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Seafood Choices: Balancing Benefits and Risks 4 Health Risks Associated with Seafood Consumption This chapter reviews the potential risks associated with chronic exposure to particular seafoodborne contaminants and risks associated with certain more acute seafoodborne hazards. The discussion includes consideration of the extent to which seafood consumption might increase consumers’ risk of adverse health impacts due to exposure to toxicants, depending upon the critical dose-response relationships for the contaminant, the distribution of contaminant body burden in the population, and the extent to which the body burden is due to seafood consumption rather than to other sources and pathways of exposure. The chapter concludes with a discussion of the interaction between nutrients and contaminants—in particular, selenium and methylmercury—in seafood, and measures that consumers can take to reduce exposure to contaminants that may be present in seafood. ENVIRONMENTAL CHEMICALS Consumers seeking the health benefits associated with the consumption of seafood are concerned about potential health risks associated with the presence of chemical contaminants, both those occurring naturally and those resulting from human activities, in seafood. These contaminants include inorganic compounds such as methylmercury and other metals, as well as persistent organic pollutants (POPs) such as dioxins and polychlorinated biphenyls (PCBs). Of these, methylmercury is the contaminant that has elicited the most concern among consumers.
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Seafood Choices: Balancing Benefits and Risks Methylmercury Mercury is a heavy metal that is present in the environment as a result of both human activities (referred to as anthropogenic sources) and natural processes. The primary anthropogenic source is the combustion of fossil carbon fuels, particulary from coal-fired utility boilers; other sources include municipal, medical, and hazardous waste incineration (NRC, 2000). The natural sources include volcanic emissions and the weathering of rock containing mercury ore. Mercury can be deposited locally or travel long distances in the atmosphere and contaminate sites far from its point of release. Further, the complex biogeochemistry of mercury fate and transport creates uncertainty in efforts to apportion the relative contributions of these processes to global mercury pollution. The US Environmental Protection Agency (US EPA) estimated that 50 to 75 percent of the total yearly input of mercury into the environment is anthropogenic (US EPA, 1997), while the United Nations Environment Programme (UNEP) suggests that this source accounts for more than half of the inputs (UNEP, 2002). Mercury exists in the environment in several different forms, including metallic, inorganic, and organic, and interconversion between forms can occur. The form of mercury of greatest concern with regard to seafood consumption is methylmercury (MeHg). Methylmercury results when mercury in other forms is deposited in water bodies and biotransformed through the process of methylation by microorganisms. It bioaccumulates up the aquatic trophic food chain as smaller organisms are consumed by larger organisms. Because methylmercury is persistent, this bioaccumulation process results in large long-lived predatory species, such as certain sharks, swordfish, and tuna, or freshwater species such as bass, walleye, and pickerel having the highest concentrations (Kraepiel et al., 2003). Methylmercury levels can also be high in marine mammals such as whales, and in animals that feed on marine life, such as polar bears and sea birds. Consumption of aquatic life is the major route of human exposure to methylmercury. The seafood choices a consumer makes, and the frequency with which different species are consumed, are thus important determinants of methylmercury intake. Because of the global dispersion of methylmercury and migration of species, the extent of regional variation in body burdens among different aquatic animals is less striking than the regional variations in certain other water contaminants, such as PCBs or dioxin-like compounds (DLCs). This implies that the location in which an aquatic animal was caught might provide relatively little information about its methylmercury content. Methylmercury is not lipophilic (lipid soluble) and is thus present in the largest concentrations in the muscle tissue of aquatic animals rather than in fat or oils. Approximately 95 percent of ingested methylmercury is absorbed across the gastrointestinal tract into the blood. The half-life
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Seafood Choices: Balancing Benefits and Risks of methylmercury in blood in humans is estimated to be 50 days, and the whole-body half-life to be 70–80 days, although the residence time of mercury in the brain appears to be considerably longer (NRC, 2000). Hair is frequently used as an exposure biomarker for methylmercury. Hair is a route of methylmercury excretion, and approximately 80 to 90 percent of the total mercury found in hair is in the methylated form. Hair mercury is a good biomarker in fish-consuming populations. Autopsy studies suggest that maternal hair mercury level correlates reasonably well with the level of mercury in the fetal brain (Cernichiari et al., 1995). Mercury Burdens in the US Population The first nationally representative estimates of blood and hair mercury levels were provided by the National Health and Nutrition Examination Survey (NHANES) of 1999–2000. Among women 16–49 years old, the geometric mean hair mercury level was 0.2 parts per million (ppm), with 75th, 90th, and 95th percentiles of 0.42, 1.11, and 1.73 ppm, respectively (McDowell et al., 2004). The geometric mean blood mercury level was 1.02, with 75th, 90th, and 95th percentiles of 2.07, 4.84, and 7.13 ppm, respectively (Mahaffey et al., 2004). The prevalence of levels in excess of 5.8 µg/L (benchmark dose lower bound [BMDL] adjusted for uncertainty and for population variability) was 5.66 percent. Levels were 50 percent higher among older women (30–49 years) compared to younger women, and levels were highest among women who self-identified as “Other” racial/ethnic category (Asians, Native Americans, Pacific Islanders). Mercury burdens were strongly associated with the amount of self-reported fish consumption (Mahaffey et al., 2004). Among women reporting eating 5–8 fish meals per month, these figures were 2.56, 4.54, 8.80, and 11.60 ppm, respectively. Levels were seven times greater among women who reported eating nine or more fish meals in the previous 30 days, compared to women who reported no consumption. Among these relatively high fish-consumers, the 50th, 75th, 90th, and 95th percentiles for blood mercury were 3.02, 6.68, 12.00, and 13.40 ppm, respectively. Data on blood and hair mercury levels in adult men in the United States were not collected as part of NHANES until 2003, and no data for this group has been reported. Therefore, estimates must be made based on mercury biomarker data reported as part of large cohort studies. Urine and blood mercury levels of 1127 Vietnam-era pilots were measured for a study of the health effects of exposure to dental amalgam (Kingman et al., 1998). The mean blood mercury level in this group of men was 3.1 ppm, with a range up to 44 ppm, but the contribution of fish consumption to blood mercury levels is unknown because data were not collected on fish intake.
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Seafood Choices: Balancing Benefits and Risks An important limitation of NHANES as a source of data on population exposures to methylmercury is that the sampling plan used to identify the 3637 women who contributed data in the 1999–2002 survey is likely to have missed subgroups of high fish-consumers, including sport fishers and subsistence fishers. Examples of such groups include individuals living in areas that provide ready access to seafood (e.g., island populations) (Ortiz-Roque and Lopez-Rivera, 2004), fishers (Burge and Evans, 1994; Bellanger et al., 2000), groups for whom fish or marine mammals are an especially important component of overall diet, and individuals who consume a high-fish diet for its cardioprotective effects. For example, one report described a case series of 116 patients who consumed large quantities of fish and had their blood tested; almost all (89 percent) had blood mercury levels greater than 5 µg/L, ranging up to 89 µg/L (Hightower and Moore, 2003). Evidence from the Third National Report on Human Exposure to Environmental Chemicals (CDC, 2005b) suggests that population exposures to mercury might have decreased between 1999–2000 and 2001–2002. Among women 16–49 years of age, the geometric mean declined from 1.02 µg/L (95% CI 0.825-1.270) to 0.833 (95% CI 0.738-0.940). An even greater decline was evident at the high end of the distribution, as the level corresponding to the 95th percentile in the earlier survey was 7.10 (95% CI 5.30-11.30) compared to 4.6 (95% CI 3.7-5.9) in the later survey. Because of the short time period covered by these data, however, the possibility that the observed time trend reflects sampling variability cannot be rejected. Health Effects in Critical Target Organs Organs of the central nervous and cardiovascular systems are considered to be the critical target organs with regard to methylmercury. Neurological Toxicity The tragic epidemic of frank neurological disease that was identified in the late 1950s in Minamata, Japan, first brought to the world’s attention the devastating effects of methylmercury on the developing fetal brain. Children exposed in utero to high levels of MeHg presented with cerebral palsy, mental retardation, movement and coordination disorders, dysarthria, and sensory impairments.The neuropathological lesions associated with Congenital Minamata Disease (mercury poisoning) were diffuse, occurring throughout the brain. In individuals exposed only in adulthood, the lesions were highly focal, clustering in regions that matched clinical presentation (e.g., motor disorders = precentral gyrus and cerebellum, constriction of visual fields = calcarine fissure of occipital cortex). The major molecular mechanisms of MeHg neurotoxicity include inhibition of protein and macromolecular synthesis, mitochondrial dysfunction, defective calcium and ion flux, disruption of neurotransmitter homeostasis, initiation
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Seafood Choices: Balancing Benefits and Risks of oxidative stress injury, microtubule disaggregation, and post-translational phosphorylation (Verity, 1997). The diffuse injury associated with prenatal exposure is attributable to the ability of MeHg to arrest mitotic cells in metaphase, disrupting the exquisitely choreographed processes of cell proliferation, differentiation, and migration. The result is a brain in which there are reduced cortical cell densities, islands of heterotopic neurons in cerebral and cerebellar white matter, anomalous cytoarchitecture, disturbance in laminar pattern of cerebral cortex, absence of granule and Purkinje cells in the cerebellum, incomplete myelination in the hypoplastic corpus callosum, glial proliferation (“bizarre astrocytes in the white matter”), and limited gyral differentiation (Choi, 1989). No cases of Congenital Minamata Disease have been reported in the United States, where the primary concern has been whether chronic exposure to MeHg, as the result of seafood consumption among the general population, is associated with subtle adverse health outcomes. Therefore, several risk assessments have been conducted in the past decade in which the goal was to identify a fetal mercury burden that can be interpreted as being without appreciable risk. The basis for most risk assessments for MeHg exposure has been one or more of the three major epidemiologic studies available: the New Zealand study (Kjellstrom et al., 1986), the Faroe Islands study (Grandjean et al., 2001), and the Seychelles study (Myers et al., 2003) (see Box 4-1). The New Zealand and Faroe Islands studies, but not the Seychelles study, have generally been regarded as providing evidence of harm from MeHg exposures at which clinical effects are not evident, although it should be noted that benchmark dose analyses of the data from the 9-year evaluation of children in the Seychelles study cohort produced BMDLs in the range of 17–23 ppm (Van Wijngaarden et al., 2006), only slightly higher than the BMDLs based on the New Zealand and Faroe Islands studies data. In view of the perceived discrepancies in the findings of the three studies, the choice of critical study has stimulated considerable controversy. Some risk assessors chose the Faroe Islands study (US EPA, 2001; NRC, 2000), while others chose the Seychelles study (ATSDR, 1999). In an effort to use all of the best available data, the Joint Expert Committee on Food Additives and Contaminants (JECFA), a joint committee of the World Health Organization (WHO) and the Food and Agricultural Organization of the United Nations (FAO), averaged the effect estimates reported for the Faroes and Seychelles studies; including the New Zealand study did not significantly change the results (FAO/WHO JECFA, 2003). In all these assessments, however, the final result was a single number interpreted as a reference level for intake for the most sensitive subgroup, the fetus, as shown in Table 4-1. These reference levels differ largely because of differences in the uncertainty factors applied. These levels were derived on the basis of health effects observed, rather than
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Seafood Choices: Balancing Benefits and Risks BOX 4-1 Three Major Epidemiological Studies on Methylmercury These three studies were conducted among geographically disparate island populations with a high availability of seafood (tuna is an important export product of Seychelles, approximately one-third of the Faroese workforce is employed in the fishing industry, and both aquaculture and marine fishing feature in the economy of New Zealand). Cohen (2004) summarized these three cohorts in reviews. Seychelles Child Development Study The Seychelles Child Development Study (SCDS) is an ongoing collaboration between the Ministry of Health of Seychelles, a small archipelago country in the Indian Ocean, and the University of Rochester, New York. “Initially the objectives focused on two primary questions. Firstly, could clinical neuro-development effects be found in children after exposure to methylmercury (MeHg) in utero from a maternal diet high in fish and, secondly, what is the lowest level of foetal [sic] exposure to cause such effects?” (Shamlaye, 2004). Seychelles was determined to be a favorable location for this study for a number of reasons: the Seychellois regularly consume fish (an average of 12 meals per week), and the number of annual births allowed for recruitment of a large cohort of mothers and children in a short period of time (Shamlaye, 2004; Myers et al., 2003). The Seychelles Child Development Study enrolled 779 mother-infant pairs between 1989 and 1990, of which 717 were eligible for analysis. Among the tests administered at 107 months were the Wechsler Intelligence Scale for Children—Third Edition, the Boston Naming Test, the California Verbal Learning Test, the Bruininks-Oseretsky Test of Motor Proficiency, a Continuous Performance Test, the Developmental Test of Visual-Motor Integration, the Grooved Pegboard, and selected subtests of the Woodcock-Johnson Tests of Achievement. The children were evaluated (i.e., cognitive, language, motor, adaptive behavior, and social-emotional development) at 6, 19, 29, 66, and 107 months. Maternal hair samples were also collected at enrollment. The information provided here, along with the results from the study, can be accessed in the Special Issue of the Seychelles Medical and Dental Journal, Volume 7, Issue 1, 2004. [Online]. Available: http://www.seychelles.net/smdj/ [accessed July 7, 2005]. Also, in 2000, Clarkson et al. recruited a new cohort of mother-infant pairs in Seychelles, and this project is due for completion in 2006. Faroe Islands Study The Faroe Islands Study, conducted in this North Atlantic Ocean archipelago located between Scotland, Norway, and Iceland, consisted of a cohort of
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Seafood Choices: Balancing Benefits and Risks 1022 consecutive singleton births from 1986–1987. The objective of this study was to investigate possible neurobehavioral effects of prenatal exposure to neurotoxicants, such as methylmercury. The Faroese are high consumers of seafood, including pilot whale, which exposes them to high levels of methylmercury. The study team analyzed maternal hair mercury concentrations and cord blood mercury concentrations at birth and conducted neurobehavioral examinations on 917 of the children just before school entry (about 7 years of age) and at 14 years of age. The detailed examinations, which lasted about 5 hours for each child, took place mostly in the National Hospital in Torshavn, the capital of the Faroes Island. The examination included finger tapping; hand-eye coordination; reaction time on a continuous performance test; Wechsler Intelligence Scale for Children—Revised Digit Span, Similarities, and Block Design; Bender Visual Motor Gestalt Test; Boston Naming Test; and California Verbal Learning Test. The parent accompanying the child (usually the mother) was also asked to fill out a self-administered questionnaire on the child’s past medical history, current health status, and social factors (Grandjean, 1997). New Zealand Study The New Zealand Study involved the screening of 11,000 children born in 1978, over 900 of whose mothers consumed fish more than four times per week during pregnancy. As with the other cohorts, the objective of this study was to investigate the association between prenatal mercury exposure and subsequent development during childhood (Crump, 1998). Maternal hair samples were collected at birth to assess mercury exposure during pregnancy. At 4 years of age, the Denver Developmental Screening Test and a set of neurological screening tests were completed on 74 children, 38 with “high” maternal hair mercury levels (> 6µg/g) and 36 with “low” maternal hair mercury levels, matched on maternal demographic characteristics, age, hospital where the birth took place, and date of birth. Maternal interviews about the ages at which the child achieved developmental milestones were also conducted (Kjellstrom et al., 1986). At 6 years of age, 238 children were evaluated. A child with a high maternal hair mercury was matched with three children with low hair mercury levels, but similar in gender, maternal ethnic group, age, smoking habits, location of residence, and number of years living in New Zealand (Kjellstrom et al., 1989). The tests administered included the Test of Oral Language Development, the Weschlar Intelligence Scale for Children-Revised, and the McCarthy Scales of Children’s Abilities.
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Seafood Choices: Balancing Benefits and Risks TABLE 4-1 Reference Levels for Fetal Exposure to Methylmercury Source Reference Level JECFA provisional tolerable weekly intake 1.6 µg/kg body weight/week US EPA reference dose 0.1 µg/kg body weight/day Agency for Toxic Substances and Disease Registry minimal risk level 0.3 µg/kg body weight/day SOURCES: FAO/WHO JECFA, 2003; US EPA, 2001; ATSDR, 1999. the general population, and are risk management guidelines rather than estimates of threshold of effect. While such numbers can be used to estimate the number of individuals at potential risk (i.e., for whom the margin of exposure is less than 10-fold), they convey nothing about the quantitative characteristics of the dose-response relationship, i.e., for the risk associated with each unit increase in mercury burden above the reference level. A variety of hypotheses have been proposed to explain the apparent discrepancy between the results of the Seychelles and Faroe Islands studies. The National Research Council (NRC) committee did not consider that any of them is clearly supported by the evidence, however. The issues evaluated include differences between populations in the temporal characteristics of exposure (presumed to be stable among the Seychellois, but potentially episodic among the Faroese due to occasional consumption of pilot whale), reliance on different biomarkers of exposure (cord blood mercury vs. maternal hair mercury), population differences in vulnerability to methylmercury, the influence of other aspects of nutrition on methylmercury toxicity, and differences in the neuropsychological tests administered and the ages at which children were assessed. Consideration has also been given to the possibility of residual confounding in one or both studies, particularly with regard to the high exposures of the Faroese to PCBs and other POPs. Although considerable debate has ensued seeking to identify the reasons for the apparent discrepancies among the three major studies of fetal MeHg neurotoxicity, their magnitude might be less dramatic than commonly supposed. As the analyses of the National Research Council Committee on the Toxicological Effects of Methylmercury showed, the BMDLs calculated for the three major studies vary by much less than the 10-fold (one order of magnitude) uncertainty factor applied to the BMDL to achieve the Reference Dose (RfD) (NRC, 2000). Figure 4-1 shows a qualitative effort to assess the degree of concordance among studies of the “no observed adverse effect levels” (NOAEL) estimated for each study on the basis of benchmark dose analysis. An estimate of 10 to 20 ppm appears to be reasonably accurate. Interestingly, this is the range identified by WHO (1990) based solely on the relatively poor-quality data available from a mass poisoning episode
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Seafood Choices: Balancing Benefits and Risks FIGURE 4-1 Integration of data from the New Zealand, Faroe Islands, and Seychelles studies of prenatal methylmercury neurotoxicity. Two ranges are provided for the NOAEL from the New Zealand study. The estimate labeled (1) was derived when the data for a child with a very high maternal hair mercury level (86 ppm) were included in the analyses. The estimate labeled 2 was derived when the data for this child were excluded. This child’s mercury level was more than fourfold higher than the level for any of the 236 other children in this cohort. NOTE: NOAEL = No observed adverse effect level. SOURCE: Personal communication, Clarkson et al., University of Rochester, March 2005. that occurred in Iraq in the 1970s (Personal communication, Clarkson and colleagues, University of Rochester, March 2005). Ryan (2005) conducted an analysis of data from the three previously described studies using maximum likelihood and Bayesian hierarchical models to derive an estimate of the slope of the dose-response relationship between children’s neurodevelopment and their prenatal methylmercury exposure. This analysis, presented to the Committee on Nutrient Relationships in Seafood (Ryan, 2005), suggested that children’s IQ scores decline by 0.1 to 0.25 points for each ppm increase in maternal hair mercury level. The point estimates were nearly identical in the three studies (results for the New Zealand study differed considerably depending on whether one particular observation was included or excluded) (see Figure 4-2). The point estimates of the slopes for the other neurodevelopmental endpoints measured in the three studies, some of which were common across studies, were also surprisingly similar (Figure 4-3).
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Seafood Choices: Balancing Benefits and Risks FIGURE 4-2 Point estimates and 95 percent confidence intervals, based on regression analyses, for the changes in full scale IQ (“coefficients”) associated with each ppm increase in maternal hair mercury reported in the three studies. A coefficient with a negative sign indicates that the IQ scores for children within a study cohort decreased with increasing hair mercury level. Two estimates are provided for the New Zealand study, one based on the inclusion of the child with a maternal hair mercury level of 86 ppm and one based on the exclusion of this child. SOURCE: Ryan, 2005. These analyses, therefore, suggest that although the findings of the Seychelles study appear discrepant from those of the Faroe Islands and New Zealand studies if one focuses only on the p-values of the reported analyses, at a deeper, quantitative level that focuses on the rates of decline in scores as mercury burden increases, the findings of the three studies are remarkably concordant. Part of the challenge in characterizing the health risks associated with increased MeHg exposure in seafood is related to the fact that this source also provides nutrients that might have health effects which mitigate those of MeHg. Thus, studies tend not to provide a “pure” estimate of MeHg toxicity but an estimate that represents the balance between the putative harm caused by the contaminant and the putative benefits provided by the
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Seafood Choices: Balancing Benefits and Risks FIGURE 4-3 Coefficients for achievement and cognition-related endpoints from the three studies. The symbols Q, C, and B denote the three endpoints that are common to two or more studies, namely IQ (Q), California Verbal Learning Test (C), and Boston Naming Test (B), respectively. X’s indicate endpoints that were unique to one of the studies. Coefficients reflect the change in test score for each ppm increase in maternal hair mercury. A coefficient with a negative sign indicates that a test score decreased as maternal hair mercury level increased. New Zealand estimates are based on including the child with a maternal hair mercury level of 86 ppm. The Faroe Islands median hair:cord blood ratio of 200 (Budtz-Jorgensen, 2004b) was used to convert the Faroe Islands results to units of hair mercury. SOURCE: Ryan, 2005. nutrients in seafood. This issue is critical, however, because the goal in giving advice regarding seafood consumption should be to enable people to obtain the greatest benefit for the least risk. An illustration of the delicacy of this balance is provided by a study of 135 mother-infant pairs in Boston (Oken et al., 2005). Mothers reported consuming an average of 1.2 fish servings per week during the second trimester of pregnancy (range 0–5.5 servings/week), and had a mean hair
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