Lead Poisoning and Nutrition

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Lead Poisoning and Nutrition
Deborah A. McMahan, MD Health Commissioner Fort
Wayne Allen County Department of Health
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Agenda

• Lifestyle
• Miscellaneous
• Micronutrients
• Pregnancy Issues
• Recommendations

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• Lifestyle
• Hunger
• Folk remedies
• Candies

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Hunger
Lead is much more readily absorbed on an empty
stomach

• After ingestion, lead goes from the stomach to
• The blood and then into the bone
• GI tract and out through the stool

Kids absorb 50 of lead ingested vs. 10 for
adults
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Use of Assistance Programs by Hunger Status
May not be easy to identify hungry children
Cutts, D. B. et al. Arch Pediatr Adolesc Med
1998152489-493.
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Cutts, D. B. et al. Arch Pediatr Adolesc Med
1998152489-493.
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Hunger
Anemia, low hemoglobin, can be a marker for
malnutrition
Even obese children can be hungry and/or
malnourished
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Estimates of Food Poverty in Indiana
In school year 2002-2003, 333,607 children
received free or reduced school lunches
In 2003, there was an almost 20 increase in the
value of food stamps issued in Indiana from 2002
Kids Count in Indiana 2004 County Profiles of
Child Well-Being
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Specific Recommendations

• To better assess calories, have parents provide a
  food diary for children

• Instruct parents that children should eat at
  least four to six times a day

• Refer parents to food banks, churches or other
  food resources

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Dietary Fat and Lead Poisoning
Animal studies suggest that increased intake of
dietary fat may increase lead absorption
But also important to remember that for young
children, fat and cholesterol play important
roles in brain development
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Dietary Fat Recommendations

• For kids below 2 years old, fat should not be
  restricted
• Starting at 2 years old, children should have
  about 30 to 35 of their total calories from fat
• Children 4 to 18 years the percentage should be
  about 25 to 35

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Folk Remedies
Greta and Azarcon are Mexican folk remedies used
to treat diarrhea and/or upset stomach contains
93.4 powdered lead
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Case history
Two Hispanic children were identified during
routine screening to have elevated lead levels of
88.0 g/dL and 69.0 µg/dL They parents had used
Greta powder which had 770,000 parts per million
(ppm) of lead
MMWR August 9, 2002 / 51(31)684-686
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Folk Remedies
Ba baw san is a Chinese remedy used for colic and
to pacify kids
Cheng et al performed a study of 319 children
aged 1 to 7 years demonstrated that consumption
was associated with increased BLLs
Cheng TJ, Wong RH, Lin YP, et al Chinese herbal
medicine, sibship, and blood lead in children.
Occup Environ Med 1998 Aug 55(8) 573-6
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Folk Remedies
Pay-loo-ah is southeast Asian remedy used to
treat fevers contains variable amounts of lead
6-month-old Hmong girl was found to have lead
poisoning (blood lead (BL) 60 ug/dl that was
traced back to using this herb
MMWR October 28, 1983 / 32(42)555-6
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Candies
Lead has been identified in a number of candies
imported from Mexico. 
Ingredients such as chili powder and tamarind may
be a source of lead exposure But even the
wrappers may contain lead
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Candies
Of approximately 1,000 cases of elevated BLLs
among California children that were reported to
CDHS during May 2001--January 2002, candy
produced in Mexico was identified as a possible
exposure source in approximately 150 cases
MMWR October 28, 1983 / 32(42)555-6
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• Miscellaneous
• Gardening
• Tap water
• Dishes

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Lead Poisoning and Soil
Important to remember that food grown in soils
that are contaminated with lead may absorb the
lead
Lead enters the soil from peeling lead based
paint or from auto/truck exhaust Especially if
the garden is near a highway, busy road, or
smelting plant
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Lead Poisoning and Soil
For many low-income people, home-grown is the
only way they can afford fresh produce
Important to recommend that they wash the produce
well before consuming
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Lead Poisoning and Drinking Water

• Water becomes contaminated when lead leaches into
  water from corrosion from
• Lead pipes
• Copper pipes with lead solder

Even newer homes are at risk!
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Lead Poisoning and Drinking Water
Lead contaminated water is also significant risk
factor for infants who are formula fed
Important to remind parents not to boil water for
formula as that may concentrate lead coming from
the water or the pot
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Recommendations for Drinking Water

• Parents should let cold water run for greater
  than one minute before using it for
• Drinking
• Cooking
• Cleaning food

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Dishes and Crystal
Lead stored in ceramic dishes or leaded glass
containers can leach into food products
Lead can leach into beverages, especially with
acidic fruit juices, when they are stored in
glazed ceramic containers
Toy dishes can have lead also
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• Micronutrients
• Iron
• Calcium
• Vitamin C

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Lead Absorption
Lead is absorbed in the gut and then distributed,
via the blood stream, to the liver, bone and
excreted through urine and stool
Micronutrient levels in the gut are one of the
most important risk factors for lead absorption
because they all compete with lead for receptors
that will facilitate absorption
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Micronutrients
Micronutrients include Iron Calcium
Other nutrients act as cofactors that can promote
absorption of lead Vitamin C
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Iron Deficiency
Iron is used to make hemoglobin which is the
protein that carries oxygen in the blood.
Iron deficiency can both cause anemia and
increase the bodys absorption of lead that is
ingested
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Anemia and Lead Poisoning
Anemia is defined as a decreased concentration of
hemoglobin and RBC mass compared with that in
age-matched controls
It is very common, estimates are that 20 of kids
in US are anemic
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Anemia and Lead Poisoning
The most common cause of anemia in children is
iron deficiency, which can occur without lead
poisoning
Lead poisoning can mimic iron deficiency as well
as cause anemia
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Iron Deficiency
A common time for iron deficiency is between 9
and 24 months of age

• This is also when they are
• Moving and interacting with their environment
• At-risk for lead poisoning
• Most susceptible to the negative effects of lead

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Anemia and Lead Poisoning
But the most serious situation is if both types
of anemia occur simultaneously
Anemia is more severe in these children and up to
50 percent more lead may be absorbed in children
with an iron deficiency than in those with normal
hemoglobin levels
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Iron Levels and Lead Poisoning
According to the American Academy of Pediatrics
iron deficiency, even without anemia, appears to
be the single most important predisposing factors
for increased absorption of lead
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Pediatric Iron Needs
Children need to absorb an average of 1mg per day
of iron to keep up with the needs of their
growing bodies
Children only absorb about 10 of the iron they
eat, most children need to ingest 8-10mg per day
of iron to absorb the 1 mg per day needed
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Recommended Levels of Iron
The Recommended Dietary Allowance (RDA) for iron
for children from age 6 months to 10 years is 10
mg per day
The absorption of iron in foods will be enhanced
when iron-rich foods are consumed with foods high
in vitamin C
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Sources of Iron
Good -- Tuna, oatmeal, apricots, raisins,
spinach, kale, greens, prunes. Better -- Eggs,
meat, fish, chicken, turkey, soybeans, dried
beans, peanut butter, peas, lentils, molasses.
Best -- Breast milk (the iron is very easily
used by the child), formula with iron, infant
cereals, other iron-fortified cereals, liver,
prune juice
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Amounts of Iron in Foods
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Calcium and Lead Poisoning
Calcium and lead compete for similar binding
sites on intestinal mucosal proteins
Studies have shown that absorption of lead by the
gastrointestinal tract is inversely related to
dietary calcium
Effects of Micronutrients on Metal Toxicity
Marjorie A. Peraza, Felix Ayala-Fierro, David S.
Barber, Elizabeth Casarez, and Leonard T. Rael
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Calcium and Lead Poisoning
Dietary calcium deficiency increases lead
concentration in critical organs.
The absorption of lead decreases as calcium
intake increases
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Lead, Calcium and Bone
Lead and calcium are both used by bone Lead has
an affinity for bone and acts by replacing
calcium
Lead uptake in bone occurs faster than release
from bone
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Calcium Recommendations
Because good dietary levels of lead inhibit lead
absorption, children should be sure to have the
recommended daily amount of calcium
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Recommended Dietary Allowances for Calcium
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Dietary Calcium and Lead Poisoning
Super doses of calcium do not provide additional
benefit for children that are lead poisoned
Studies have shown that some supplements are made
from bone and contain lead and should not be
used check FDA website
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Food Sources for Calcium
Calcium equivalents (300 mg)
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Vitamin C and Lead Poisoning
Vitamin C, also called ascorbic acid, helps the
body absorb iron
The exact mechanism between vitamin C intake and
blood lead levels is not known, although it is
believed that vitamin C may either inhibit
intestinal absorption of lead or facilitate
excretion of lead in the urine
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RDA for Vitamin C
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Dietary Sources of Vitamin C
Fruits and vegetables
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Vitamin C and Allen County Kids
38.3
41.3
30.2
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Other Micronutrients

• Other micronutrients have shown promise in animal
  studies including
• Zinc
• Selenium

Both are believed to reduce absorption of lead
and the toxic effects of lead
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Pregnancy and Lead Poisoning
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Pregnancy Lead Poisoning
NHANES III reported in 1997 that some 900,000
children aged one to five years have EBLL 10
That means a lot of young women will be at risk
during their pregnancy in the next several years
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Pregnancy Lead Poisoning
During pregnancy, hormonal changes can cause lead
that had been stored in bone to be released into
blood
The lead can then cross the placenta and harm the
baby
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Nutritional Info for Pregnant Women
Eat frequent regular meals lead is absorbed more
easily on an empty stomach
Eat diet rich in calcium and Iron
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Breastfeeding
Breastfeeding is generally safe and is an
excellent source of iron which is important if
baby is exposed to lead in utero
If Moms EBLL is 10, she can still breastfeed
but monitor babies lead level stop if babies
level is 10
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Baby Issues

• Important to remind new moms to use pacifiers
  that attach to babies clothing to avoid falling
  into potential dust on floor

• Prepare baby formula by running cold water for
  one minute or using bottled water if tap water
  exceeds EPA limits of 15 ppb

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General Recommendations
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General Recommendations

• Make sure you identify any food, supplement,
  remedy or other ingestion related factors
  contributing to lead levels

• Ensure that the child does not have coexisting
  iron deficiency

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General Recommendations

• Obtain a good food history from parent
• ask open ended questions
• have them keep a food diary

• Lets you know what they are really eating
• Make recommendations that they can live with

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General Recommendations

• Make sure they have enough to eat

• Assist them in finding good sources for produce
  and other foods

• Food banks and cheaper grocery stores may not
  have the types of foods the child needs

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Summary

• There are a lot of food related sources of lead
  poisoning for kids that may make it difficult to
  get their levels down to zero

• A child may have underlying medical conditions
  and micronutrient deficiencies that contribute to
  lead poisoning

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Summary
Epidemiological and scientific evidence support
the role that nutrition can have in minimizing
the impact of lead poisoning in children
Especially in vulnerable populations that are at
risk for substandard housing and nutritional
deficits which highlights the importance of case
management
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Summary

• Good case management can
• Identify these issues
• Make relevant recommendations
• Assist parents in accessing hard to find/afford
  resources