Therapeutic Order: Navigating an Ever-Increasing Toxic World

Healing Chronic Illness through Environmental Medicine

By Kim Furtado, N.D.

Exposure to heavy metals, persistent organic pollutants, and other chemicals is rising, with no clear end in sight. The identification of novel forever chemicals, contamination of everyday household products and food, toxic impacts of natural and human-caused disasters, and the general deluge of research implicating the ongoing role of environmental pollutants in chronic illness are enough to make anyone feel a sense of loss, violation, and helplessness. While navigating Environmental Medicine, clinicians can fall prey to overwhelm and despondence.

As evidence mounts, research supports that toxic exposure is a driving factor of chronic illness, exceeding commonly associated factors such as nutritional deficiencies and sedentary lifestyles.^1,2,3,4 The increase in chronic illnesses over the past 50 years affects all age groups. 

Environmental medicine (EM) is a branch of medicine that explores how the environment interacts with the human body. It also relates to toxicology, industrial medicine, and public health. Using a holistic, systems-wide model, EM evaluates how various toxicants, pollutants, chemicals, and microbes may compromise the body.

Training in EM involves enhancing a clinician’s ability to identify patient signs, symptoms, and clinical laboratory test results that may be caused by environmental toxicant exposure. Several resources exist for this evolving branch of medicine.  Providing a more detailed assessment requires a more intrinsic knowledge of the toxicants, their impacts on pathophysiology, and the nuances of their elimination.  The capacity to instruct your clients exponentially expands as your knowledge of the toxicants deepens. 

Patients will present in varying stages of symptomatology. As succinctly described by Joe Pizzorno, ND, there are three clinical presentations where the principles of EM should be applied.⁵ First are patients with a known high-dose exposure to toxicants. Second, Pizzorno describes the “yellow canaries” as chronically unwell without an apparent cause or explicit toxicant exposure. These patients often have underlying disruptions in detoxification pathways, particularly involving glutathione, hepatic cytochrome P450 (CYP450) enzymes, and methylation impairments.

Lastly, Pizzorno asserts that all patients with chronic illness are, to some extent, affected by environmental toxicants.  Examining the top ten causes of death in the U.S. further highlights the growing body of research linking pollution to adverse health outcomes.

Closer Look at Pollution Impact and Epidemiology 

Top Ten Causes of Death in the US6	Number of Deaths (2022 data)	Data Related to Pollution Impact
Heart disease	702,880	24 percent of the global burden of ischemic heart disease is due to air pollution7
Cancer	608,371	For every 10 micrograms per cubic meter (µg/m3) of increased exposure to PM2.5, the risk of dying from any cancer rose by 22 percent.8 PCBs are significantly associated with breast cancer.9
Accidents (unintentional injuries)	227,039	n/a
COVID-19	186,552	Empirical estimates demonstrate an association between the environmental pollutants PM2.5, CO, NO2, and O3 and SARS-CoV-2 infections.10
Stroke (cerebrovascular diseases)	165,393	Environmental exposure to lead, even at blood concentrations lower than 5 μg/dL, entails a population-attributable risk of cardiovascular mortality of 37.4%, thereby equaling the risk of smoking.11 Lead and cadmium are considered independent risk factors for cardiovascular disease.12
Chronic lower respiratory diseases	147,382	Higher short-term exposure to PM2.5 and traffic-related pollutants is associated with an increased risk of symptomatic acute respiratory infections among adults.13
Alzheimer’s disease	120,122	Greater exposure to PM2.5, NO2/NOx, and CO in the review were all associated with an increased risk of dementia. The evidence for air pollutant exposure and cognitive decline was more equivocal.14
Diabetes	101,209	Air pollutants may be associated with impaired glucose metabolism, insulin resistance (IR), and type 2 diabetes mellitus (T2DM)15 Serum concentrations of dioxins, PCBs, and chlorinated pesticides were significantly associated with T2D risk; BPA and phthalates were also associated.16,17
Nephritis, nephrotic syndrome, and nephrosis	57,937	The kidney is an organ of elimination. Elevated blood pressure related to toxic metals like lead can damage the kidneys. Environmental pollutants such as heavy metals, PM, industrial degreasers, PFAS, insecticides, and herbicides are reported to influence kidney disease.18,19
Chronic liver disease and cirrhosis	54,803	The liver is an organ of elimination. Polychlorinated biphenyls, lead, and mercury associated with liver disease20

Therapeutic Order Creates Path to Implement Principles of EM

The Therapeutic Order (TO) is influential in harsh, complex terrain. Principles of clinical detoxification involve the same clinical directives found in the TO. Still, the identification of toxicants is often considered only in acute, high-dose exposures or known contact with a point source pollutant. Most commonly, clinicians overlook the insidious, debilitating effects of daily, ubiquitous, low-dose exposures and thus miss the opportunity to remove a potentially impactful obstacle to cure.^21,22   

Clinical Detoxification Key Steps	Correlation to Therapeutic Order
Identify and avoid toxicants	Determinants of Health (DOH): Environmental Pollutants
Support adrenals and balance sympathetic /parasympathetic nervous system (Optimize rest, digest, repair, detox pathways)	DOH: Stress/Resilience DOH: Sleep/Relaxation
Nourish and neutralize (nutrition therapy, high fiber, high antioxidants, balance microbiome, and gut health)	DOH: Nutrition/HydrationDOH: Micro-organisms Use Natural Therapies to Address Pathology and Symptoms
Enhance blood and lymphatic circulation	DOH: Movement/Exercise Support and Restore Weakened Systems Correct Structural Integrity
Enhance detoxification pathways	Support and Restore Weakened SystemsUse Natural Therapies to Address Pathology and Symptoms
Chelate, as indicated to remove identified toxicants	Use Natural Therapies to Address Pathology and SymptomsUse Pharmaceutical or Synthetic Substances to Stop Progressive Pathology

EM Assessment Tools

A thorough history is critical to identifying and removing environmental pollutants affecting your patient’s clinical picture. Listen for stories of running in the wake of trucks spraying DDT for mosquitoes, playing with mercury thermometers, or several years of known occupational exposures, but don’t count on your client casually mentioning the primary emerging data you need to understand their toxic body burden. 

If you’re not actively investigating, testing for toxicants (as able), and assessing detox pathways, a simple interrogation of the client, who reports any environmental exposures from memory, may prove woefully inadequate.  

The Environmental Health Questionnaire (EHQ) can help inform environmental factor investigations. The National Association of Environmental Medicine (NAEM), an affiliate organization of the AANP, freely provides this tool; training on implementing it is also available.

Another step is to investigate symptoms of toxin overload or poor metabolism. For example, inquiring along these lines helps identify clients needing EM support but have not reported any known high-dose pollution exposures.  Instead of waiting to be told what toxicant has been involved, listen for key indicators of detoxification pathway imbalances.

For example, is there a sudden onset of symptoms (headaches, skin rashes, nausea, fatigue, shortness of breath, etc.) on exposure to fragrance, cigarettes, mold, dust, pollen, or other environmental allergens? Does your patient report they smell odors when others can’t, or do they regularly avoid walking down the detergent/fertilizer aisles in a store because it makes them feel ill or have other symptoms?  Do they become symptomatic when sitting in traffic with car exhaust? Does a patient frequently have to lower regular prescription doses, over-the-counter medications, or herbal supplements because they are intolerant of full doses?  Ask directly if they ever had to leave their residence or job because the environment was making them feel sick. Does the client quickly get rashes or skin irritation through contact with clothing or body care products? Does the client quickly get drunk or have a hangover on one or less alcoholic beverages? Do they avoid caffeine because it makes them jittery, irritated, or causes insomnia?

In an investigation beyond clinical history, you are informed of conventional laboratory markers such as serum glutathione, vitamin D, GGTP, ALT, and uric acid. Other markers of the impact of toxicants, such as organic acid testing and microbiome stool analysis, and markers of oxidative stress, such as 8-OHdG and lipid peroxides, should also be included. Genomic markers related to phase II conjugation and oxidative stress pathways are critical to successful clinical outcomes. 

Testing for toxicants is a complex, confounding, and valuable part of the inquiry. Determining which toxicants to test for relies on informed clinical history.  It also can be guided by a clinical indication and knowledge about associated toxicants.  Training in toxicant testing and detox pathway assessment is available through NAEM and its partner organizations.  NAEM’s clinical guidelines, which augment but do not replace training in EM, are available for Plastics, Solvents and Volatile Organic Compounds (VOCs), Pesticides, Metals, Mold, Persistent Organic Pollutants (POPs), Electro-Magnetic Fields (EMFs), Personal Care Products, and Allergens.

Most importantly, patients must be educated on how to remove or limit exposure to everyday toxicants. This can foster fear in our patients, leaving them scared to interact with the world. Rather than feeling like we need to place our patients into protective bubbles, work to empower them to do the best of both worlds:  create an oasis of low toxin exposure within their homes and optimize nutrition and the organs of elimination to protect and defend in today’s complex industrial world. 

It is key to engage solution-oriented resources that educate patients on consumer product decisions, toxicant avoidance, and water and air filtration options for their specific needs. Your in-depth understanding of these tools makes you an excellent resource for clients overwhelmed by the magnitude of this topic.  Resources are available in patient handouts from NAEM, specifically on Plastics, EMF, personal care products, solvents & VOCs, and pesticides.  There are also various patient-facing materials and several clinical tools, including free webinars, book recommendations, podcasts, and online class modules available.  

Support and Restore Liver, Microbiome, and Lymphatic Functions

For practical impact on EM practice, clinicians serve patients well by focusing on supporting and restoring weakened systems, with a focus on the liver, microbiome, and lymphatics.  Most chronic illnesses are not overt liver diseases, and toxicants may not directly affect all the liver’s functions. Upon closer analysis, however, one may find that the liver has a role in the pathophysiology of several common, pervasive chronic illnesses.  Toxicants also have an association with diseases, and the presence of that disease can also inform the need to attend to clinical detoxification.  

Clinical detoxification provides a way to bridge optimized liver function to the resolution of chronic inflammatory illness.  The toxicant may or may not be linked with a specific liver disease. Still, a functional role of the liver may be involved in either the disease pathophysiology or being impacted by the effects of the toxicants. 

Examples of Liver Functions that relate to Diseases and their Association with Toxicants
Functions of the Liver	Sample of Diseases Influenced by Specific Liver Functions	Toxicants that Influence Associated Diseases23
Albumin production
It creates osmotic balance in the blood and carries hormones, vitamins, and enzymes through the body.  This relates in general, to many conditions/hormone issues	Pulmonary edema	Ammonia, beryllium, chloro-phosphate compounds,diquat, ethylene oxide, formaldehyde, hydrofluoric acid, hydrogen sulfide, mercury, methyl bromide, nickel, nitrogen oxides, organophosphates, paraquat,phosgene, phosphine,tetrachloroethylene (PCE), thioureas
Bile Production
Bile is critical for digestion and absorption of fats in the small intestine.  Fats are critical for good nerve function.	Cognitive impairment (includes impaired learning, impaired memory, and decreased attention span) / mental retardation / developmental delay	1,1-dichloroethane, carbamates, carbon disulfide,carbon monoxide, cocaine, DDT/DDE, ethyl alcohol (ethanol), lead, mercury,methyl bromide, nicotine,nitrates/nitrites, organochlorine pesticides,organophosphates, PCBs (polychlorinated biphenyls), not otherwise specified,pentachlorophenol (PCP), pesticides, solvents, styrene,tetrachloroethylene (PCE), tobacco smoke, tobacco smoke (secondhand), toluene,trichloroethylene (TCE), xylene
	Attention Deficit Disorder	ethyl alcohol (ethanol), lead, DDT, mercury, organophosphate pesticides, PAHs, PCBs (polychlorinated biphenyls), not otherwise specified
Filters Blood/ Removes toxins
All blood leaving the gastrointestinal tract passes through the first pass effect through the liver to remove toxins, byproducts, and other harmful substances.  This function is relevant to many clinical diseases associated with toxins.	Cirrhosis	Aflatoxins, arsenic, carbon tetrachloride, chlorinated naphthalene’s, ethyl alcohol (ethanol), halothane, PCBs (polychlorinated biphenyls), not otherwise specified, solvents, tetrachloroethane, TNT (trinitrotoluene), trichloroethylene (TCE)
Hormone metabolism
Critical role in peripheral conversion of thyroid hormone and steroid hormone metabolism	Hypothyroidism	Organochlorine compounds (PCBs, DDT, dioxins), pesticides (chlorinated organophosphates), mercury, cadmium, perchlorates, PBDE, phthalates
	Menstrual disorders (abnormal bleeding, short cycles, long cycles, irregular cycles, painful periods)	2-bromopropane, atrazine, Benzene, carbon disulfide, chlordecone, chlorination byproducts, DDT/DDE, dioxins / TCDD, estrogens / DES, ethyl alcohol (ethanol), Formaldehyde, fungicides, Herbicides, hexachlorobenzene, ionizing radiation, Lead, lindane, mancozeb, mercury, organochlorine pesticides, organophosphates, PCBs (polychlorinated biphenyls), not otherwise specified, pesticides, solvents, tetrachloroethylene (PCE), tobacco smoke (secondhand), toluene, toxaphene, trihalomethanes, xylene
	Infertility	Chlorinated pesticides, PCBs, organophosphate pesticides, BPS, herbicides, solvents, mercury, cadmium, trihalomethanes, PFOS, phthalates
Processes Glucose
The liver removes excess glucose from the blood, stores it as glycogen, and converts it back to glucose.	Diabetes	Arsenic, mercury, persistent organic pollutants, polycyclic aromatic hydrocarbons, BPA, PCBs, dioxins, organochlorine pesticides
Regulates Amino Acids
All protein production in the body relies on amino acids	Psychiatric disturbances (disorientation, hallucinations, psychosis, delirium, paranoias, anxiety/depression, emotional lability, mood changes, euphoria)  (neurotransmitters are made from amino acids)	carbon disulfide, chlorpyrifos, DDT/DDE,Dichloropropene, ethyl alcohol (ethanol), ethylene oxide, lead, manganese, mercury, methyl bromide,Organophosphates, pesticides, trichloroethylene (TCE)
Cholesterol Production	Coronary artery disease, peripheral vascular disease, atherosclerosis	Arsenic, cadmium, carbon disulfide, carbon monoxide, dinitrotoluenes, dioxins / TCDD, lead, mercury, particulate air pollution (soot), TNT (trinitrotoluene), tobacco smoke (active smoking),tobacco smoke (secondhand)
Resists Infections
Filters microbes from the bloodstream and influences immune function with antibody production, nutrients, and other factors	Asthma – allergen, sensitizer	acid anhydrides, acrylates,aluminum, amines, amylase, animal antigens, captafol, chlorothalonil, chromium, cobalt, colophony, egg lysozyme, enzymes, epoxy resins, ethanolamine’s, ethylenediamine, fiber dust, fungal antigens, glutaraldehyde, grain dust,insect antigens, isocyanates,latex, metal fumes, methacrylates, nickel, p-phenylenediamine, papain,pepsin, plant pollens, plastic dusts, plastic fumes, platinum, polypropylene, PVC, subtilase, trypsin,tungsten carbide, vanadium, wood dust
	Autoimmune antibodies (positive ANA, anti-DNA, RF, etc.)	1,1,1-trichloroethane, asbestos, benzene, carbon tetrachloride, formaldehyde,mercury24, silica, solvents,trichloroethylene (TCE)
	Immune suppression	Aldicarb, asbestos, benzene,benzo(a)pyrene, carbamates,chlordane, chlorpyrifos, dichlorvos, dioxins / TCDD, ionizing radiation, lead, mercury, methyl isocyanate,nickel, nitrogen dioxide,organochlorine pesticides,organophosphates, PAHs,PBBs, PCBs (polychlorinated biphenyls), not otherwise specified, PCDDs, PCDFs, pentachlorophenol (PCP),pesticides, phosgene, tobacco smoke (active smoking), tobacco smoke (secondhand), UV radiation
Stores Vitamins and Minerals
The liver stores significant amounts of Vitamins A, D, E, K, and B12, as well as iron and copper. These vitamins are related to many conditions. Vitamin D is particularly influential in cellular proliferation and refers to cancer risks.	Breast cancer (example of one cancer)	aromatic amines, estrogens / DES, ethyl alcohol (ethanol), ionizing radiation, oryzalin,PAHs, PCBs (polychlorinated biphenyls)25, not otherwise specified, progestins, solvents, tetrachloroethylene (PCE), tobacco smoke (active smoking), tobacco smoke (secondhand) BPA is significantly associated with breast cancer26
	Osteoporosis	Lead, cadmium, fluoride, tobacco smoke

Common clinical detoxification support includes herbs, nutrients, binding, and chelation agents to optimize the detoxification system.  Nutritional supplementation is helpful in a clinical detoxification process for two key reasons. The first is the ability of various nutrients to protect vulnerable cells from oxidative stress and inflammation generated by the movement of toxins. The second is to support the highly nutrient-dependent CYP450 enzyme function or to enhance the toxicants’ excretion essentially.

Common antioxidant supplements include vitamins C and E, selenium, glutathione, N-acetyl cysteine (NAC), magnesium, quercetin, anthocyanins, polyphenols, and omega-3 essential fatty acids.  Vitamins B2, B3, B6, B12, and C, folic acid, niacin, magnesium, copper, zinc, and flavonoids also support phase 1 and II detoxification.

Specific nutrients can target the support of the highly nutrient-dependent CYP450 enzymes. For example, support for phase I can be provided with a high protein, low carbohydrate, low-fat diet, anthocyanins (found in berries and grapes), quercetin, and magnesium. The conjugation pathways in phase II enzymes can also be specifically targeted for support. The most active pathways for clearing environmental toxins are amino acid conjugation, glucuronidation, glutathione conjugation, and methylation.

Botanical medicine has a time-honored tradition of targeting liver and kidney function to aid the body to rid itself of metabolic wastes and environmental toxicants. Herbs with hepatoprotective properties include Curcuma longa (turmeric), Cynara scolymus (artichoke) and Silybum marianum (Carduus marianum, milk thistle.) This affinity arises from their anti-inflammatory, antioxidant, antifibrotic, antiviral, and immunomodulatory actions created by components such as sulfur compounds, resins, salicylates, steroidal and triterpenoid saponins, essential fatty acids, flavonoids, and volatile oils.

Most liver-supportive herbs have cholagogue and choleretic properties that can increase the flow of bile released by the liver and gallbladder.  In addition, some clinicians will include herbs with laxative properties to improve bowel function and eliminate stool. Bulk laxatives provide fiber, which bulks up the stool and eases constipation by calming an inflamed bowel. Sequestrants are activated charcoal, rice bran fiber, chlorophyll, and cholestyramine. Soluble and insoluble fibers like lignan, alfalfa, bran, and guar can bind 10 percent to 30 percent of bile acids.

Clinicians must also balance the gut microbiome to interrupt the cycle of toxicant exposures and chronic disease development. Significant research has implicated the role of pollution in disrupting the microbiome. Studies show that a dose-related continuum of exposure to short- and long-term ambient particulate air pollution reduces lower gut diversity and shifts taxa, including evidence of higher levels of gut damage, inflammation, oxidative stress, and permeability. ^27,28   

Not surprisingly, pollution wreaks havoc on the microbiome, yet researchers also implicate them in the capacity to biotransform and eliminate pollutants such as arsenic.²⁹ Notably, the mechanism of action is beginning to emerge, and gut microbiota can play a role in the biotransformation of forever chemicals such as perfluoroalkyl substances (PFAS) and bisphenols.^30,31

This understanding leads us to educate our patients that the microbiome may epitomize the front-line defense system.  The microbiota takes on heavy casualties and dysregulation but also are critical for defense and disarming industrial combatants. Healing this requires both the bolstering of biodiversity and the strength of the microbiome while also removing the toxicants.  Failure to accomplish both clinical goals leaves the microbiome in disarray. 

In addition, lymphatic support is imperative.  Unfortunately, many chemicals persist in the body and are stored in various tissues.  Heat liberates toxicants from fats, moving through the lymphatics to the skin, liver, and kidneys.  CPYP450 enzymes essentially work to bio-transform those lipid-soluble toxicants into more water-soluble excretory derivatives. However, the enzymes can’t access the molecules if sequestered in tissues like adipose, muscle, and bone. The lymph system operates at the lowest pressure gradient—physical movement, including exercise, massage, and skin brushing, all support lymphatic circulation. 

Saunas can be gentle, effective tools in today’s toxic world and have been reliably the best tools for encouraging the movement of environmental pollutants by increasing metabolic and oxygen consumption rates and reducing oxidative stress.  Perhaps sauna is less effective for mercury, lead, cadmium, nickel, and antimony but more effective for bisphenol A, phthalates, chlorinated pesticides, various OCPs, and metabolites, including DDT, DDE, methoxychlor, endrin, and endosulfan sulfate.³² 

Depuration therapy is never the first step in an EM protocol because if the toxicants are mobilized without first avoidance, balancing chronic stress, optimizing nutrition, gut microbiome, and enterohepatic circulation, the impact of mobilizing toxins may worsen an inflammatory clinical situation. Once determinants of health are addressed, depuration with a sauna may very well prove to be the most reliable and consistent ally in an EM treatment process.^{33,34,35,36,37}

Identified Toxin	Supportive Nutrients/Herbs/Relevant Pathways38
Arsenic	Methylation supportGreen and black teas
Cadmium	ALA, anthocyanins (berries), magnesium, NAC, selenium
Lead	ALA, curcumin, NAC, SAMe, Vitamins C and E, zinc
Mercury	Methylation supportBrassica sp. Curcumin, methionine, NAC, selenium, Vitamin E, zinc
Pesticides	Glutathione supportBrassica sp, curcumin, green tea, magnesium, NAC
Polycyclic Aromatic Hydrocarbons (PAH)	Glutathione supportBrassica sp., curcumin, fish oil, green tea quercetin
Solvents	Glycine conjugation supportGlucuronidation supportCurcumin, green tea, NAC, milk thistle

Detox Pathway	Supportive Nutrients and Herbs
Acetylation	Vitamins B1, B5 and vitamin C
Amino Acid conjugation	Arginine, glycine, cysteine, ornithine, taurine, glutamine
Glucuronidation	Cruciferous vegetables, Bifidobacterial longum, fish oil, green tea extract, Lactobacillus rhamnosus, limonene from the peel of oranges, lemons, limes and grapefruits
Glutathione Conjugation	Curcumin, green tea extract, liposomal GSH, Magnesium, NAC, Vitamin C
Methylation	S-adenosyl-L-methionine (SAMe), methylfolate, methylcobalamin, L-methionine, curcumin, choline, vitamin B6
Sulfation	Cysteine, methionine, molybdenum, niacin, Vitamin C

No specific drug on the market can comprehensively protect from oxidative stress and other deleterious effects of the arsenal of toxicants created by our industrial practices.   However, some notable both natural and pharmaceutical chelation agents are commonly included in clinical detoxification protocols.³⁹  

In medical therapeutics, chelation is a process in which the organic chelator molecules bind the target metal ions with high affinity. This complex is then more readily filtered by the kidneys or excreted by the liver than the metal ion alone. The agents most widely recognized and utilized for heavy metal chelation are 2,3-dimercapto-1propanesulfonic acid (DMPS), 2,3-dimercaptosuccinic acid (DMSA), edetate disodium (disodium ethylenediaminetetraacetic acid) (EDTA), and deferoxamine (DFO). 

While the bond requirement for affinity with toxic metals is high, some natural substances and herbs have shown some limited ability to act as natural chelators, such as NAC, Alpha lipoic acid, high doses of antioxidants, and, to some extent, modified citrus pectin. Chlorella-broken cell wall (Chlorella regularis) can be utilized as a natural chelator with varied results.  EM resources offer in-depth training for the safe and effective use of chelation agents.  

As clinicians navigate EM through their application of the therapeutic order, the larger conversation requires a deeper understanding of environmental social justice.  With this lens, we affirm that communities and individuals are not equally affected by pollution, industry, consumer choices, and climate change. Instead, wealth, geography, race, and ethnicity influence the harm subtly and overtly. Inequity relates to exposures, incidence of disease, and access to clean food, air, and water.  Beyond the scope of this conversation, it inevitably leads us to work to educate and advocate against social and environmental injustices while we deepen our capacity to practice EM. 

Our ecosystems require comprehensive, sustainable solutions to the mess that industrial pollution has created. Albert Einstein asserts, “We cannot resolve the problems of the world by using the same techniques that have created them.”  Leaders in planetary health chart a course involving sustainable agriculture, climate change mitigation, energy and resource management, policy, and healthcare.⁴⁰ Bioremediation consists of using microorganisms to assimilate, digest, or transform hazardous substances into less harmful or nontoxic forms and is emerging as a part of the solution.⁴¹

Just as we deem the medieval practice of tossing raw sewage into streets utterly ignorant and dangerous, our survival depends on radical shifts in current thinking and practice.  Change must occur in how our toxic releases permeate the environment and ultimately in our capacity to cease the destabilizing and traumatic practices that create such contamination.  In the face of pervasive pollution, one reality remains undeniably present.  The healing power of Mother Nature reigns.

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​​Environmental Medicine Resources

Category	Resource Name & Description	Link
Organizations	National Association of Environmental Medicine (NAEM) – Affiliate of AANP, offering clinical guidelines, patient handouts, community forums, and educational resources.	NAEM
	NAEM Partnering Organizations:
	– American Academy of Anti-Aging Medicine (A4M)
	– GMO Science
	– Change the Air Foundation
	– Integrative Healers Action Network (IHAN)
	– American Academy of Environmental Medicine (AAEM)
	– Psychiatry Redefined
	– Clean Label Project
	– Made Safe
Training Programs	Environmental Medicine Education International (EMEI) – A one-year post-grad online program with live meetings, Q&As, and CME credits.	EMEI
	Consult Dr. Anderson Medical Group – Webinars and continuing education for naturopathic doctors, including a large archive of CE-credit courses.	Consult Dr. Anderson
Webinars & Courses	Leveraging Environmental Medicine in Your Practice – Dr. Joseph Pizzorno on top toxins and their health effects.	Fullscript Webinar
	How to Thrive in a Toxic World – Course by EMEI on avoiding toxins and supporting detoxification pathways.	EMEI Course
Books	Clinical Environmental Medicine (Crinnion & Pizzorno, 2019)	–
	Toxic (Nathan, 2016)	–
	The Toxin Solution (Pizzorno, 2017)	–
Downloads	Introduction to Environmental Medicine (Fullscript) – Systems-based approach to toxic chemicals.	Fullscript Download
	An Introduction to Clinical Detoxification (Integrative Practitioner) – Guide to detox in integrative medicine.	Integrative Practitioner Download

References

1.      Cave M, Appana S, Patel M, et al. Polychlorinated biphenyls, lead, and mercury are associated with liver disease in American adults: NHANES 2003-2004. Environ Health Perspect. 2010;118(12):1735-1742.

2.      Prüss-Ustün A, Wolf J, Corvalán C, Bos R, Neira M. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. World Health Organization. 2016. https://apps.who.int/iris/handle/10665/204585

3.      Laden F, Neas LM, Dockery DW, Schwartz J. Association of fine particulate matter from different sources with daily mortality in six US cities. Environmental Health Perspectives. 2000 Oct; 108(10): 941–947;  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1240126/

4.      Pizzorno J. (2016). Is the Diabetes Epidemic Primarily Due to Toxins?. Integrative medicine (Encinitas, Calif.), 15(4), 8–17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4991654/

5.      Pizzorno, J. How to Practice Environmental Medicine. Integrative Medicine . Vol. 16, No. 5. October 2017. Integrative Medicine – A Clinician’s Journal – Archives (imjournal.com)

6.      National Center of Health Statistics. Leading cause of death. CDC/National Center for Health Statistics. October 25, 2024. Viewed February 5, 2025. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

7.      Prüss-Üstün, Annette, Wolf, J., Corvalán, Carlos F., Bos, R. & Neira, Maria Purificación. (‎2016)‎. Preventing disease through healthy environments: a global assessment of the burden of disease from environmental risks. World Health Organization. https://iris.who.int/handle/10665/204585

8.      Wong, et al. Cancer Mortality Risks from Long-term Exposure to Ambient Fine Particle. Cancer Epidemiol Biomarkers Prev (2016) 25 (5): 839–845. https://doi.org/10.1158/1055-9965.EPI-15-0626

9.      Morgan M, Deoraj A, Felty Q, Roy D. Environmental estrogen-like endocrine disrupting chemicals and breast cancer. Mol Cell Endocrinol. 2017 Dec 5;457:89-102. doi: 10.1016/j.mce.2016.10.003. Epub 2016 Oct 4. PMID: 27717745.

10. Meo SA, Abukhalaf AA, Alessa OM, Alarifi AS, Sami W, Klonoff DC. Effect of Environmental Pollutants PM2.5, CO, NO2, and O3 on the Incidence and Mortality of SARS-CoV-2 Infection in Five Regions of the USA. Int J Environ Res Public Health. 2021 Jul 23;18(15):7810. doi: 10.3390/ijerph18157810. PMID: 34360104; PMCID: PMC8345586.

11. Lanphear BP, Rauch S, Auinger P, Allen RW, Hornung RW. Low-level lead exposure and mortality in US adults: a population-based cohort study. Lancet Public Health. 2018 Apr;3(4):e177-e184. doi: 10.1016/S2468-2667(18)30025-2. Epub 2018 Mar 12. PMID: 29544878.

12. Gervasio, L. Ujeta, F., Navas-Acien, A. Lead and Cadmium as Cardiovascular Risk Factors: The Burden of Proof Has Been Met. Journal of the American Heart Association.2021;10.10. https://www.ahajournals.org/doi/epub/10.1161/JAHA.120.018692

13. Kipruto Kirwa, Carly M Eckert, Sverre Vedal, Anjum Hajat, Joel D Kaufman – Ambient air pollution and risk of respiratory infection among adults: evidence from the multiethnic study of atherosclerosis (MESA): BMJ Open Respiratory Research 2021;8:e000866.

14. Peters R, Ee N, Peters J, Booth A, Mudway I, Anstey KJ. Air Pollution and Dementia: A Systematic Review. J Alzheimers Dis. 2019;70(s1):S145-S163. doi: 10.3233/JAD-180631. PMID: 30775976; PMCID: PMC6700631.

15. Li Y, Xu L, Shan Z, Teng W, Han C. Association between air pollution and type 2 diabetes: an updated review of the literature. Ther Adv Endocrinol Metab. 2019 Dec 24;10:2042018819897046. doi: 10.1177/2042018819897046. PMID: 31903180; PMCID: PMC6931138.

16. Song Y, Chou EL, Baecker A, You NC, Song Y, Sun Q, Liu S. Endocrine-disrupting chemicals, risk of type 2 diabetes, and diabetes-related metabolic traits: A systematic review and meta-analysis. J Diabetes. 2016 Jul;8(4):516-32. doi: 10.1111/1753-0407.12325. Epub 2015 Sep 1. PMID: 26119400.

17. Lee DH, Lee IK, Song K, Steffes M, Toscano W, Baker BA, Jacobs DR Jr. A strong dose-response relation between serum concentrations of persistent organic pollutants and diabetes: results from the National Health and Examination Survey 1999-2002. Diabetes Care. 2006 Jul;29(7):1638-44. doi: 10.2337/dc06-0543. PMID: 16801591.

18. Kshirsagar AV, Zeitler EM, Weaver A, Franceschini N, Engel LS. Environmental Exposures and Kidney Disease. Kidney360. 2022 Oct 17;3(12):2174-2182. doi: 10.34067/KID.0007962021. PMID: 36591345; PMCID: PMC9802544.

19. Lin P-ID, et al. , Per- and polyfluoroalkyl substances and kidney function: Follow-up results from the Diabetes Prevention Program trial. Environment International, 2021. 148.

20. Cave M, Appana S, Patel M, et al. Polychlorinated biphenyls, lead, and mercury are associated with liver disease in American adults: NHANES 2003-2004. Environ Health Perspect. 2010;118(12):1735-1742.

21. Wu X, Cobbina SJ, Mao G, Xu H, Zhang Z, Yang L. A review of toxicity and mechanisms of individual and mixtures of heavy metals in the environment. Environ Sci Pollut Res Int. 2016 May;23(9):8244-59. doi: 10.1007/s11356-016-6333-x. Epub 2016 Mar 11. PMID: 26965280.

22. Cobbina SJ, Chen Y, Zhou Z, Wu X, Zhao T, Zhang Z, Feng W, Wang W, Li Q, Wu X, Yang L. Toxicity assessment due to sub-chronic exposure to individual and mixtures of four toxic heavy metals. J Hazard Mater. 2015 Aug 30;294:109-20. doi: 10.1016/j.jhazmat.2015.03.057. Epub 2015 Mar 28. PMID: 25863025.

23. Collaborative on Health and the Environment. Disease and Toxicant Database. Retrieved from: https://www.healthandenvironment.org/our-work/toxicant-and-disease-database/?showdisease=627

24. Pollard KM, Cauvi DM, Toomey CB, Hultman P, Kono DH. Mercury-induced inflammation and autoimmunity. Biochim Biophys Acta Gen Subj. 2019 Dec;1863(12):129299. doi: 10.1016/j.bbagen.2019.02.001. Epub 2019 Feb 10. PMID: 30742953; PMCID: PMC6689266.

 25. Wan MLY, Co VA, El-Nezami H. Endocrine disrupting chemicals and breast cancer: a systematic review of epidemiological studies. Crit Rev Food Sci Nutr. 2022;62(24):6549-6576. doi:10.1080/10408398.2021.1903382

26. Morgan M, Deoraj A, Felty Q, Roy D. Environmental estrogen-like endocrine disrupting chemicals and breast cancer. Mol Cell Endocrinol. 2017 Dec 5;457:89-102. doi: 10.1016/j.mce.2016.10.003. Epub 2016 Oct 4. PMID: 27717745.

27. Mousavi SE, Delgado-Saborit JM, Adivi A, Pauwels S, Godderis L. Air pollution and endocrine disruptors induce human microbiome imbalances: A systematic review of recent evidence and possible biological mechanisms. Sci Total Environ. 2022 Apr 10;816:151654. doi: 10.1016/j.scitotenv.2021.151654. Epub 2021 Nov 14. PMID: 34785217.

28. Van Pee T, Nawrot TS, van Leeuwen R, Hogervorst J. Ambient particulate air pollution and the intestinal microbiome; a systematic review of epidemiological, in vivo and, in vitro studies. Sci Total Environ. 2023 Jun 20;878:162769. doi: 10.1016/j.scitotenv.2023.162769. Epub 2023 Mar 11. PMID: 36907413.

29. Wang P, Du H, Fu Y, Cai X, Yin N, Cui Y. Role of human gut bacteria in arsenic biosorption and biotransformation. Environ Int. 2022 Jul;165:107314. doi: 10.1016/j.envint.2022.107314. Epub 2022 May 20. PMID: 35635965.

30. Peskett ST, Rand AA. The human fecal microbiome contributes to the biotransformation of the PFAS surfactant 8:2 monosubstituted polyfluoroalkyl phosphate ester. Environ Sci Process Impacts. 2022 Oct 19;24(10):1758-1768. doi: 10.1039/d2em00225f. PMID: 35979739.

31. Emanowicz P, Średnicka P, Wójcicki M, Roszko M, Juszczuk-Kubiak E. Mitigating Dietary Bisphenol Exposure Through the Gut Microbiota: The Role of Next-Generation Probiotics in Bacterial Detoxification. Nutrients. 2024; 16(21):3757. https://doi.org/10.3390/nu16213757

32. Genuis SJ, Lane K, Birkholz D. Human Elimination of Organochlorine Pesticides: Blood, Urine, and Sweat Study. Biomed Research International. 2016 ;2016:1624643. DOI: 10.1155/2016/1624643.

33. Patrick RP, Johnson TL. Sauna use as a lifestyle practice to extend healthspan. Exp Gerontol. 2021;154:111509. doi:10.1016/j.exger.2021.111509

34. Dahlgren J, Cecchini M, Takhar H, Paepke O. Persistent organic pollutants in 9/11 world trade center rescue workers: reduction following detoxification. Chemosphere. 2007 Oct;69(8):1320-5. doi: 10.1016/j.chemosphere.2006.05.127. Epub 2007 Jan 17. PMID: 17234251.

35. Genuis SJ. Elimination of persistent toxicants from the human body. Hum Exp Toxicol. 2011 Jan;30(1):3-18. doi: 10.1177/0960327110368417. Epub 2010 Apr 16. PMID: 20400489.

36. Genuis SJ, Lane K, Birkholz D. Human Elimination of Organochlorine Pesticides: Blood, Urine, and Sweat Study. Biomed Research International. 2016 ;2016:1624643. DOI: 10.1155/2016/1624643.

37. Genuis SJ, Beesoon S, Lobo RA, Birkholz D. Human elimination of phthalate compounds: blood, urine, and sweat (BUS) study. ScientificWorldJournal. 2012;2012:615068. doi: 10.1100/2012/615068. Epub 2012 Oct 31. PMID: 23213291; PMCID: PMC3504417.

38. Crinnion W, Pizzorno J. Clinical Environmental Medicine. Identification and Natural Treatment of Disease Caused by Common Pollutants. Elsevier Inc, St. Louis MO. 2019

39. Rahimian, Aliasghar & Mehrandish, Reza. (2019). Heavy metals detoxification: A review of herbal compounds for chelation therapy in heavy metals toxicity. Journal of HerbMed Pharmacology. 8. 69-77. 10.15171/jhp.2019.12

40. Whitmee, S, Haines, A., Beyrer C. (2015).Safeguarding human health in the Anthropocene epoch: Report of The Rockefeller Foundation-Lancet Commission on planetary health. The Lancet, 386.41. Maglione G, Zinno P, Tropea A, et al. Microbes’ role in environmental pollution and remediation: a bioeconomy focus approach. AIMS Microbiol. 2024;10(3):723-755. Published 2024 Aug 23.doi:10.3934/microbiol.2024033