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 

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   

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. 

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}

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.

Kim Furtado, ND, received her Doctor of Naturopathic Medicine (ND) degree from Bastyr University in Kenmore, Washington in 2000. Inspired by the healing power of naturopathic medicine, she has been in private practice in Lewes, Delaware. She specializes in environmental medicine and women’s health.  She is an executive board member of the National Association of Environmental Medicine (NAEM). She is a founding director for SNAC Gardens Foundation, working to enrich communities through cultivating meaningful relationships to nature, food, and personal well-being.  She is author of E-Book: An Introduction to Clinical Detoxification in Integrative Medicine  

​​Environmental Medicine Resources

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Author: Razi Ann Berry