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Considering Some Negative Implications of an Ever-Decreasing U.S. Centers for Disease Control and Prevention (CDC) Blood Lead Threshold and “No Safe Level” Health Messaging
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Environmental Science & Technology

Cite this: Environ. Sci. Technol. 2023, 57, 35, 12935–12939
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https://doi.org/10.1021/acs.est.3c04766
Published August 23, 2023

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Published as part of the Environmental Science & Technology virtual special issue “The Exposome and Human Health”.

The mean blood lead level (BLL) in the United States in the 1930s–1940s was 27–58 μg/dL, and the geometric mean (GM) BLLs in U.S. children have decreased by ∼95% (from 15.2 to 0.83 μg/dL) in the past half-century (Figure 1 and Table S1) as a result of policies banning lead in gasoline, food, paint, plumbing, and industrial emissions. (1) These dramatic reductions were identified as some of the most prominent public health achievements of the 1980s, 1990s, and 2000s. (2)

Figure 1

Figure 1. Blood lead trends in the United States from 1935 to 2023. Data sources are available in the Supporting Information (Text S1). Inspiration for this graph comes from EWG. (40)

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The Centers for Disease Control and Prevention’s (CDC’s) childhood lead poisoning threshold has been reduced along with the GM blood lead [i.e., a 94% reduction from 60 (1960–1969) to 3.5 (2021 to the present) μg/dL] (Figure 1). (1) In fact, there is a strong correlation (R2 = 0.70; p = 0.019) between the CDC threshold and childhood GM BLLs (Table S1). Virtually no U.S. children had BLLs of <5 μg/dL in 1976–1980, (1) whereas a level exceeding 3.5 μg/dL is now considered concerning and is often labeled “lead poisoning” by the media and some health professionals. (3,4)
The arguments for decreasing the CDC threshold from 25 to 10 μg/dL (5) involved contentious public debates discussing health effects, costs, and benefits through at least 1991. (6−8) However, in 2012, the CDC adopted a recommendation that the blood lead level of concern be reset every four years, so that ∼2.5% of U.S. children are above the threshold. (9) There is no other environmental contaminant for which the public health threshold of concern (or poisoning) decreases in lockstep with societal progress in reducing the hazard.

Does Lead Dose Matter?

During the 1991 debate about decreasing the threshold, a significant body of scientific data was presented indicating that decreases in IQ worsened with higher levels of lead in blood. While there was, and still is, a scientific consensus that “no “safe” threshold for [BLLs] in young children had been identified,” (1,6,9,10) as is the case for all environmental contaminants that are carcinogens, no study has refuted the reasonable expectation that larger lead doses cause greater harm than smaller doses. In fact, none of the relevant Bradford Hill criteria for causation, (11−13) a staple of epidemiology for more than 50 years, are satisfied (14) for the proposition that a low level of lead causes as much or more harm as a high level of lead.
At some point, the precise CDC language asserting “no “safe” threshold ... has been identified” morphed into statements from pediatricians, journalists, nongovernmental organizations, and even CDC’s Lead Poisoning Prevention Branch chief that there is “no safe level of lead exposure” (e.g., refs (15−20)). In extreme cases, this has been further misrepresented by some to publicly assert that lead dose “doesn’t really matter” (21) and “any level of lead exposure is harmful”. (22,23)

Potential Costs and Dangers of a Nocebo Effect

The official public messaging on lead risks evolved in a well-intentioned attempt to avoid harm, by making sure that the public takes risks seriously, and to raise funding for lead prevention programs and victims of exposure. (24) However, in light of the dramatic progress in reducing blood lead levels, we are concerned about potential adverse consequences associated with this messaging that are not being fully considered.
We have worked with parents whose children’s BLLs were less than or equal to the current national GM (0.8 μg/dL) and who understandably interpret claims that “dose does not matter” to indicate their children have the same risks as those with blood lead levels of more than 5, 10, 20, or 100 μg/dL. We have also been forced to explain that it is impossible to avoid the intake of a few atoms of lead per day in the course of consuming normal water, food, and air and that this exposure should not trigger serious parental angst. For these and other reasons, one of the authors (K.N.D.) was the sole dissenting expert member of the CDC Science Advisory Board to argue against the new policy of continuously reducing the blood lead threshold. (25)
We have also begun to realize that there is a serious danger of a nocebo and other effects, which could make the well-intentioned messaging harmful. Simply put, falsely telling or implying to someone that they have been lead poisoned, and then providing them a list of harms that may befall them, may be unethical due to the possibility of inducing a powerful nocebo effect in which the harms occur as a self-fulfilling prophecy. In the aftermath of the 2014–15 Flint, Michigan, Water Crisis, many children were repeatedly and falsely told by some media, celebrities, physicians, politicians, teachers, and parents that they were victims of an unprecedented lead poisoning event that would cause health harms and irreversible adverse life outcomes. In stark terms, children were repeatedly described as horrifically poisoned and “brain damaged” from water lead exposure. Recent longitudinal data from a variety of government sources prove that even during the worst of the Flint crisis, the blood lead level of Flint children never increased significantly above the average for the State of Michigan and was always less than half of that of children in nearby Detroit. (26) With benefit of hindsight, we have argued that such language should have been avoided by physicians and scientists (including ourselves) due to the serious damage it might have done. (27)
In the early stages of the Flint media coverage, some warned of the dangers of such hyperbole [e.g., in Scientific American (M.A.E. and K.N.D.) and The New York Times (H.F.G. and K.N.D.)], (28−30) but others insisted that all Flint children should be labeled and treated as if they were lead poisoned. (17,31,32) The debate is ongoing, but here, we consider similar possible adverse consequences, if caretakers of children take some of the more extreme public health messaging on potential harm from low lead exposure literally.

What Threshold Is Too Low to Label Children Lead Poisoned?

Officially, the current CDC blood lead threshold should not be used “to inform medical, diagnostic, or treatment protocols for childhood lead poisoning” but rather as a “public health benchmark” and a “policy tool” to “identify children in the upper end of [BLL] distribution”. (10,33) However, in practice, the perception of the media, the public, and many health professionals is that each decrease in the threshold is changing “its definition of lead poisoning in young children” (Table S2). This, in turn, is “widely and incorrectly imbued with biological significance for the individual child”. (34) In 2018, CDC leadership acknowledged that the label “lead poisoning” should not be used “unless it’s for a high-level exposure”, but their ongoing silence in correcting such “confusion” (19) may be considered as acquiescence.
In expressing this concern, we are not minimizing the desirability of reducing BLLs in children. Worldwide ∼400 million children in 34 low- and middle-income countries have BLLs of >10 μg/dL, (35) and there are still nearly 200,000 such cases in North America. (36) However, using the most recent CDC level of concern to declare that one in three children is lead poisoned globally (36) is also misleading and potentially problematic.
The possible adverse consequences of “no safe level” labeling for per- and polyfluoroalkyl substances (PFAS) (Table S3) and several other contaminants is also worthy of a discussion that considers possible nocebo effects, at least to the extent that occurred for completely avoidable exposures to alcohol or second-hand tobacco smoke. (37,38)
It has been stated that the “history of public health [is] successive redefining of the unacceptable”. (39) In the past, society has benefited from making unnecessary exposure to lead and other contaminants unacceptable, but at some level, harms arising from a nocebo effect for trace contaminant exposures may also be considered unacceptable. To strike an appropriate balance, we believe that the public health community should set a single, scientifically defensible health-based threshold for lead exposure that should not pose an undue concern to consumers, just as it does for virtually every other environmental toxin that has some natural occurrence. We also believe that the ever-decreasing blood lead level of concern should not be considered a threshold associated with the horrific health consequences of “lead poisoning” and that some adverse unintended consequences of “no safe level” messaging should be considered.

Supporting Information

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The Supporting Information is available free of charge at https://pubs.acs.org/doi/10.1021/acs.est.3c04766.

  • Blood lead data underlying Figure 1, list of representative media headlines equating the new CDC blood lead reference level to a “lead poisoning” threshold, and exemplar “no safe level” language used for PFAS chemicals (PDF)

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Author Information

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  • Corresponding Author
  • Authors
    • Kim N. Dietrich - Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, United States
    • Hernan F. Gomez - Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan 48109, United States;  Department of Emergency Medicine, University of Michigan, Hurley Medical Center, One Hurley Plaza, Flint, Michigan 48503, United States
    • Marc A. Edwards - Department of Civil and Environmental Engineering, Virginia Tech, 418 Durham Hall, Blacksburg, Virginia 24061, United States;  Orcidhttps://orcid.org/0000-0002-1889-1193
  • Funding

    The authors received no financial support for the research, authorship, and/or publication of this article. This Viewpoint is based on more than a century of combined clinical and research experience, including (a) serving as PI on the Cincinnati Lead Study (the “longest, continuously active prospective study of lead exposure and child development in the world”) and Co-PI of the DMSA study, the only multicenter, double-blind, placebo-controlled clinical trial of DMSA (Succimer) in lead-poisoned children (K.N.D., from 1979 to the present), (b) practicing as a pediatrician, treating children with toxic exposures, including lead (Board-certified in Medical Toxicology, Pediatrics and Emergency Medicine), and conducting research in Flint and elsewhere (H.F.G., from the 1980s to the present), and (c) conducting research on lead in drinking water and helping to expose the Washington, DC, Flint, MI, and Denmark, SC, water lead crises (M.A.E., from the 1990s to the present; S.R., from 2015 to the present).

  • Notes
    The authors declare the following competing financial interest(s): M.A.E. and S.R. worked with Flint residents to expose the Flint Water Crisis, and their data, testimony, and emails have been subpoenaed in several lawsuits. They are not party to any of these lawsuits. M.A.E. has been subpoenaed as a fact witness in many of the lawsuits but has refused all financial compensation for time spent on those activities. S.R. is serving as a scientific consultant on the use of biosolids to track water lead exposure, a topic unrelated to this Viewpoint, in a Flint lawsuit and has been financially compensated for that work by VNA. K.N.D. and H.F.G. declare they have no competing interests.

Biographies

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Siddhartha Roy is a Research Associate at the University of North Carolina at Chapel Hill’s Water Institute. He conducts research in the areas of drinking water, public health, citizen science, international development, and environmental justice in the United States and West Africa. He and his team’s scientific and humanitarian relief work, along with residents of Flint, Michigan, helped uncover the Flint Water Crisis. Roy’s work has won prizes and recognition from the American Association for the Advancement of Science, the American Civil Liberties Union, the American Society of Civil Engineers, the American Water Works Association, The Boston Globe, the International Water Association, and the Obama Foundation.

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Kim N. Dietrich is Professor Emeritus of Environmental Health and Epidemiology at the University of Cincinnati College of Medicine. He has directed or co-directed large-scale prospective studies and clinical trials concerned with environmental chemical influences on child development. Dr. Dietrich has served as an expert on numerous boards and scientific committees impaneled by the National Institutes of Health, Environmental Protection Agency, CDC, and other agencies. He has devoted his career to the study and prevention of the adverse effects of environmental chemicals on human health and development.

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Hernan F. Gomez is Associate Professor of Emergency Medicine at the University of Michigan Health System (UMHS). He is a medical toxicologist, pediatrician, internal medicine, and emergency medicine specialist and practices pediatric emergency medicine at the Hurley Medical Center, Flint, Michigan, teaching site of UMHS. He has devoted his career to the study and treatment of natural toxins in vulnerable populations and authored several papers and op-eds on lead exposure associated with the Flint Water Crisis.

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Marc A. Edwards is a University Distinguished Professor of Civil Engineering at Virginia Tech, where he teaches courses in environmental engineering, applied aquatic chemistry, and engineering ethics. His research group conducted the investigative science uncovering the 2001–2004 D.C. Lead Crisis, the 2014–2016 Flint Water Disaster, and illegal pesticide dosing to water of Denmark, SC, 2008–2018. Edwards won a MacArthur Fellowship in 2007, and in 2013, he was the ninth recipient (in a quarter century) of the IEEE Barus Award for “courageously defending the public interest at great personal risk”. In 2016, Edwards was named amongst TIME’s 100 Most Influential People in the World, the World’s 50 Greatest Leaders by Fortune, Politico’s Top 50 Visionaries who have transformed American politics, and Foreign Policy’s 100 World’s Greatest Thinkers and was short-listed amongst Flint whistleblowers as TIME person(s) of the year. He was co-recipient of the inaugural 2017 MIT Disobedience Award and received the AAAS Scientific Freedom and Responsibility award (2018) and the Hoover Humanitarian Medal (2019).

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    Finding the Next Flint: The Need to Update the Blood Lead Reference Value
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    Lead was one of the most dangerous environmental toxic substances for a long time in western countries, and this is still the case for many places on earth today. Its neurotoxic potential is highly significant but its secure blood level concentration remains unknown. The aim of this study was to approach the above issue from the perspective of social psychiatry. A systematic search was made of Dialog and Datastar interfaces for data regarding the neuropsychiatric complications of direct or chronic exposure to lead, and a review of the relevant literature was conducted using the databases Medline, Embase, CAB Global Health and Cochrane. Lead affects the cholinergic, dopaminergic and gloutamergic systems, thus intervening in the normal function of neurotransmion. The consequence of neurotoxicity in the central nervous system includes apoptosis and excitotoxicity. Direct as well as chronic exposure causes serious neurological symptoms and possibly constant cognitive impairment. Acute encephalopathy, the most serious expression of lead poisoning, occurs in blood level concentrations over 100 μg/dL in adults and 80-100 μg/dL in children. Early symptoms of lead neurotoxicity include irritability, headaches and difficulties in concentration in both children and adults. Continuous exposure in children produces neurobehavioral symptoms, such as decreased concentration, inability to follow instructions, difficulty to play games and low IQ, which are associated with concentrations of 10-35 μg/dL. However, some studies claim that cognitive decline and low IQ can occur in concentrations <10 μg/dL. The commonest symptom in adults is peripheral neuropathy with foot drop. Prenatal exposure to lead has been correlated with antisocial behavior and schizophrenia. Long-term lead exposure causing low and medium lead concentration in blood has been linked to depression as well as generalized anxiety disorder and other behavioral disorders. High blood level concentrations correlate with psychotic symptoms like delusions and hallucinations but more rarely with psychotic syndromes. Despite the fact that lead has been banned from gasoline, paint and water pipes, quite significant quantities of lead still exist, particularly in deprived areas of modern cities, in transition zones and city centers, and there are also great concentrations around lead mines and in developing countries, but even for the remaining areas there is no safe threshold. CONCLUSIONS: Lead was and still is an environmental factor that increases neurologic and psychiatric morbidity. It also causes developmental disorders, especially in deprived areas. Prevention should be the single most important way of dealing with lead poisoning.
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  1. Yang Liu, Yuchuan Wu, Xiaolu Shi, Ye Tian, Shaobo Zhai, Zheng Yang, Shunli Chu. Association between blood lead and periodontitis among American adults: a cross-sectional study of the national health and nutrition examination survey. Frontiers in Pharmacology 2024, 15 https://doi.org/10.3389/fphar.2024.1420613
  2. Gabriel M. Filippelli, Matthew Dietrich, John Shukle, Leah Wood, Andrew Margenot, S. Perl Egendorf, Howard W. Mielke. One in Four US Households Likely Exceed New Soil Lead Guidance Levels. GeoHealth 2024, 8 (6) https://doi.org/10.1029/2024GH001045
  3. Siddhartha Roy, Marc Edwards, Keith J. Petrie, Greg D. Gamble, Ellie Jacques. A Possible Nocebo Effect in Children Following the Flint Water Crisis: Evidence From Schoolteacher Perceptions and Neuropsychological Evaluations. SSRN Electronic Journal 2024, 2 https://doi.org/10.2139/ssrn.4790654
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  • Abstract

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    Figure 1

    Figure 1. Blood lead trends in the United States from 1935 to 2023. Data sources are available in the Supporting Information (Text S1). Inspiration for this graph comes from EWG. (40)

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    Siddhartha Roy

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    Siddhartha Roy is a Research Associate at the University of North Carolina at Chapel Hill’s Water Institute. He conducts research in the areas of drinking water, public health, citizen science, international development, and environmental justice in the United States and West Africa. He and his team’s scientific and humanitarian relief work, along with residents of Flint, Michigan, helped uncover the Flint Water Crisis. Roy’s work has won prizes and recognition from the American Association for the Advancement of Science, the American Civil Liberties Union, the American Society of Civil Engineers, the American Water Works Association, The Boston Globe, the International Water Association, and the Obama Foundation.

    Kim N. Dietrich

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    Kim N. Dietrich is Professor Emeritus of Environmental Health and Epidemiology at the University of Cincinnati College of Medicine. He has directed or co-directed large-scale prospective studies and clinical trials concerned with environmental chemical influences on child development. Dr. Dietrich has served as an expert on numerous boards and scientific committees impaneled by the National Institutes of Health, Environmental Protection Agency, CDC, and other agencies. He has devoted his career to the study and prevention of the adverse effects of environmental chemicals on human health and development.

    Hernan F. Gomez

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    Hernan F. Gomez is Associate Professor of Emergency Medicine at the University of Michigan Health System (UMHS). He is a medical toxicologist, pediatrician, internal medicine, and emergency medicine specialist and practices pediatric emergency medicine at the Hurley Medical Center, Flint, Michigan, teaching site of UMHS. He has devoted his career to the study and treatment of natural toxins in vulnerable populations and authored several papers and op-eds on lead exposure associated with the Flint Water Crisis.

    Marc A. Edwards

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    Marc A. Edwards is a University Distinguished Professor of Civil Engineering at Virginia Tech, where he teaches courses in environmental engineering, applied aquatic chemistry, and engineering ethics. His research group conducted the investigative science uncovering the 2001–2004 D.C. Lead Crisis, the 2014–2016 Flint Water Disaster, and illegal pesticide dosing to water of Denmark, SC, 2008–2018. Edwards won a MacArthur Fellowship in 2007, and in 2013, he was the ninth recipient (in a quarter century) of the IEEE Barus Award for “courageously defending the public interest at great personal risk”. In 2016, Edwards was named amongst TIME’s 100 Most Influential People in the World, the World’s 50 Greatest Leaders by Fortune, Politico’s Top 50 Visionaries who have transformed American politics, and Foreign Policy’s 100 World’s Greatest Thinkers and was short-listed amongst Flint whistleblowers as TIME person(s) of the year. He was co-recipient of the inaugural 2017 MIT Disobedience Award and received the AAAS Scientific Freedom and Responsibility award (2018) and the Hoover Humanitarian Medal (2019).

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      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; [Formula: see text]) in U.S. children ages 1-11 y from 1976 to 2016. For all children with valid BLLs ([Formula: see text]), geometric mean (GM) BLLs [95% confidence intervals (CI)] and estimated prevalence [Formula: see text] (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 [Formula: see text] (95% CI: 14.3, 16.1) in 1976-1980 to [Formula: see text] (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 [Formula: see text] (95% CI: 11.9, 13.4) in 1976-1980 to [Formula: see text] (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 [Formula: see text]. 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.
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      Gottesfeld, P. Finding the next Flint: the need to update the blood lead reference value. American Journal of Public Health 2021, 111 (10), 1746– 1749,  DOI: 10.2105/AJPH.2021.306429
      33
      Finding the Next Flint: The Need to Update the Blood Lead Reference Value
      Gottesfeld Perry
      American journal of public health (2021), 111 (10), 1746-1749 ISSN:.
      There is no expanded citation for this reference.
    34. 34
      Vorvolakos, T.; Arseniou, S.; Samakouri, M. There is no safe threshold for lead exposure: Α literature review. Psychiatriki 2016, 27 (3), 204– 214,  DOI: 10.22365/jpsych.2016.273.204
      34
      There is no safe threshold for lead exposure: Α literature review
      Vorvolakos Th; Arseniou S; Samakouri M
      Psychiatrike = Psychiatriki (2016), 27 (3), 204-214 ISSN:1105-2333.
      Lead was one of the most dangerous environmental toxic substances for a long time in western countries, and this is still the case for many places on earth today. Its neurotoxic potential is highly significant but its secure blood level concentration remains unknown. The aim of this study was to approach the above issue from the perspective of social psychiatry. A systematic search was made of Dialog and Datastar interfaces for data regarding the neuropsychiatric complications of direct or chronic exposure to lead, and a review of the relevant literature was conducted using the databases Medline, Embase, CAB Global Health and Cochrane. Lead affects the cholinergic, dopaminergic and gloutamergic systems, thus intervening in the normal function of neurotransmion. The consequence of neurotoxicity in the central nervous system includes apoptosis and excitotoxicity. Direct as well as chronic exposure causes serious neurological symptoms and possibly constant cognitive impairment. Acute encephalopathy, the most serious expression of lead poisoning, occurs in blood level concentrations over 100 μg/dL in adults and 80-100 μg/dL in children. Early symptoms of lead neurotoxicity include irritability, headaches and difficulties in concentration in both children and adults. Continuous exposure in children produces neurobehavioral symptoms, such as decreased concentration, inability to follow instructions, difficulty to play games and low IQ, which are associated with concentrations of 10-35 μg/dL. However, some studies claim that cognitive decline and low IQ can occur in concentrations <10 μg/dL. The commonest symptom in adults is peripheral neuropathy with foot drop. Prenatal exposure to lead has been correlated with antisocial behavior and schizophrenia. Long-term lead exposure causing low and medium lead concentration in blood has been linked to depression as well as generalized anxiety disorder and other behavioral disorders. High blood level concentrations correlate with psychotic symptoms like delusions and hallucinations but more rarely with psychotic syndromes. Despite the fact that lead has been banned from gasoline, paint and water pipes, quite significant quantities of lead still exist, particularly in deprived areas of modern cities, in transition zones and city centers, and there are also great concentrations around lead mines and in developing countries, but even for the remaining areas there is no safe threshold. CONCLUSIONS: Lead was and still is an environmental factor that increases neurologic and psychiatric morbidity. It also causes developmental disorders, especially in deprived areas. Prevention should be the single most important way of dealing with lead poisoning.
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      Ericson, B.; Hu, H.; Nash, E.; Ferraro, G.; Sinitsky, J.; Taylor, M. P. Blood lead levels in low-income and middle-income countries: a systematic review. Lancet Planetary Health 2021, 5 (3), e145– e153,  DOI: 10.1016/S2542-5196(20)30278-3
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  • Supporting Information

    Supporting Information

    The Supporting Information is available free of charge at https://pubs.acs.org/doi/10.1021/acs.est.3c04766.

    • Blood lead data underlying Figure 1, list of representative media headlines equating the new CDC blood lead reference level to a “lead poisoning” threshold, and exemplar “no safe level” language used for PFAS chemicals (PDF)


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