Abstract
Exposure to environmental toxins presents substantial health risks, particularly for individuals facing heightened exposure due to occupational hazards. This analytic review highlights the critical need to address these risks through a lifestyle medicine approach, advocating for integrated care strategies to mitigate the long-term health impacts of toxic environmental exposures. We explore exposures to environmental toxins in 2 at-risk populations, military service members exposed to airborne hazards and burn pits during overseas deployments and first responders to the World Trade Center terrorist attack. The review highlights the immediate and long-term chronic health effects of toxic environmental exposures, emphasizing the variable symptoms, long latency, and long-term complex outcomes that necessitate an exposure-informed health care model. Exposure-informed care can enhance overall well-being and reduce the risks of chronic illnesses by incorporating lifestyle medicine principles supported by a learning community system. The proposed model makes recommendations for a shift to exposure-informed preventative care. This enhanced approach aims to promote a longer and healthier life for those at increased risks following toxic environmental exposures. Understanding the context of military burn pit and World Trade Center environmental exposures and the possibilities of exposure-informed care is paramount in shifting from a traditional disease-centered model to a holistic, person-centered approach.
Keywords
“Environmental toxic exposures can lead to detrimental acute and long-term health effects seen following exposures by military service members and WTC responders.”
Introduction
Exposure to environmental toxins can result in both acute and chronic health conditions.1,2 Two populations, military service members exposed to airborne hazards and burn pits during deployments and individuals affected by toxic exposure following the World Trade Center terrorist attack, offer invaluable insights into post-exposure care. Military personnel exposed to airborne toxins have reported respiratory illnesses, cancers, and other chronic conditions. 1 Similarly, first responders and civilians living or working near the World Trade Center (WTC) site have experienced chronic respiratory and gastrointestinal disorders, various cancers, long-term psychological effects, and other health issues linked to environmental toxins.1,2 These populations have benefited from more than a decade of research and clinical evidence of health outcomes and post-exposure care models. They provide an opportunity for critical case studies identifying exposure-informed care strategies for not only Veterans and WTC survivors, but also other at-risk groups, including industrial workers, disaster first responders, and similar populations.
Lifestyle medicine employs evidence-based behavioral interventions to prevent, treat and manage chronic disease and shifts the focus from treating chronic illness after it has occurred to “recognizing, educating, and supporting patients’ healthy and disease-reversing behaviors in their contextual environment” by addressing the root causes and life choices that underlie chronic illness. 3 A lifestyle medicine model is an ideal match for chronic health problems that are multi-system and may be best treated from a “whole person” perspective rather than an organ-by-organ approach. Following this “whole person” perspective, lifestyle medicine has 3 primary goals for individuals: remain healthy, remain independent, and live well as long as possible. 4 This holistic approach to health and wellness can be universally beneficial, especially for individuals at increased risks for chronic diseases following toxic environmental, occupational and other exposures.
The aim of this analytic review is to increase awareness about the wide-ranging health effects of toxic environmental exposure and discuss the potential benefits of a lifestyle medicine approach to post-exposure care. To accomplish this, we will discuss 2 populations at-risk for acute and chronic health effects following toxic exposures: (1) post 9/11 military service members exposed to airborne hazards and open-air burn pits, and (2) first responders to the World Trade Center terrorist attack. The goal for this review is to develop a deeper understanding of post-exposure care in these, and other, vulnerable populations.
Lifestyle Medicine Following Toxic Environmental Exposure
Lifestyle medicine addresses chronic diseases by promoting positive health behaviors 5 and is defined as “the evidence-based practice of helping individuals and communities with comprehensive lifestyle changes (including nutrition, physical activity, stress management, social support, and environmental exposures) to help prevent, treat, and even reverse the progression of chronic diseases by addressing the underlying cause.” 6 Lifestyle medicine is an upstream preventative approach rather than a response after illness and focuses on 6 main areas: increasing physical activity; developing strategies to manage stress; forming and maintaining meaningful relationships; improving sleep; avoidance of risky substances; and healthful eating. 5
Lifestyle medicine has several important benefits including the potential for the additive effects of lifestyle interventions. For example, improving mental health often leads to improvements in physical health. 7 Thus, an intervention aimed at strengthening mental health will also likely reduce the risk of chronic illness by also improving physical health. 7 Lifestyle medicine is administered by a multidisciplinary team to meet the medical and psychological needs of individuals. Lifestyle medicine practitioners use motivational interviewing, health coaching, routine health visits, and other tools to provide education and direction. 6 A team-based approach also addresses importance of key social risk factors on wellness such as housing, employment, financial distress, and education, 7 which are known to contribute to poor health outcomes.
Chronic Health Conditions Post-toxic Exposure Matched to Evidence-Based Lifestyle Medicine Interventions.
Note: not inclusive of all chronic health conditions post-exposure. COPD (Chronic Obstructive Pulmonary Disease), GERD (Gastroesophageal Reflux Disease), PTSD (Post-traumatic stress disorder).
Epidemiology Program, Health Outcomes Military Exposures, Office of Patient Care Services, Department of Veterans Affairs. (2021). Post Deployment Health Surveillance Tables of Prevalence and Incidence: 2010-2019. Washington, DC: Author. (URL).
Kubale T, Katruska A, Brown EP, Santiago-Colón A, Daniels RD, Reissman DB [2022]. Summary of World Trade Center Health Program research: NIOSH research compendium. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health:1-684.
Military Service Members
Military service members exposed to environmental hazards during deployments may experience lasting detrimental health effects. 9 Veterans of the Gulf War exposed to toxic substances show a significant increase in adverse respiratory conditions and chronic multi-symptom illness. 10 The deleterious health effects are persistent, increase over time, and remain higher in deployed Veterans 20 years following exposure than in non-deployed Veterans. 11 Millions of U.S. military Veterans who served in Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), and New Dawn (OND) or deployed to Western Asia were exposed to airborne hazards and open-air burn pits.12-15 The U.S. Department of Veterans Affairs defines “airborne hazards” as any contaminant or potentially toxic substance that is in the air we breathe. 16 Burn pits were utilized at over 250 sites with larger sites burning an estimated 85,000 pounds (227 metric tons) of hazardous waste daily using JP-8 jet fuel to ignite the fires.17,18 Burn pits were located adjacent to military housing, work areas, and dining facilities. 19 Items burned included, but were not limited to, electronics, weapons, medical waste, lithium-ion batteries, plastics, Styrofoam, insecticide canisters, and vehicles. 17 Burn pit emissions contained particulate matter in a range of sizes coated with toxic chemicals such as polycyclic aromatic hydrocarbons (PAH), volatile organic compounds (VOCs) and heavy metals (titanium, iron). 20 The health effects of airborne hazards are compounded by other common environmental factors related to military deployment including sandstorms, extreme temperatures, psychological stress, noise, and sleep deprivation. 19
Post 9/11 Veterans exposed to burn pits and other airborne hazards report a wide range of respiratory symptoms and diseases, including persistent dyspnea, chronic cough, asthma, chronic obstructive pulmonary disease, constrictive bronchiolitis, and other chronic respiratory conditions. These symptoms, collectively referred to as Deployment-Related Respiratory Disease (DRRD), often result from inhalation of toxic fumes, particulate matter, and other environmental contaminants during deployment. The term DRRD provides a broad descriptor for these conditions, emphasizing the need for comprehensive diagnostic evaluations and proactive, exposure-informed care strategies tailored to this population.12,21-23 Findings from the Airborne Hazards and Open-Air Burn Pit Registry (AHOBPR) indicate that almost half of the Veterans enrolled report dyspnea and almost one-third report decreased exercise tolerance or cough after exposures. 1 A recent retrospective cohort study of Veterans Health Administration medical records and deployment records identified that prolonged deployment was associated with increased risks for asthma (adjusted conditional odds ratio [AOR] 1.01; 95% CI 1.01 – 1.02), chronic obstructive pulmonary disease (AOR, 1.04; 95% CI, 1.02 – 1.07), hypertension (AOR, 1.02; 95% CI, 1.02-1.03), and ischemic stroke (AOR, 1.06; 95% CI, 0.97 – 1.14). 21 During post 9/11 deployment, many service members were in their 20s and 30s and at the peak of their physical health and lung functions, and yet reported an increase in respiratory symptoms (chronic persistent cough, dyspnea, and wheezing) from pre- to post-deployment. 24 Further, significant associations between their burn pit exposure and chronic respiratory symptoms are emerging, including increased risk of respiratory symptoms in women. 25
Military service members (service from 1990 – 2021) report migraines, hypertension, major depressive disorder, arthritis, dermatitis, decreased functional status, and other symptoms following burn pit exposures. 26 In a recent study, 29% of post 9/11 Veterans reported hematuria and high rates of urinary frequency (84%) and urgency (76%) post-deployment. 27 Secondary data from a qualitative survey found that post 9/11 Veterans reported all parts of their body being affected during and post-deployment. 28 Specifically, Veterans reported fatigue, general pain, memory issues, slow recovery from illness, and chronic sleep problems. 28
The current model of care following toxic environmental or occupational exposures is primarily treatment focused. The Department of Veterans Affairs (VA) takes a “Whole Health” approach to care, believing that “every health system’s primary purpose should be to help the people that it serves achieve whole health.” 29 The VA has been a leader in this approach, implementing a Whole Health System approach in 18 sites that focus on chronic pain, mental health, and disabilities. 29 The recent passage of the Sergeant Heath Robinson Promise to Address Comprehensive Toxins (PACT) Act expands VA health care and benefits for all Veterans exposed to burn pits and other airborne hazards. (https://www.va.gov/resources/the-pact-act-and-your-va-benefits/) The PACT Act will ensure that all Veterans who have been exposed to toxic environments are screened for health effects of exposure and, thus, identify those Veterans who may benefit from a lifestyle medicine approach to care.
Lifestyle medicine programs within the VA system have had positive results. While not specific to post-exposure Veterans, they provide evidence of the benefits of a lifestyle medicine model of care. A comprehensive lifestyle medicine program for post-stroke Veterans (including any era of military service) includes exercise, cooking, mindfulness, education, and group support delivered over 12 weeks. 30 Following this program, significant improvements were seen in exercise duration, balance, blood pressure management and, importantly, high self-reported satisfaction rates. 30 A study of a remote health coaching, lifestyle medicine intervention for Veterans (including any era of military service) incorporated clinical recommendations with health goals identified by Veterans. 31 Individual health goals identified by Veterans (including physical activity, mindset and diet) were fully met (56%) or partially met (44%) in the study. 31
World Trade Center Responders
The attacks at the World Trade Center (WTC) in 2001 expelled a combustion plume and ambient dust that contaminated New York City. The first responders to the attack and the population who lived and worked nearby were exposed to the initial plume created by the fire and building collapses, from ongoing fires that lasted at least 3 months, and from exposures to toxic air particles during the cleanup and transport of debris.32,33 The complex mixture of fine particulate matter and coarse WTC dust was filled with asbestos, lead, mercury, polyvinyl chloride, and dioxins that are known to cause acute and chronic adverse health effects. 34
Numerous detrimental health effects have been reported in first responders after exposures at the WTC site. 35 The most frequent reported health effects include aerodigestive disorders, cancer, and mental ill health. 35 Cancer has been documented in 16% of all WTC responders, raising particular concerns as survivors age and their risk of cancer increases. 35 Twenty years after Sept 11th related toxic exposures, the first responders to the WTC had higher rates of all cancers combined as well as higher rates of prostate cancer, thyroid cancer, and leukemia. 35 Individual characteristics such as age and smoking status may contribute to these increases. 2 In WTC responders, mental and physical illness are often intertwined, necessitating a multidisciplinary coordinated approach to care.36,37
The World Trade Center Health Program (WTCHP) includes medical monitoring and treatment of first responders and survivors who lived, worked, or attended school in the affected area. 37 The WTCHP includes components of lifestyle medicine such as smoking cessation, dietary support, and mental health care. In addition to a medical exam and clinical testing, the WTCHP includes diagnostic testing, health education and counseling aimed to empower individuals with the knowledge to manage their health more effectively. 38
Recent studies have identified a significantly lower than expected mortality among WTCHP firefighters and general survivors as compared with national, state, and local populations.39-42 Singh and colleagues investigated if the mortality benefit could be from the “healthy worker effect” 43 by comparing 2 cohorts of firefighters: WTC-exposed firefighters and firefighters from 3 urban fire departments with similar occupational exposures (except for the WTC exposure). 44 Both firefighter cohorts had lower than expected all-cause mortality. However, the WTC-exposed firefighters had lower all-cause mortality and cancer-specific, cardiovascular-specific, and respiratory disease-specific mortality as compared with the non-WTC-exposed firefighters.44,45 These findings suggest both cohorts had a healthy worker effect, but the WTC-exposed firefighter had an additional improvement in mortality. The lower mortality may be attributed to improved access to free, comprehensive health monitoring (including components of lifestyle medicine) and treatment received from the WTCHP. How much of an effect the lifestyle medicine components (diet, mental health, avoidance of risky behaviors, and others) had on this mortality improvement is not known and warrants further study.
Discussion
Environmental toxic exposures can lead to detrimental acute and long-term health effects seen following exposures by military service members and WTC responders. Each population continues to experience high rates of both acute and chronic respiratory disease as well as increased morbidity and risks for cancer. Our analytic review highlights the immediate and long-term health effects of toxic exposures, emphasizing the variable symptoms, long latency, and long-term outcomes that benefit from a holistic care model incorporating lifestyle modification as a cornerstone of treatment.
Other populations are also routinely exposed to toxic environments and would also benefit from an exposure-informed plan of care. A recent study identified blue-collar workers from “Construction,” “Professional, Scientific, Technical Services,” “Real estate, Rental, Leasing,” “Manufacturing,” and “Wholesale Trade” as having higher biomarker levels of toxicants including arsenic (16%-58%), led (1%-3%) and volatile organic compounds (VOCs) (1% - 33%). 46 Ongoing research to identify and characterize toxic exposures and health effects in these high-risk populations is an important component to exposure-informed care models.
A holistic care model focuses on lifestyle medicine factors to enhance patient engagement and support positive behavior change. Shifting the focus from a reactive approach to a proactive approach where lifestyle behaviors are considered medical interventions that are promoted, implemented, and sustained is an important goal. 47 Importantly, lifestyle behaviors tend to cluster 4 and while addressing all behaviors should be a goal, even making a change in 1 behavior is likely to show lasting health benefits. This additive benefit is important and cost-effective in resource-limited settings where improving behaviors in 1 lifestyle domain can have ripple effects on other lifestyle factors. In a general population of U.S. adults, adherence to 5 low-risk lifestyle medicine factors (never smoking, healthy weight, regular physical activity, healthy diet and moderate alcohol consumption) could extend life expectancy at age 50 by 14.0 years for female and 12.2 years for male adults, compared to individuals who did not adopt these lifestyle factors. 48 For populations at high-risk for chronic disease post-exposure, such as military service members or responders to the World Trade Center attack, these benefits are welcome.
Conclusions
Exposures to toxic environmental hazards leads to detrimental health outcomes. A lifestyle medicine approach has the potential to mitigate and even prevent some of these post-exposure detrimental outcomes. The decrease in cancer mortality seen in the WTCHP, which includes components of lifestyle medicine, provides encouraging evidence for the benefits of this approach. Future research on the quantitative and qualitative benefits of lifestyle medicine models points to a better understanding of post-exposure care and how best to implement these models at the point of care. Applying care management lessons learned from military service members and the WTC population can inform care for other populations at-risk following toxic environmental exposures.
Supporting individuals and families in maintaining a healthy lifestyle should be standard in post-exposure care and requires management and organizational processes that help individuals adopt, engage and maintain healthy behaviors.4,49 A majority of military service members (65.7%) report that a lifestyle medicine approach is an extremely or very important part of the discussion with their health care providers. 50 However, few (10.3%) military service members have knowledge of the elements that underpin lifestyle medicine. 49 Health care systems should work to integrate a lifestyle medicine approach into exposure-informed care, and include patients and families in this planning (co-design) to ensure the care models meet their needs. Implementing a lifestyle medicine approach requires a coordinated effort and represents an opportunity to improve the health of populations exposed to toxic environmental exposures. 51
Footnotes
Acknowledgments
Rosie Lopez Tores, BS, Burn Pits 360; Sunny Chung, MLIS, AHIP, Stony Brook University Health Sciences Librarian; VA BLRD 1 I01 BX004146 (to TAB). VA BLRD Field Planning Award-MTEC (to TAB, MAK and JHT). UMN -CTSI The MN Pulmonary Airborne Clinical Toxin (M-PACT) Study (to TAB, MAK and JHT).
Author Contributions
PKG conceptualized the theme of the manuscript. PKG, PBA, TAB, JP, JHT, JT, MAK and PBA conceptualized and drafted the original manuscript. All authors reviewed and edited the draft manuscript and read and approved the final manuscript.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The views expressed in this material are those of the authors, and do not reflect the official policy or position of the U.S. Government, the Department of Defense, the Department of Veterans Affairs, or the Department of the Army.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
