Antibiotic Overuse: A Worldwide Emergency


For most of human history, infectious diseases have been the leading causes of illness and death.  Most ancient peoples used botanicals as the earliest antibiotics to combat various plagues, even without specific knowledge regarding the microbes responsible.  With the advent of modern pharmaceutical techniques, industrialized nations no longer rely on plants for cures, and millions of lives have been saved. However, we have now entered an age where the indiscriminate use of antibiotics in health and the food industries is causing significant harm to all living forms on Earth – and to the planet itself.  According to a Princeton Environmental Institute study published in The Lancet, worldwide antibiotic use increased an incredible 36 percent from 2000 to 2010.   The United States, sadly but not surprisingly, led the world in antibiotic use per person during this time period.  The report also noted the grave consequences of the escalation: rising resistance to many of our most commonly used life-preserving medications.

How profound is the resulting cost?  Staggering, both in terms of human health and healthcare costs.  One report, “A Brief History of the Antibiotic Era: Lessons Learned and Challenges for the Future,” notes, “The mortality rates due to multidrug-resistant bacterial infections are high. Each year, about 25,000 patients in the EU die from an infection with the selected multidrug-resistant bacteria (ECDC/EMEA Joint Working Group, 2009), and more than 63,000 patients in the United States die every year from hospital-acquired bacterial infections. Estimated economic costs due to infections by multidrug-resistant bacteria in the EU result in extra healthcare costs and productivity losses of at least EUR 1.5 billion each year (ECDC/EMEA Joint Working Group, 2009). The annual additional cost of treating hospital-acquired infections from just six species of antibiotic-resistant bacteria was estimated to be at least $1.3 billion in 1992 dollars ($1.87 billion in 2006 dollars) – more than the annual spending on influenza.”  A newly publishedstudy directly links antibiotic abuse in animals with significant pediatric health concerns.  The authors warn, “Antimicrobial resistance is considered one of the major threats to the world’s health. The use of antimicrobial agents in agriculture can harm public health, including child health, through the promotion of resistance. Because of the link between antibiotic use in food-producing animals and the occurrence of antibiotic-resistant infections in humans, antibiotic agents should be used in food-producing animals only to treat and control infectious diseases and not to promote growth or to prevent disease routinely.”

In addition to the surge of antibiotic resistant infections, other related health ills are of increasing concern.  Children regularly exposed to antibiotics gain weight faster than those never prescribed such medications and are atsignificantly higher risk of obesity later in life.  The mechanism is likely through altered metabolism caused by dysbiosis, or the imbalance of microbes in the gastrointestinal tract.  Antibiotics destroy not only harmful bugs but also the health-promoting bacteria that help regulate metabolic energy efficiency.  This disruption in the microbiome increases our likelihood of developing other metabolic diseases like diabetes and impairs our ability to defend against environmental toxins, thereby increasing risk for a whole host of other diseases like cancer and neurological disorders.  And we are not the only victims.  As I’ve previously written, the spread of resistant infections has also been tied to massive die-offs in various animal and insect species, in turn threatening the health of our planet and all who reside here.

The good news?  Finally, doctors are taking notice.  A 2014 Consumer Reports National Research Center poll found that greater than 95 percent of those surveyed are very concerned about antibiotic overuse.  Most are actively following CDC-recommended steps to prescribe only when medically necessary, not use broad-spectrum drugs when simpler options will work, and talk to patients about why these medications are not needed for all infections.  The CDC is also targeting consumers, in particular, parents who historically ask for and expect antibiotics for self-limited conditions like upper respiratory infections and non-streptococcal sore throats.

While we may be making progress in reducing antibiotic demand and prescribing, we are failing miserably in another industry, one that is responsible for about 80% of antibiotic sales in the U.S.  According to a 2014 report by the FDA, “the amount of medically important antibiotics sold to farmers and ranchers for use in animals raised for meat grew by 16 percent from 2009 to 2012.”  The meat and poultry industries are now increasingly feeding broad-spectrum antibiotics to healthy animals to not only prevent disease but primarily to promote growth.  Ironically, this rampant overuse has been linked to increased transmission of resistant organisms (causing life-threatening infections) to humans eating meat from antibiotic-fed animals.  The CDC now actively supports the FDA’s call for “the judicious use of antibiotics that are important in treating humans (and) recommends that such antibiotics should be used in food-producing animals only under veterinary oversight and only to address animal health needs, not to promote growth.”  Healthcare professionals are urged to petition food industry organizations responsible for antibiotic misuse to change their practices, citing evidence of human harm.  Other strategies to limit antibiotic resistance include reducing or eliminating meat consumption and only purchasing meat and animal products (milk and eggs) that come from animals not exposed to antibiotics.

(originally written for the Deirdre Imus Environmental Health Center)

Does America Really Want Change?

is the title of my debut article for the Huffington Post.  I'm now writing pieces for the well-known blog in addition to my work for Kiwi Magazine and the Deirdre Imus Environmental Health Center.  This rounds out my blog portfolio – my HuffPo posts will be more about health care policy and "big picture" ideas; Kiwi's The Green Pediatrician site will continue to feature articles on holistic children's health; the DIEHC Healthy Blogger pieces profile the latest studies in integrative and environmental health.  Thanks to all who read and contribute.

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Overlooked: Type 1 Diabetes and the Environment

"Diabetes and obesity
are two of the most common and most costly health problems today.  12% of U.S. adults have diabetes, and if
current trends continue, more than 50% will have diabetes or pre-diabetes by
2020.  Annual U.S. spending on diabetes
is $194 billion (2010) and could reach $500 billion by 2020."

Source: The Collaborative on Health and the Environment Working Group
on Diabetes-Obesity Spectrum

As troubling as these statistics are, the number of children
diagnosed with diabetes continues to increase at a staggering rate and will add
exponentially to the toll on public health and health care expenditures.  The explosion in pediatric type 2 (formerly
known as “adult onset”) diabetes diagnoses has drawn much needed attention to
the impact of environmental factors (e.g., nutrition, exercise, poverty,
chemicals) on insulin resistance and metabolic syndrome.  Often overlooked, though, are the equally
devastating effects of these factors on the rise in type 1 (autoimmune)
diabetes, still the most prevalent form of diabetes in children.   Before
examining new research investigating the links between the environment and
autoimmune diabetes, let’s look at current epidemiology and how distinctions
between “type 1” and “type 2” diabetes are less clear-cut than previously

Epidemiology of Pediatric Diabetes

From the CDC: The SEARCH for
Diabetes in Youth is a multicenter study funded by CDC and NIH to examine
diabetes (type 1 and type 2) among children and adolescents in the United
States. SEARCH findings for the communities studied include the following:

  • During
    2002–2005, 15,600 youth were newly diagnosed with type 1 diabetes annually, and
    3,600 youth were newly diagnosed with type 2 diabetes annually.
  • Among
    youth aged <10 years, the rate of new cases was 19.7 per 100,000 each year
    for type 1 diabetes and 0.4 per 100,000 for type 2 diabetes. Among youth aged
    10 years or older, the rate of new cases was 18.6 per 100,000 each year for
    type 1 diabetes and 8.5 per 100,000 for type 2 diabetes.
  • Non-Hispanic
    white youth had the highest rate of new cases of type 1 diabetes (24.8 per
    100,000 per year among those younger than 10 years and 22.6 per 100,000 per
    year among those aged 10–19 years).
  • Type 2
    diabetes was extremely rare among youth aged <10 years. While still
    infrequent, rates were greater among youth aged 10–19 years than in younger
    children, with higher rates among U.S. minority populations than in
    non-Hispanic whites.
  • Among
    non-Hispanic white youth aged 10–19 years, the rate of new cases was higher for
    type 1 than for type 2 diabetes. For Asian/Pacific Islander and American Indian
    youth aged 10–19 years, the opposite was true—the rate of new cases was greater
    for type 2 than for type 1 diabetes. Among non-Hispanic black and Hispanic
    youth aged 10–19 years, the rates of new cases of type 1 and type 2 diabetes
    were similar.

To summarize, the most recent data in the U.S. demonstrates
that new cases of pediatric type 1 diabetes are still much more common than of type
2, but in certain populations, new cases of type 2 are more prevalent.  Certainly social determinants are notable
contributing to major health disparities, but for youth <20 years old as a
whole, we are still seeing many more new cases of type 1 diabetes versus type

Even so, differentiating between types 1 and 2 is not so
straightforward.  The Collaborative
on Health and the Environment
(CHE) points out, “There is overlap among the various types of diabetes, and scientists
are beginning to look at diabetes as a spectrum of disease, with type 1
(autoimmune) on one end, and type 2 (metabolic) on the other. Indeed,
researchers have found that 15-35% of type 2 patients diagnosed before age 45
test positive for antibodies to GAD, one of the markers of type 1 diabetes.
Many children with diabetes, meanwhile, show signs of autoimmunity as well as
insulin resistance. It may be that a large number of people with diabetes have
both autoimmune and metabolic processes contributing to their disease.”

This change in thinking about
types of diabetes is supported by data from the CDC’s SEARCH study.  In an article published in 2011,
authors reviewed data on classification of diabetes type by autoimmunity and
insulin sensitivity (IS)/resistance (IR); a large overlap was noted. 

Most subjects fell into either the autoimmune plus IS (54.5%) or
nonautoimmune plus IR categories (15.9%) and had characteristics that align
with traditional descriptions of type 1 or type 2 diabetes. The group
classified as autoimmune plus IR (19.5%) had similar prevalence and titers of
diabetes autoantibodies and similar distribution of HLA risk genotypes to those
in the autoimmune plus IS group, suggesting that it includes individuals with
type 1 diabetes who are obese. The group classified as nonautoimmune plus IS
(10.1%) likely includes individuals with undetected autoimmunity but may also
include those with monogenic diabetes and thus requires further testing.

So it’s no longer simply type 1 OR
type 2 – many diabetics in fact have evidence of autoimmunity AND insulin
resistance.  In fact, many of the same
environmental factors suspected to influence epigenetic expression of insulin
resistance and metabolic syndrome (including obesity) also are likely to
contribute the rising numbers of patients with autoimmune conditions like

Environmental Factors

After several years of intense
focus on the environment and type 2 diabetes, researchers are now intently
looking at rising rates of type 1 diabetes and the role of potential
environmental factors.  Two recently
published studies from Australia are of great interest.  “Cyclical Variation in the Incidence of Childhood Type 1 Diabetes in
Western Australia (1985-2010)”
that “the incidence of type 1 diabetes in children aged 0–14 years increased by
an average of 2.3% a year between 1985 and 2010, and a significant 5-year
cyclical pattern in the incidence rate trend was observed” and concludes, “The
cyclical pattern in incidence observed in Western Australia supports the role
of environmental factors in childhood type 1 diabetes. These factors may either
be environmental risk or protective factors that modify the likelihood of developing
type 1 diabetes de novo or of progressing to clinical type 1 diabetes in those
with established autoimmune prediabetes.” 
This last sentence highlights the fact that environmental factors may
push those at risk, already with immune dysregulation, past some tipping point
to develop what we clinically diagnose as diabetes.  I’ve written previously about the “iceberg” model of
disease progression for other conditions, specifically for autism and atopic
disorders (e.g., asthma, allergies). 
This functional medicine model works well to explain root cause factors
likely responsible for the increases in prevalence noted over the past 20 years
for many chronic childhood health conditions. 

One of the implicated factors,
vitamin D deficiency, is the subject of a second important diabetes paper to
emerge recently from Australia.  “Serum vitamin D levels are lower in Australian children and
adolescents with type 1 diabetes than in children without diabetes”
that “children with T1DM have lower 25OHD than controls, even in an environment
of abundant sunlight.  Whether low
vitamin D is a risk factor or consequence of T1DM is unknown.”  25OHD is the most commonly evaluated lab
marker for vitamin D status, and low levels have also been associated
with a need for more insulin in children with existing type 1 diabetes.  One notable publication reviewed the impact
of maternal vitamin D
status and the risk of type 1 diabetes
developing later in offspring.   The Norwegian authors discovered that “the
odds of type 1 diabetes was more than twofold higher for the offspring of women
with the lowest levels of 25-OH D compared with the offspring of those with levels
above the upper quartile” and commented, “Given future replication in
independent cohorts, our findings provide support for the initiation of a
randomized intervention trial to prevent type 1 diabetes in children by
enhancing maternal 25-OH D status during pregnancy.”  A nutritional trial of vitamin D to prevent
diabetes?  That is exactly the type of
preventive approach that could change the lives of millions of children – for relatively
low cost with potentially huge health care cost savings down the line. 

What other environmental factors
are under investigation?  CHE hosts a wealth
of resources
on their Diabetes/Obesity Working Group site, and Working
Group Coordinator Sarah Howard has created another website with specific
information about type 1 diabetes and environmental contaminants including persistent
organic pollutants, air pollutants, bisphenol A and phthalates, flame
retardants, trichloroethylene, heavy metals, pesticides and radiation.  Also under the microscope, as in many other
autoimmune disorders, is the role of gut microbiota in the development of type
1 diabetes.  According to Dr. Vaarala
from the National Public Health Institute in Helsinki, Finland, “The gut immune
system has a key role in controlling insulin-specific immunity induced by
dietary insulin. Indeed, indications for aberrant function of the gut immune
system have been reported in type 1 diabetes, such as intestinal immune activation
and increased intestinal permeability. Research on the gut immune system in
human type 1 diabetes is needed to reveal the role of oral immunity in this
disease.”  Research is needed to evaluate
whether specific pre- and probiotic strains could modify these gut immune
interactions to prevent diabetes in susceptible children.  Finnish studies have
shown that administering probiotics to pregnant and breastfeeding mothers can
lower the rate of atopy in offspring – perhaps the same will be true for

(Originally written for the Deirdre Imus Environmental Health Center, September 2012)

Is Discussing the Safety of Vaccines the Third Rail of Pediatrics?

Absolutely the most common questions I get from parents are about immunizations.  This has become the dominant topic of conversation at all well-child visits beginning with the very first visit after birth. In fact, at my monthly prenatal group sessions, it has become the first question without fail.

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Home, Sweet Medical Home

If you could build the ideal pediatric practice for your family, what would it look like?

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August 2011 Kiwi Post: “Past, Present, Future”

Happy Birthday, KIWI!  You’re almost 5-years-old, ready to start grade school. As a pediatrician, I’m so used to thinking about age this way… what is five years actually in magazine years? I think it’s a very significant milestone, especially in this age of digital media. KIWI is relevant in 2011 because it speaks to the growing number of families interested in natural, healthy, “green” living. You’ve come a long way, KIWI, and I am proud to work with you. In many ways, my pediatric practice and family life have grown in parallel with you.

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June 2011 Kiwi post: Summertime’s Natural Toolbox

Bug bites, cuts and bruises, sunburns—sounds like summer! What’s a parent to do that’s safe and natural for these common childhood ailments?

(read more…)

April 2011 Kiwi post: Autism Awareness Month

April is here, once again marking the return of Autism Awareness Month. This month will be filled with numerous events reminding us that the autism is still more prevalent than ever, and that more families are still struggling with what’s frustratingly termed “the mystery of autism.” To these families, autism is something they live with every day, not just one month a year, of course—but the increased focus is important.

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February 2011 Kiwi post: “Fever Phobia”

Fever Phobia

Every winter I am reminded of the great “Fever Phobia” that plagues parents everywhere. In the Northeastern U.S., where I practice, we’re up to our necks in snow, ice and viruses. Cough and cold viruses, stomach viruses, and flu viruses—you name it, we’re seeing it. And the number one reason by far parents call us is—you guessed it—fever… (to read more, click on the link above)

Finding a Green Pediatrician

Check out this new piece from Fox News on "Finding a Green Pediatrician."

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