  contain NSAIDs so that the patient can identify the drugs they’ve taken rather than having to list the names of the medications.



About the author
Laura Plantinga, Sc.M., is a researcher whose interests include kidney disease awareness and outcomes. She is currently working on a doctoral degree in epidemiology at Emory University and setting a world record for oldest graduate student.

References
1. Plantinga L, Grubbs V, Sarkar U, Hsu CY, Hedgeman E, Robinson B, Saran R, Geiss L, Burrows NR, Eberhardt M, Powe N; CDC CKD Surveillance Team. Nonsteroidal anti-inflammatory drug use among persons with chronic kidney disease in the United States. Ann Fam Med. 2011;9(5):423-30.
2. Plantinga LC, Tuot DS, Powe NR. Awareness of chronic kidney disease among patients and providers. Adv Chronic Kidney Dis. 2010 May;17(3):225-36.
Images courtesy of Google images