The lead and copper rule: Limitations and lessons learned from Newark, New Jersey.

Flint, Michigan reignited the public discourse surrounding lead contamination in drinking water with Newark, New Jersey recently experiencing its own lead-in-water crisis. Following Flint's experience, the Environmental Protection Agency proposed changes to the Lead and Copper Rule (LCR), but these changes may not produce better detection of contamination. LCR testing requirements were evaluated for their ability to predict or identify problems from the recent (2015-2019) Newark lead exceedance data. LCR compliance and water quality data were obtained from the New Jersey Department of Environmental Protection (NJDEP) website. Between 2002 and 2015, Newark sampled on a reduced sampling plan (50 samples once every 3 years), as required, for lead and copper. These samples were divided between Newark's two water sources with uneven sampling distribution across the city, further limiting the potential to identify a risk of lead in drinking water. Results suggest a more rigorous testing requirement may have identified the problem sooner. Limitations related to the LCR that prevented Newark water suppliers from earlier detection of lead risk will continue under the revised LCR. This article is categorized under:Engineering Water > Water, Health, and SanitationScience of Water > Water Quality.

Dietary Influences on Urinary Fluoride over the Course of Pregnancy and at One-Year Postpartum.

Dietary factors are known to influence urinary fluoride (UF) levels in nonpregnant people. Maternal UF is used as a biomarker of fluoride exposure; however, dietary influences on UF during pregnancy are unknown. We compared UF levels and assessed the associations between UF and five select dietary influences in pregnancy vs. one-year postpartum: dietary fluoride (F), calcium intake from diet (Ca-diet), calcium intake from supplements (Ca-sup), dietary acid load (AL), and table salt use (TS) in 421 women exposed to fluoridated salt in the Mexican diet. Spot UF (mg/L) was measured by microdiffusion/fluoride-specific electrode and dilution-corrected with specific gravity (SG). Dietary variables were estimated from a validated Food Frequency Questionnaire. Comparisons among UF in pregnancy vs. one-year postpartum were performed with non-parametric tests. Associations between dietary variables and UF were assessed using random effect models (for pregnancy) and linear regression (for one-year postpartum). SG-corrected UF (median, range) during pregnancy (0.77, 0.01-4.73 mg/L) did not significantly differ from one-year postpartum (0.75, 0.15-2.62 mg/L) but did increase every 10 gestational weeks, ß = 0.05 (CI: 0.00-0.10). Different dietary influences on UF were identified at each state. Although Ca-diet and AL were not associated with UF in either state, Ca-sup decreased UF only during pregnancy, ß = - 0.012 mg/L (CI: - 0.023-0.00). Reporting TS use was associated with 12% increase in UF only at one-year postpartum (p = 0.026). These results suggest different dietary influences on UF in the pregnant state, which need consideration when using UF as a biomarker of fluoride exposure.

Cake Decorating Luster Dust Associated with Toxic Metal Poisonings - Rhode Island and Missouri, 2018-2019.

During 2018-2019, the Rhode Island Department of Health (RIDOH) and the Missouri Department of Health and Senior Services (DHSS) investigated cases of metal poisonings associated with commercially and home-prepared cakes decorated with products referred to as luster dust. Several types of glitters and dusts, broadly known as luster dust,* for use on prepared foods can be purchased online and in craft and bakery supply stores (1). Decorating foods with luster dust and similar products is a current trend, popularized on television programs, instructional videos, blogs, and in magazine articles.† Some luster dusts are specifically produced with edible ingredients that can be safely consumed. Companies that make edible luster dust are required by law to include a list of ingredients on the label (2). Luster dusts that are safe for consumption are typically marked "edible" on the label. Some luster dusts used as cake decorations are not edible or food grade; labeled as "nontoxic" or "for decorative purposes only," these luster dusts are intended to be removed before consumption (3). RIDOH (2018) and Missouri DHSS (2019), investigated heavy metal poisonings associated with commercially and home-prepared cakes decorated with luster dust after receiving reports of children (aged 1-11 years) who became ill after consuming birthday cake. Cases in Rhode Island were associated with copper ingestion, and the case in Missouri was associated with a child's elevated blood lead level. In Rhode Island, luster dust products that had been used in cake frosting were found to contain high levels of multiple metals.§ These events indicate that increased vigilance by public health departments and further guidance to consumers and bakeries are needed to prevent unintentional poisonings. Labeling indicating that a product is nontoxic does not imply that the product is safe for consumption. Explicit labeling indicating that nonedible products are not safe for human consumption is needed to prevent illness from inappropriate use of inedible products on foods. Educating consumers, commercial bakers, and public health professionals about potential hazards of items used in food preparation is essential to preventing illness and unintentional poisoning from toxic metals and other nonedible ingredients.

Blood Lead Levels in U.S. Children Ages 1-11 Years, 1976-2016.

BACKGROUND: Lead can adversely affect child health across a wide range of exposure levels. We describe the distribution of blood lead levels (BLLs) in U.S. children ages 1-11 y by selected sociodemographic and housing characteristics over a 40-y period. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) II (1976-1980), NHANES III (Phase 1: 1988-1991 and Phase II: 1991-1994), and Continuous NHANES (1999-2016) were used to describe the distribution of BLLs (in micrograms per deciliter; 1µg/dL=0.0483µmol/L) in U.S. children ages 1-11 y from 1976 to 2016. For all children with valid BLLs (n=27,122), geometric mean (GM) BLLs [95% confidence intervals (CI)] and estimated prevalence ≥5µg/dL (95% CI) were calculated overall and by selected characteristics, stratified by age group (1-5 y and 6-11 y). RESULTS: The GM BLL in U.S. children ages 1-5 y declined from 15.2µg/dL (95% CI: 14.3, 16.1) in 1976-1980 to 0.83µg/dL (95% CI: 0.78, 0.88) in 2011-2016, representing a 94.5% decrease over time. For children ages 6-11 y, GM BLL declined from 12.7µg/dL (95% CI: 11.9, 13.4) in 1976-1980 to 0.60µg/dL (95% CI: 0.58, 0.63) in 2011-2016, representing a 95.3% decrease over time. Even so, for the most recent period (2011-2016), estimates indicate that approximately 385,775 children ages 1-11 y had BLLs greater than or equal to the CDC blood lead reference value of 5µg/dL. Higher GM BLLs were associated with non-Hispanic Black race/ethnicity, lower family income-to-poverty-ratio, and older housing age. DISCUSSION: Overall, BLLs in U.S. children ages 1-11 y have decreased substantially over the past 40 y. Despite these notable declines in population exposures to lead over time, higher GM BLLs are consistently associated with risk factors such as race/ethnicity, poverty, and housing age that can be used to target blood lead screening efforts. https://doi.org/10.1289/EHP7932.

Association between cumulative childhood blood lead exposure and hepatic steatosis in young Mexican adults.

BACKGROUND: Exposure to environmental toxicants may play a role in the pathogenesis of Non Alcoholic Fatty Liver Disease (NAFLD). Cumulative exposure to lead (Pb) has chronic and permanent effects on liver function. Pediatric populations are vulnerable to the toxic effects of Pb, even at low exposure levels. The purpose of the study was to estimate the association between cumulative Pb exposure during childhood and hepatic steatosis biomarkers in young Mexican adults. METHODS: A subsample of 93 participants from the ELEMENT cohort were included in this study. Childhood blood samples were collected annually from ages 1-4 years and were used to calculate the Cumulative Childhood Blood Lead Levels (CCBLL). Hepatic steatosis during adulthood was defined as an excessive accumulation of hepatic triglycerides (>5%) determined using Magnetic Resonance Imaging (MRI). Liver enzymes were also measured at this time, and elevated liver enzyme levels were defined as ALT (≥30 IU/L), AST (≥30 IU/L), and GGT (≥40 IU/L). Adjusted linear regression models were fit to examine the association between CCBLL (quartiles) and the hepatic steatosis in young adulthood. RESULTS: In adulthood, the mean age was 21.4 years, 55% were male. The overall prevalence of hepatic steatosis by MRI was 19%. Elevate levels of the enzymes ALT, AST, and GGT were present in 25%, 15%, and 17% of the sample, respectively. We found a positive association between the highest quartile of CCBLL with the steatosis biomarkers of hepatic triglycerides (Q4 vs. Q1: ß = 6.07, 95% CI: 1.91-10.21), elevated ALT (Q4 vs. Q1: ß = 14.5, 95% CI: 1.39-27.61) and elevated AST (Q4 vs. Q1: ß = 7.23, 95% CI: 0.64-13.82). No significant associations were found with GGT. CONCLUSIONS: Chronic Pb exposure during early childhood is associated with a higher levels of hepatic steatosis biomarkers and hepatocellular injury in young adulthood. More actions should be taken to eliminate sources of Pb during the first years of life.

Dietary fluoride intake over the course of pregnancy in Mexican women.

OBJECTIVE: To estimate dietary fluoride intake (F) over the course of pregnancy and the overall adjusted difference in dietary F intake by pregnancy stages and levels of compliance with dietary recommendations. DESIGN: Secondary data analysis from a longitudinal pregnancy cohort study in a population exposed to fluoridated salt. Women were followed during the early, middle and late stages of their pregnancy (n 568). The dietary intake of recommended prenatal nutrients according to Mexican dietary guidelines and F intake (mg/d) was estimated with a validated FFQ. Data were summarised with descriptive statistics. Levels of F intake were compared with the USA's Institute of Medicine adequate intake (AI) of 3 mg/d for pregnancy. Adjusted differences in F intake by pregnancy stages and levels of compliance with recommendations were estimated using random effects models. SETTING: Mexico City. PARTICIPANTS: Women participating in the Early Life Exposures in Mexico to ENvironmental Toxicants (ELEMENT) project, from 2001 to 2003. RESULTS: Median dietary F intake throughout pregnancy ranged from 0·64 (interquartile range (IQR) 0·38) in the early to 0·70 (IQR 0·42) in the middle, and 0·72 (IQR 0·44) mg/d in the late stage (0·01 mg F/kg per d). Corresponding adjusted intakes of F were 0·72 (95 % CI 0·70, 0·74), 0·76 (95 % CI 0·74, 0·77) and 0·80 (95 % CI 0·78, 0·82) mg/d. Women who were moderately and highly compliant with Mexican dietary recommendations ingested, on average, 0·04 and 0·14 mg F/d more than non-compliant women (P < 0·005). CONCLUSIONS: Dietary F intake was below current AI, was greater with the progression of pregnancy and in women who were moderately and highly compliant with dietary recommendations.

Use of the CUSUM and Shewhart control chart methods to identify changes of public health significance using childhood blood lead surveillance data.

BACKGROUND: Local, state, and national childhood blood lead surveillance is based on healthcare providers and clinical laboratories reporting test results to public health departments. Increased interest in detecting blood lead level (BLL) patterns and changes of potential public health significance in a timely manner has highlighted the need for surveillance systems to rapidly detect and investigate these events. OBJECTIVE: Decrease the time to detect changes in surveillance patterns by using an alerting algorithm developed and assessed through historical child blood lead surveillance data analysis. METHODS: We applied geographic and temporal data-aggregation strategies on childhood blood lead surveillance data and developed a novel alerting algorithm. The alerting algorithm employed a modified cumulative summary/Shewhart algorithm, initially applied on 113 months of data from two jurisdictions with a known increase in the proportion of children <6 years of age with BLLs =>5 µg/dl. RESULTS: Alert signals retrospectively identified time periods in two jurisdictions where a known change in the proportion of children <6 years of age with BLLs >=5 µg/dl occurred. Additionally, we identified alert signals among six of the 18 (33%) randomly selected counties assessed where no previously known or suspected pattern changes existed. CONCLUSION: The modified cumulative summary/Shewhart algorithm provides a framework for enhanced blood lead surveillance by identifying changes in the proportion of children with BLLs >=5 µg/dl. The algorithm has the potential to alert public health officials to changes requiring further important public health investigation.

Blood Lead Levels in U.S. Women of Childbearing Age, 1976-2016.

BACKGROUND: Lead can adversely affect maternal and child health across a wide range of exposures; developing fetuses and breastfeeding infants may be particularly vulnerable. We describe the distribution of blood lead levels (BLLs) in U.S. women of childbearing age and associations with sociodemographic, reproductive, smoking, and housing characteristics over a 40-y period. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) II, NHANES III Phase I and Phase II, and 1999-2016 continuous NHANES were used to describe the distribution of BLLs (given in micrograms per deciliter; 1µg/dL=0.0483µmol/L) in U.S. women 15-49 years of age between 1976 and 2016. For all women with valid BLLs (n=22,408), geometric mean (GM) BLLs and estimated prevalence of BLLs ≥5µg/dL were calculated overall and by selected demographic characteristics. For NHANES II, estimated prevalence of BLLs ≥10 and ≥20µg/dL were also calculated. RESULTS: The most recent GM BLLs (2007-2010 and 2011-2016, respectively) were 0.81µg/dL [95% confidence interval (CI): 0.79, 0.84] and 0.61µg/dL (95% CI: 0.59, 0.64). In comparison, GM BLLs in earlier periods (1976-1980, 1988-1991, and 1991-1994) were 10.37µg/dL (95% CI: 9.95, 10.79), 1.85µg/dL (95% CI: 1.75, 1.94), and 1.53µg/dL (95% CI: 1.45, 1.60), respectively. In 2011-2016, 0.7% of women of childbearing age had BLLs ≥5µg/dL, and higher BLLs were associated with older age, other race/ethnicity, birthplace outside the United States, four or more live births, exposure to secondhand tobacco smoke, and ever pregnant or not currently pregnant. DISCUSSION: Lead exposure in U.S. women of childbearing age is generally low and has substantially decreased over this 40-y period. However, based on these estimates, there are still at least 500,000 U.S. women being exposed to lead at levels that may harm developing fetuses or breastfeeding infants. Identifying high-risk women who are or intend to become pregnant remains an important public health issue. https://doi.org/10.1289/EHP5925.

Prenatal Lead Exposure, Type 2 Diabetes, and Cardiometabolic Risk Factors in Mexican Children at Age 10-18 Years.

CONTEXT: Several cross-sectional studies have assessed the association of lead exposure with type 2 diabetes and cardiometabolic risk factors in adults; however, studies of such associations in childhood are rare. OBJECTIVE: We assessed the prospective associations of prenatal exposure to lead with type 2 diabetes and cardiometabolic risk factors in children. DESIGN: The Early Life Exposure in Mexico to Environmental Toxicants is a birth cohort study of pregnant women and their offspring. SETTING: Public hospitals in Mexico City. PATIENTS OR OTHER PARTICIPANTS: Women were recruited during pregnancy; their offspring were recruited for a follow-up visit at age 10 to 18 years (n = 369). MAIN OUTCOME MEASURES: We measured fasting serum markers of type 2 diabetes and cardiometabolic risk factors in children, including fasting glucose, insulin, and lipids. The index of insulin resistance was calculated. RESULTS: The geometric mean of maternal blood lead levels (BLLs) during pregnancy was 4.3 µg/dL (95% confidence interval [CI]): 4.0-4.6 µg/dL) in the entire sample. In boys, those with maternal BLLs ≥ 5 µg/dL (compared with those with BLLs < 5 µg/dL) had significantly lower z scores for total cholesterol (ß = -0.41, 95% CI: -0.71, -0.12), high-density lipoprotein cholesterol (ß = -0.32, 95% CI: -0.59, -0.05), and low-density lipoprotein cholesterol (ß = -0.52, 95% CI: -0.81, -0.22), adjusting for covariates. No associations were detected in girls. CONCLUSIONS: In our study, we found that higher prenatal exposure to lead was associated with lower levels of cholesterol in children following a sex-specific pattern. Further studies with a larger sample size that examine whether sex is a potential modifier are needed to confirm our findings.

An examination of sex differences in associations between cord blood adipokines and childhood adiposity.

BACKGROUND: Though the physiological roles of adipokines in metabolism, insulin resistance and satiety are clear, literature regarding associations between cord blood adipokine levels and childhood adiposity is equivocal. OBJECTIVES: To determine whether cord blood levels of leptin and adiponectin are associated with adiposity in children 2 to 5 years of age, and whether such associations are modified by sex. METHODS: Leptin and adiponectin levels were measured in cord blood and anthropometric measures were completed on 550 children enrolled in the Maternal-Infant Research on Environmental Chemicals Child Development Plus study (MIREC-CD Plus). We used multivariable linear and Poisson regression models to determine associations between cord blood adipokine levels and child body mass index (BMI), triceps and subscapular skinfold thickness and risk of overweight/obesity and to assess effect modification by child sex. RESULTS: Cord blood adiponectin was significantly associated with modest increases in BMI and the sum of triceps and subscapular skinfold z-scores in boys but not girls. A doubling of adiponectin levels was associated with a 30% increased risk of overweight/obesity in boys (RR = 1.30; 95% CI: 1.02, 1.64). Leptin was not associated with anthropometric measures in either sex. CONCLUSIONS: The observed associations between adiponectin and adiposity in boys were statistically significant, of moderate magnitude, and underscore the value of considering sex-specific patterns.

Association between fluoride exposure and cardiometabolic risk in peripubertal Mexican children.

BACKGROUND: Several animal studies have suggested that fluoride exposure may increase the levels of cardiometabolic risk factors, but little is known about whether fluoride exposure is associated with such risk in humans. OBJECTIVES: We examined the cross-sectional association between peripubertal exposure to fluoride and markers of cardiometabolic risk in 280 girls and 256 boys at age 10-18 years living in Mexico City. METHODS: We measured plasma fluoride concentration using a microdiffusion method. We collected data on anthropometry including BMI, waist circumference (WC) and trunk fat percentage. We measured serum markers of cardiometabolic risk, including fasting glucose, insulin and lipids. All the indicators of outcome were converted to age- and sex-specific z-scores. We also calculated a summary cardiometabolic risk score for each participant. Multivariable linear regression models were used to examine these associations. RESULTS: The geometric mean (95% confidence interval (CI)) of plasma fluoride was 0.21 µmol/L (0.20, 0.23 µmol/L) in the total sample. In girls, plasma fluoride concentrations were associated with higher z-scores for all the individual markers (except for lipids) and for the combined cardiometabolic risk score (risk score: ß = 1.28, 95% CI: 0.57-2.00, p-sex interaction = 0.02)), adjusting for covariates. No associations were found in boys. CONCLUSIONS: We found that higher peripubertal fluoride exposure at the levels observed in this study population was significantly associated with increased levels of cardiometabolic risk factors in Mexican girls but not boys. Future studies with a longitudinal design are needed to confirm our findings and further elucidate the role of fluoride in cardiometabolic risk.

Early Life Exposure in Mexico to ENvironmental Toxicants (ELEMENT) Project.

PURPOSE: The Early Life Exposure in Mexico to ENvironmental Toxicants (ELEMENT) Project is a mother-child pregnancy and birth cohort originally initiated in the mid-1990s to explore: (1) whether enhanced mobilisation of lead from maternal bone stores during pregnancy poses a risk to fetal and subsequent offspring neurodevelopment; and (2) whether maternal calcium supplementation during pregnancy and lactation can suppress bone lead mobilisation and mitigate the adverse effects of lead exposure on offspring health and development. Through utilisation of carefully archived biospecimens to measure other prenatal exposures, banking of DNA and rigorous measurement of a diverse array of outcomes, ELEMENT has since evolved into a major resource for research on early life exposures and developmental outcomes. PARTICIPANTS: n=1643 mother-child pairs sequentially recruited (between 1994 and 2003) during pregnancy or at delivery from maternity hospitals in Mexico City, Mexico. FINDINGS TO DATE: Maternal bone (eg, patella, tibia) is an endogenous source for fetal lead exposure due to mobilisation of stored lead into circulation during pregnancy and lactation, leading to increased risk of miscarriage, low birth weight and smaller head circumference, and transfer of lead into breastmilk. Daily supplementation with 1200 mg of elemental calcium during pregnancy and lactation reduces lead resorption from maternal bone and thereby, levels of circulating lead. Beyond perinatal outcomes, early life exposure to lead is associated with neurocognitive deficits, behavioural disorders, higher blood pressure and lower weight in offspring during childhood. Some of these relationships were modified by dietary factors; genetic polymorphisms specific for iron, folate and lipid metabolism; and timing of exposure. Research has also expanded to include findings published on other toxicants such as those associated with personal care products and plastics (eg, phthalates, bisphenol A), other metals (eg, mercury, manganese, cadmium), pesticides (organophosphates) and fluoride; other biomarkers (eg, toxicant levels in plasma, hair and teeth); other outcomes (eg, sexual maturation, metabolic syndrome, dental caries); and identification of novel mechanisms via epigenetic and metabolomics profiling. FUTURE PLANS: As the ELEMENT mothers and children age, we plan to (1) continue studying the long-term consequences of toxicant exposure during the perinatal period on adolescent and young adult outcomes as well as outcomes related to the original ELEMENT mothers, such as their metabolic and bone health during perimenopause; and (2) follow the third generation of participants (children of the children) to study intergenerational effects of in utero exposures. TRIAL REGISTRATION NUMBER: NCT00558623.

Dietary Intake of Selenium in Relation to Pubertal Development in Mexican Children.

Alterations in pubertal timing have been associated with long-term health outcomes. While a few reports have shown that dietary intake of selenium is associated with fertility and testosterone levels in men, no human studies have considered the association between selenium and pubertal development in children. We examined the cross-sectional association of childhood dietary intake of selenium with pubertal development among 274 girls and 245 boys aged 10-18 years in Mexico City. Multiple logistic and ordinal regression models were used to capture the association between energy-adjusted selenium intake (below Recommended Dietary Allowance (RDA) vs. above RDA) and stages of sexual maturity in children, adjusted for covariates. We found that boys with consumption of selenium below the RDA had lower odds of a higher stage for pubic hair growth (odds ratio (OR) = 0.51, 95% confidence interval (95% CI): 0.27-0.97) and genital development (OR = 0.53, 95% CI: 0.28-0.99) as well as a lower probability of having matured testicular volume (OR = 0.37, 95% CI: 0.15-0.88) compared with boys who had adequate daily dietary intake of selenium (above RDA). No associations were found in girls. According to our results, it is possible that inadequate consumption of selenium may be associated with later pubertal development in boys, suggesting a sex-specific pattern. Future work with a larger sample size and measures of selenium biomarkers is needed to confirm our findings and improve understanding of the role of this mineral in children's sexual development.

Early lead exposure and childhood adiposity in Mexico city.

BACKGROUND: Prenatal and early childhood lead exposures have been associated with reduced weight in infants and young children, while studies that have examined such associations in children during peripubescence are rare. OBJECTIVES: We investigated the associations of prenatal and early-life exposure to lead with indices of adiposity in peripubertal children living in Mexico City. METHODS: Maternal bone lead (as a proxy for cumulative fetal exposure) was assessed at 1 month postpartum. Blood samples were obtained from children annually from 1 to 4 years. Multivariable linear regression models were used to examine the association between each lead biomarker and BMI z-score, waist circumference, sum of skinfolds and body fat percentage in 248 children aged 8-16 years. RESULTS: After adjusting for covariates, maternal patella lead was associated with lower child BMI z-score (ß = -0.02, 95% CI: 0.03, -0.01, p = 0.004), waist circumference (ß = -0.12 cm, 95% CI: 0.22, -0.03, p = 0.01), sum of skinfolds (ß = -0.29 mm, 95% CI: 0.50, -0.08, p = 0.007) and body fat percentage (ß = -0.09%, 95% CI: 0.17, -0.01, p = 0.03). No significant associations were detected from the postnatal exposure period. CONCLUSIONS: We observed a significant and inverse association of prenatal lead exposure with body composition in Mexican children, suggesting the potential role of early lead exposure in the fetal programming of child growth. Further research on the biological mechanisms underlying these associations is needed.

Dietary Sources of Fructose and Its Association with Fatty Liver in Mexican Young Adults.

Fructose intake has been associated with non-alcoholic fatty liver disease (NAFLD). The objective of this study was to assess the consumption of dietary fructose according to: 1) classification of hepatic steatosis by two indexes and 2) diagnosis of NAFLD by MRI. We conducted a cross-sectional analysis among 100 young adults from Mexico City. The Hepatic Steatosis Index (HSI) and the Fatty Liver Index (FLI) were estimated using Body Mass Index (BMI), waist circumference, and fasting concentrations of glucose, triglycerides, and hepatic enzymes (ALT, AST, GGT). A semi-quantitative food frequency questionnaire was administered to obtain dietary sources of fructose. We estimated the concordance between the hepatic indices and NAFLD and the correlation between the index scores and the percentage of liver fat. Eighteen percent presented NAFLD; 44% and 46% were classified with hepatic steatosis according to HSI and FLI, respectively. We compared dietary intake of fructose by each outcome: HSI, FLI, and NAFLD. Sugar-sweetened beverages (SSB) and juices were consumed significantly more by those with steatosis by FLI and NAFLD suggesting that SSB intake is linked to metabolic alterations that predict the risk of having NAFLD at a young age.

CDC's Lead Poisoning Prevention Program: A Long-standing Responsibility and Commitment to Protect Children From Lead Exposure.

The Centers for Disease Control and Prevention's (CDC's) Childhood Lead Poisoning Prevention Program (CLPPP) serves as the nation's public health leader and resource on strategies, policies, and practices aimed at preventing lead exposure in young children. CDC supports and advises state and local public health agencies and works with other federal agencies and partners to achieve the Healthy People 2020 objective of eliminating childhood lead exposure as a public health concern. Primary prevention-the removal of lead hazards from the environment before a child is exposed-is the most effective way to ensure that children do not experience the harmful effects of lead exposure. Blood lead screening tests and secondary prevention remain an essential safety net for children who may be exposed to lead. CDC's key programmatic strategy is to strengthen blood lead surveillance by supporting state and local programs to improve blood lead screening test rates, identify high-risk populations, and ensure effective follow-up for children with elevated blood lead levels. Surveillance plays a central role in helping measure the collective progress of federal, state, and local public health agencies in protecting children from lead, as well as enhancing our ability to target population-based interventions for primary prevention to those areas at highest risk. The CDC CLPPP has been at the front line of efforts to protect children from lead exposure and the resulting adverse health effects over the last 3 decades. As we chart our path for the future, we will continue to learn from past successes and challenges, incorporate new evidence and lessons learned, and work closely with federal, state, local, and nonprofit partners, experts in academia, and the community to advance the overarching goal of eliminating lead exposure in children.