Huan Shu

Phthalates
On the issue of sources, human uptake,
time trends and health effects
Phthalates
On the issue of sources, human uptake,
time trends and health effects

Huan Shu

Faculty of Health, Science and Technology

Public Health Science

DOCTORAL THESIS | Karlstad University Studies | 2017:30

Phthalates
On the issue of sources, human uptake,
time trends and health effects

Huan Shu

DOCTORAL THESIS | Karlstad University Studies | 2017:30

Phthalates - On the issue of sources, human uptake, time trends and health effects

Huan Shu

DOCTORAL THESIS

Karlstad University Studies | 2017:30

urn:nbn:se:kau:diva-62637

ISSN 1403-8099

ISBN 978-91-7063-806-0 (Print)

ISBN 978-91-7063-902-9 (PDF)

©
The author

Distribution:
Karlstad University
Faculty of Health, Science and Technology
Department of Health Sciences
SE-651 88 Karlstad, Sweden
+46 54 700 10 00

Print: Universitetstryckeriet, Karlstad 2017

WWW.KAU.SE
Dedication

This thesis is dedicated to the memory of our beloved Professor

Bo AG Jönsson (1960/02/04 – 2016/11/24)

1
Abstract

Human health depends on a well-functioning endocrine system to

regulate hormone release for normal bodily functions. Endocrine
disrupting chemicals (EDCs) constitutes a group of chemicals, included
in many commonly used products, (e.g., PVC flooring), with properties
proven or suspected to interact with the natural hormone system in
humans and animals. EDCs are manmade compounds (there are also
natural compounds with such properties) that can bind to cell receptors
and mimic or block the functions of natural hormones potentially
resulting in adverse human health effects.

One type of widely concerning EDC is phthalates. Since phthalates

create weak chemical bonds when they are added into different
products, they readily leach into the surrounding environment.
Phthalate metabolites can therefore be frequently measured in human
biological samples. Major public health concerns regarding EDCs over
the past three decades have focused on phthalates. According to the
World Health Organization, EDCs are suspected to be associated with
altered reproductive function in males and females, increased
incidence of breast cancer, abnormal growth patterns and
neurodevelopmental delays in children, as well as changes in immune
function.

The thesis shows that PVC flooring in the home is a source for human
uptake of phthalates, that replacement of phthalates in soft PVC
products have an impact on human uptake of these chemicals, and that
exposure for phthalates in early life increase the risk for airway
disorders in children.

As we have shown, ongoing regulations on phthalates is of importance

for human uptake. Ultimately, individuals can make small changes in
their consumer product choices that can lead to changes in uptake of
chemicals with endocrine disrupting properties. Philosophically, we all
have a responsibility to protect future generations from dangerous
chemicals.

2
Contents

DEDICATION ............................................................................................... 1
ABSTRACT ................................................................................................. 2
CONTENTS ................................................................................................. 3
PREFACE .................................................................................................... 5
LIST OF PAPERS ....................................................................................... 6
ABBREVIATIONS ....................................................................................... 7
INTRODUCTION ......................................................................................... 8
ENDOCRINE DISRUPTING CHEMICALS ............................................................ 8
PHTHALATES: A HUNDRED YEAR OLD STORY .................................................. 9
 Phthalates is a high production volume group of chemicals ...... 9
 Human exposure to phthalates ................................................ 10
 Global health concern for phthalate exposure ......................... 12
 The current regulation on phthalates ....................................... 13
 Replacements and phthalate alternatives ................................ 14
THE FULL CHAIN MODEL ............................................................................. 14
RESEARCH QUESTIONS FOR THE THESIS ..................................................... 15
AIM OF THE THESIS ................................................................................ 16
METHOD ................................................................................................... 16
THE DBH-STUDY ..................................................................................... 16
THE SELMA STUDY ................................................................................. 18
 Questionnaires ........................................................................ 19
 Biomarkers in prenatal urine and serum .................................. 19
BIOSTATISTICAL ANALYSES AND MODELING ................................................. 21
ETHICAL APPROVAL................................................................................... 23
RESULT AND DISCUSSION..................................................................... 23
PVC FLOORING MATERIALS IN THE HOME AS A SOURCE FOR HUMAN UPTAKE OF
PHTHALATES ............................................................................................ 23
TIME TRENDS FOR HUMAN LEVELS OF PHTHALATES ...................................... 28
EARLY LIFE EXPOSURE TO PHTHALATES AND AIRWAY PROBLEMS IN CHILDREN 32
 PVC flooring and incidence of asthma ..................................... 33
 Prenatal phthalate exposure and croup during infancy ............ 35
OVERALL DISCUSSION OF THE FINDINGS...................................................... 37
 Leakage of phthalates from PVC to indoor dust ...................... 40

3
 Phthalates in indoor air and dust and the relation to human
urinary levels ........................................................................... 41
 Phthalates in indoor dust and the association to airway
problems in children ................................................................ 41
 The full chain for BBzP ............................................................ 42
ETHICS CONSIDERATION ............................................................................ 43
A PUBLIC HEALTH CONCERN ...................................................................... 43
CONCLUSION ........................................................................................... 44
ACKNOWLEDGEMENTS.......................................................................... 46

4
Preface

Encouraged by advertisements promising clear pores and “no more

blackheads”, many of us have stocked up on beauty products that will,
we hope, help us scrub our way to clear skin. Don’t we all have our
favorite pick-me-up scent, which we all hope will draw admiration from
friends, colleagues, and passersby on the street? Each day, from the
coffee pod in the morning and the rubber duckies our children play
with in the bathtub at night, to the non-stick frying cookware fresh out
of the dishwasher and the durable vinyl floors we stand on; we are using
products that have one thing in common. Whether we realize it or not,
these common household products contain chemicals that make them
easy to transport, make them soft and easy to clean, make fragrance
last longer, lotion easier to absorb into our skin and colorful, non-
breakable toys for kids. However, and in addition, these chemicals may
also be toxic and therefore of importance for human health and
development. About 10 years ago, an amazing co-operative working
experience with Canadian Healthy Infant Longitudinal Development
(CHILD) study brought me into this interesting field. The current
thesis is a continuation of the research on the effects of phthalate
exposure on children.

5
LIST OF PAPERS

This thesis is based on the following original publications, referred to

in the text by roman numerals (I-IV):

I. Shu H, Jonsson BA, Larsson M, Nanberg E, Bornehag CG.,

PVC flooring at home and development of asthma among
young children in sweden, a 10-year follow-up.

Indoor air 2013: 24:227-235.

II. Shu, H., Jönsson, B. A., Lindh, H., Nånberg, E. and Bornehag,
C.-G., PVC flooring at home and uptake of phthalates in
pregnant women in the Swedish SELMA study.

In manuscript

III. Shu, H., Jönsson, B. A., Genning, C., Svensson, Å., Nånberg,
E., Lindh, C., Knutz, M., Takaro, T. and Bornehag, C.-G.,
Temporal Trends in Phthalate Exposures in Swedish
Pregnant Women.

Journal of exposure science and environmental

epidemiology (submitted)

IV. Shu, H., Wikström, S., Jönsson, B. A., Svensson, Å., Nånberg,
E. and Bornehag, C.-G., Prenatal Phthalates Exposure and the
Association to Infants Croup in the Swedish SELMA Study.

Acta Paediatrica (submitted)

6
ABBREVIATIONS

 Butyl-benzyl phthalate (BBzP)

 Di-2-propylheptyl phthalate (DPHP)
 Di-butyl phthalate (DBP)
 Di-ethyl phthalate (DEP)
 Di-ethyl-hexyl phthalate (DEHP)
 Di-iso-decyl phthalate (DIDP)
 Di-iso-nonyl phthalate (DINP)
 Di-iso-nonyl-cyclohexane-di-carboxylate (DINCH)
 Endocrine disrupting chemicals (EDCs)
 European Food Safety Authority (EFSA)
 High molecular weight phthalates (HMW)
 Joint Research Centre (JRC)
 Low molecular weight phthalates (LMW)
 Mono-benzyl phthalate (MBzP)
 Mono-carboxy-iso-nonyl phthalate (MCiNP)
 Mono-carboxy-iso-octyl phthalate (MCiOP)
 Mono-carboxy-methyl-hexyl phthalate (MCMHP)
 Mono-ethyl phthalate (MEP)
 Mono-ethyl-carboxy-pentyl phthalate (MECPP)
 Mono-ethyl-hexyl phthalate (MEHP)
 Mono-ethyl-hydroxy-hexyl phthalate (MEHHP)
 Mono-ethyl-oxo-hexyl phthalate (MEOHP)
 Mono-hydroxy-iso-decyl phthalate (MHiDP)
 Mono-hydroxy-iso-nonyl phthalate (MHiNP)
 Mono-n-butyl phthalate (MnBP)
 Mono-oxo-iso-nonyl cyclohexanecarboxylic acid (MOiNCH)
 Mono-oxo-iso-nonyl phthalate (MOiNP)
 National Health and Nutrition Examination Survey (NHANES)
 Polyvinyl chloride (PVC)
 Semi-volatile synthetic chemical compounds (SVOCs)
 Swedish Environmental Longitudinal, Mother and child,
Asthma and allergy study (SELMA-Study)
 The European Chemicals Agency (ECHA)
 The European Union (EU)
 World Health Organization (WHO)

7
Introduction

Importantly, human health depends on a well-functioning endocrine

system to regulate hormones release for our bodily normal functions.
In our fast-paced daily routines, chemicals have become ingrained in
our daily lives. While many of these chemicals were designed to
improve quality of life, concerns relating to how they can affect human
health remain. One group of chemicals included in numerous
commonly used products are substances with properties proven or
suspected to interact with the natural hormone system in humans and
animals, commonly known as endocrine disrupting chemicals (EDCs).

Endocrine disrupting chemicals

EDCs are manmade compounds (there are also natural compounds

with such properties) that can bind to cell receptors and mimic or block
the functions of natural hormones potentially resulting in adverse
human health effects. Many recognized institutions, such as the EFSA
(European Food Safety Authority), the JRC (Joint Research Centre),
the European Parliament, and the European Commission accept and
base their work on the most frequently used definition for endocrine
disruptors (defined by the World Health Organization / International
Programme on Chemical Safety):

"An endocrine disruptor is an exogenous substance or mixture that alters

function(s) of the endocrine system and consequently causes adverse
health effects in an intact organism, or its progeny, or (sub)populations"
(WHO/IPCS 2002).

Increasingly, concerns of EDC exposure during early life have emerged,

with pre- and postnatal milestones contributing to health impacts later
in development. For example, during week 10 of pregnancy, the
embryo becomes a fetus and vital organs (e.g., brain, kidney, and liver)
start to function. During week 27 of the pregnancy, the lungs begin to
develop and will not be functional until several weeks later. If the fetus
is exposed to harmful environmental chemicals during this critical
developmental period, it may result in adverse health effects that may
manifest later in life.

8
Therefore, exposure to chemicals with endocrine disrupting properties
is a growing concern for the fetus, infants, children and adults alike.
One group of EDCs is phthalates.

Phthalates: a hundred year old story

Phthalates is a family of semi-volatile synthetic chemical compounds

(SVOCs) used to increase the properties of plastics such as flexibility,
transparency, durability, and longevity; they are often known as
plasticizers (Graham, 1973). Phthalates also have many other
commercial usages, such as a fragrance carrier (Api, 2001).

Phthalates is a high production volume group of chemicals

Historically, phthalates relate to the development of plastics. The

history of the first synthetic plastic goes back more than 150 years when
Alexander Parkes publicly demonstrated it at the 1862 Great
International Exhibition in London (Cate, 2009). Plastics are mainly
made from oil such as petroleum or natural gas with their rich carbon
chemical structure (Kabasci, 2013). The long carbon molecules, which
are known as polymers, are made up from individual shorter identical
building blocks known as monomers. There are infinite ways of
combining monomers to create an endless variety of plastics with
different properties (Potter et al., 1995). During polymerization, the
process where monomers combine, chemical additives are used for
changing characteristics of the plastic. Phthalates are used in a variety
of ways, most notably as a plasticizer that enables PVC to be more
flexible and subsequently easier to bend into shapes. Phthalates have
been used for the past 70 years in a variety of industrial applications,
including as plasticizers in polyvinyl chloride (PVC) products such as
toys, flooring materials, food packaging, and medical supplies; as well
as in personal care products such as shampoo, lotion, and perfume
(Carlstedt et al., 2013; Rudel et al., 2011; Sathyanarayana et al., 2008;
Wittassek et al., 2011).

A common approach to categorizing phthalates is based on the number

of carbon atoms in the main carbon chains, where different phthalates
with different carbon atom numbers have different physical, chemical
and even toxicological properties:

9
  High molecular weight phthalates (HMW), including di-iso-
nonyl phthalate (DINP), di-iso-decyl phthalate (DIDP), and di-
2-propylheptyl phthalate (DPHP), have more than seven carbon
atoms in their main carbon chain and their water solubility is
very low (National Research Council (US) Committee on the
Health Risks of Phthalates, 2008).
 Low molecular weight phthalates (LMW), such as butyl-benzyl
phthalate (BBzP), di-butyl phthalate (DBP), and di-ethyl-hexyl
phthalate (DEHP), have three to six carbon atoms, and their
water solubility is slightly higher than phthalates with higher
molecular weight (European Chemical Agency, 2016).
 Other phthalates include a group of compounds with the lowest
molecular weight and less than three carbon atoms in the carbon
chain, such as di-ethyl phthalate (DEP). Based on the chemical
structure, this group tends to have a higher volatility and
solubility in water than the HMW and LMW groups (National
Research Council (US) Committee on the Health Risks of
Phthalates, 2008).

The European Chemicals Agency (ECHA) is an Agency of the European

Union and it works for the safe use of chemicals. In the ECHA database
with registered phthalates usage (ton/year) in EU, HMW phthalates
are now predominant on the EU market and have replaced LMW
phthalates in several applications, mainly for toxic and regulation
reasons. In the Swedish chemicals agency KEMI (2015b) report, the
usage of DBP and BBzP was 0 ton/year in 2011 (Table 1).

Human exposure to phthalates

Since phthalates create weak chemical bonds when they are added into
different products, these compounds are readily leached into the
surrounding environment (Bertelsen et al., 2012). For several of the
phthalates, the major exposure route is via food ingestion (Colacino et
al., 2010; Meeker et al., 2009). Some phthalates have also been found
in fatty foods such as fish, oil and dairy products (Cheng et al., 2013;
Sharman et al., 1994). While other studies found phthalates in food that
have been contaminated with its packaging (Cirillo et al., 2011; Fierens
et al., 2012), phthalates (DEHP) have also been added purposely into
sports drink (Yang et al., 2013). Phthalates present in a mother’s body
10
can be transferred to young children via breast milk, while infant
formula contaminated with phthalates during production may also
contribute to infant phthalates exposures (Calafat et al., 2004b; Ge et
al., 2016; Mortensen et al., 2005; Zhu et al., 2006).

Table 1. Phthalate metabolites and its parent compounds, registered use in EU and
amount used in Sweden
Registered use in Amount used in
Molecular
CAS No. Compond Name Category EU Sweden
weight 1 2
(ton / year) (ton/in 2011)
84-66-2 Di-ethyl phthalate (DEP) 222.24 Other 1,000 - 10,000 12
84-74-2 Di-butyl phthalate (DBP) 278.34 1,000 - 10,000 0
LMW
85-68-7 Benzyl butyl phthalate (BBzP) 312.36 1,000 - 10,000 0
(Low molecular weight)
117-81-7 Di-(2-ethylhexyl) phthalate (DEHP) 390.56 100,000 - 1,000,000 446
68515-48-0 Di-isononyl phthalate (DiNP) 418.61 100,000 - 1,000,000 1895
HMW
68515-49-1 Di-isodecyl phthalate (DIDP) 446.66 100,000 - 1,000,000 4826
(High molecular weight)
53306-54-0 Di-(2-propylheptyl) phthalate (DPHP) 446.66 100,000 - 1,000,000 15398
1Europe commission database
2Swedeish Chemical Agency report 2015

Human exposure to phthalates can also occur through the usage of

many personal products containing phthalates, such as hair products,
cosmetics, lotions and perfume (Al-Saleh et al., 2016; Parlett et al.,
2012). Phthalates can be absorbed upon contact with skin or via
inhalation, where the product is dispensed into the air and dust
(Rakkestad et al., 2007).

Furthermore, phthalates are also present in medical devices such as

flexible bag for storing blood, intravenous tubing (Bannai et al., 1987;
Dhanya et al., 2004), or in medications (Hauser et al., 2004). These
can be significant exposure routes for women during childbearing age,
or babies who need to be cared for in intensive care units (Calafat et al.,
2004a; Van Vliet et al., 2011).

Another source of exposure that also has come on the radar for
researchers is sex toys (Biesanz, 2007; KEMI, 2017). Unlike children’s
toy, sex toys are largely unregulated and untested (Biesanz, 2007).
Biesanz (2007) mentioned a study done in 2000 by German chemist
Hans Ulrich Krieg where 10 dangerous chemicals, including DEHP,
were found in sex toys that were available in Europe. DEHP phthalate
was also found in sex toys sold on the Swedish market (KEMI, 2017).

Humans and animals routinely take up phthalates from products and

from the surrounding environment. Once phthalate compounds, such
as the ones listed above, enter the body, they can be hydrolyzed by

11
many enzymes and completely degraded into individual metabolites
(e.g., into monoesters) and further oxidation may also occur, resulting
in oxidative metabolites (Silva et al., 2006).

As a consequence of the extensive exposure described above,

metabolites of phthalates are routinely detected in children’s (S. Langer
et al., 2013) and adult’s urine (Adibi et al., 2009; Adibi et al., 2003;
Duty et al., 2005), blood (Wan et al., 2013), breast milk (Fromme et al.,
2011), and amniotic fluid (Jensen et al., 2012). Studies have further
shown that phthalate exposure varies according to age group, with
typically higher levels in children compared to adults. One exception is
DEP, with higher phthalate metabolite concentration in adult urine
samples compared to children (Gomez Ramos et al., 2016; Silva et al.,
2004).

The degradation half-time for phthalate metabolites in humans are

short, and found to be in the order of hours (Hoppin et al., 2002).
However, although the half time is short, urinary levels in humans
seem to remain stable over time. This is due to what was mentioned
above; humans are exposed to a multitude of products including
phthalates and each can yield varying durations, intensities, and
frequencies of contact with individuals. The only possibility to change
human exposure is when phthalates can be removed from products, by
changing the formula of their product recipe, or when people change
their lifestyles and stop using specific products.

Global health concern for phthalate exposure

Major public health concerns regarding EDCs over the past three
decades have focused on phthalates. In animal tests, these chemicals
(DBP, BBzP, and DEHP) have been proven to have anti-androgenic
effects on offspring, which means that they block male hormones that
guide reproductive development (Borch et al., 2006; Braun et al., 2013;
Foster, 2006; Howdeshell et al., 2007). EDCs are suspected to be
associated with altered reproductive function in males and females,
increased incidence of breast cancer, abnormal growth patterns and
neuro-developmental delays in children, as well as changes in the
immune function (Eisenberg et al., 2011; Kim et al., 2009; Lopez-
Carrillo et al., 2010; Swan et al., 2010).

12
The current regulation on phthalates

In the European Union (EU), the use of some phthalates has been
restricted in children’s toys since 1999 with DEHP, BBzP, and DBP
restricted for all toys, and DINP, DIDP, and Di-n-octyl (DNOP)
restricted in toys that can be put into mouths (Johnson et al., 2011).
This restriction also states that the amount of these phthalates may not
exceed 0.1% mass percent of the plasticized part of the toy (Cate, 2009).

Since 2015, the EU commission has published a new Directive (EU

2015/863) to amend Annex II to EU RoHS 2 (Directive 2011/65/EU)
adding the following four phthalates into the list of restricted
substances:

 DEHP: max 0.1%;

 BBzP: max 0.1%;
 DBP: max 0.1%;
 DIBP: max 0.1%.

They will be restricted from 22 July 2019 for all electrical and electronic
equipment, except from Category 8 (medical devices) and Category 9
(monitoring and control equipment), which will have an additional two
years to comply, by 22 July 2021 (European Union, 2015).

In August 2008, U.S. President George W. Bush signed the Consumer

Product Safety Improvement Act, which became public U.S. law and
included restrictions on phthalate similar to the restrictions in EU
(Moore, 2012):

 It shall be unlawful for any person to manufacture for sale, offer

for sale, distribute in commerce, or import into the United States
any children's toy or child care article that contains
concentrations of more than 0.1 percent of DEHP, DBP, or BBzP.
 It shall be unlawful for any person to manufacture for sale, offer
for sale, distribute in commerce, or import into the United States
any children's toy that can be placed in a child's mouth or child
care article that contains concentrations of more than 0.1
percent of DINP, DIDP, DNOP.

13
Replacements and phthalate alternatives

With an increasing amount of research on the exposure of phthalates

and health risk assessment, more regulations are slowly coming into
use. In parallel, the public has become increasingly concerned about
phthalate exposures and have, in many cases, requested revised
products not including dangerous chemicals. Both these circumstances
have pushed industry to replace banned or questionable molecules in
articles and goods. After banning the usage of DEHP, manufactures
began to replace DEHP with DINP and DIDP (Attina et al., 2015).
During recent years there have been new research results questioning
DIDP and DINP, which initiated the use of an alternative plasticizer
called di-iso-nonyl-cyclohexane-di-carboxylate (DiNCH) introduced
by BASF, a German chemical company (Maag et al., 2010). As per
BASF, DiNCH has been used in medical applications, food contact
applications, and toys. Until 2002, approximately 25,000 tons of it was
produced annually, increasing to 100,000 metric tons annually in
2007, and 200,000 metric tons per year in 2014 (BASF, 2015). Even
though DINCH has been used for more than a decade, data regarding
emissions, human exposure and potential health effects are limited
(Van Vliet et al., 2011).

The full chain model

In order to further understand the health risks related to chemical

exposure, and how to solve such problems, it is useful to employ a ‘full
chain model’ (Figure 1), where chemicals are tracked from their sources
to health risks. In this model sources are characterized by where the
chemical originated, followed by their environmental exposure
pathways (e.g., exposure via air or dust due to leakage from the
sources), and then by analyzing biomarkers we can examine the
quantity taken up by humans. Finally, health risks resulting from
exposure are examined. However, in order to best assess risk and
societal impacts, and thereby ensuring better risk management and
regulations for phthalates and its mixtures, epidemiological data is not
sufficient. In addition, there are modifying factors which are important

14
Figure 1. The life cycle of an endocrine disruptor from source to environmental
exposure to biomarkers, and to human health risks.

to understand (e.g., temperature, relative humidity etc. that can

influence the emission). There are different pathways for human
uptake (e.g., oral, inhalation and dermal) and these uptake pathways
may differ for infants, children, and adults. As well, there are different
biological mechanisms that can explain associations between
exposures and health effects that need to be identified. We need
information from the full chain model to establish relevant and
effective risk assessment of dangerous chemicals.

Research questions for the thesis

This thesis is focusing on phthalate exposure and includes three major

questions at issue:

 To what extent does PVC flooring contribute to the uptake of

phthalates in pregnant women?
 Can replacement of phthalates in products be reflected as
changes in human levels?
 Is exposure to phthalates in early life associated with airway
disorders in children?

15
Aim of the thesis

The overall aim of this thesis is to track phthalates from source to

human health effects as described in the full chain model, and
ultimately identify:

 Important sources for human uptake;

 Time trends in phthalate exposure related to replacement of
phthalates in products; and,
 The importance of phthalate exposure in early life for the
development of airway problems in children.

Method

Epidemiological data from two Swedish population-based cohort

studies, which were conducted in the county of Värmland, were used in
this thesis; the Dampness in Buildings and Health (DBH) study
Bornehag et al. (2004a) and the Swedish Environmental Longitudinal,
Mother and child, Asthma and allergy (SELMA) study (Bornehag et al.,
2012).

The county of Värmland is in west of Sweden with 275,904 residents as

of 2016. Värmland is divided into 16 municipalities, where the county
capital is Karlstad with almost 90,000 inhabitants and the major city
of the county. The research center for both of these cohort studies is
located in Karlstad, at Karlstad University.

The DBH-Study

The DBH-study is a longitudinal investigation with the aim to

investigate the importance of environmental factors – with a specific
focus on indoor-related factors - in early life for the development of
asthma and allergy in children and adolescents. Currently, the DBH-
study consists of four phases:

 DBH I was carried out in the year of 2000 as a baseline

questionnaire-based cross-sectional study. Parents of all
children (N=14,077) aged from 1 to 5 years in the county of
Värmland were invited to participate in a postal questionnaire.
Parents of 10,852 children responded, corresponding to a
16
 response rate of 77% (Larsson et al., 2010). The questionnaire
covered a broad spectrum of issues including family lifestyle,
environmental exposures with special focus on the
characteristics of the home, health of the family and child, and
background information about the family (Bornehag et al.,
2004b). Questions of asthma and allergy in the family and the
child were the same as in the International Study of Asthma and
Allergies in Childhood (ISAAC) concept, which is a worldwide
epidemiological research program established in 1991 to
investigate asthma, rhinitis and eczema in children (Lai et al.,
2009).
 DBH II was a nested cross-sectional, case-control study with a
subset of the DBH I cohort, when the children were 2-6 years of
age (Bornehag et al., 2005). In this study, associations between
persistent allergic symptoms and the concentrations of several
different microbiological as well as chemical exposures in indoor
air and dust were examined. One specific focus was on
phthalates in indoor dust, which was collected from the
children’s bedrooms. Associations between environmental
exposures and health outcomes were examined with a cross-
sectional design including 198 case children with asthma and
allergy and 202 controls without such symptoms. Selection
criteria for the cases were reports of at least two symptoms of
“wheezing during the last 12 months without a cold”; “rhinitis
during the last 12 months without a cold”; and, “eczema during
the last 12 months” (Bornehag et al., 2005).
 DBH III was a 5-year follow-up study, which was conducted in
2005. In this part of the study, questionnaires were sent to the
three youngest age groups (1–3 years) in DBH I who were 6–8
years old at time for investigation (N=7,509). The response rate
was 73% (Larsson et al., 2010). The major focus of this study was
on the health development of the children and the association to
environmental factors at baseline.
 DBH IV was a 10-year follow-up questionnaire study conducted
in 2010. The study was aimed at all children in Värmland, aged
11–15 years (n = 15,043) and their parents. The response rate was
51%. The overall purpose of this follow-up was to identify young
people’s health status and their living conditions, as well as to
17
 provide a better understanding of the indoor environment in
early life, in relation to the development of chronic disease in
children in Värmland.

Figure 2. Description of responses in three phases of the DBH-study; DBH I

(baseline study), DBH III (5 year follow up) and DBH IV (10 year follow
up). Data from DBH I, III, and IV including 3,228 children and their
families.

This current thesis included data from 3,228 children and their
families with data drawn from three datasets: the baseline (DBH I), the
5-year follow-up (DBH III), and the 10-year follow-up (DBH IV) as
shown in Figure 2. By including DBH III in this thesis, we identified
subjects who developed asthma after the 5-year follow-up.

The SELMA Study

The SELMA study was designed to investigate how prenatal exposure

for environmental chemicals – with a major focus on suspected or
proven endocrine disrupting chemicals – may affect health and
development in children. SELMA is a pregnancy cohort study following
mother-child pairs from early pregnancy (first trimester) over birth
and up in school age of the children. Key health domains included
18
metabolism and growth, neurodevelopment, sexual development, and
asthma and allergy. Women who could read Swedish and were not
planning to move out of the county were invited at their first antenatal
care visit; 8,394 pregnant women were identified in the county of
Värmland, 6,658 were eligible and 2,582 agreed to participate
corresponding to a participation rate of 39%. The recruitment of the
2,582 pregnant women started in September 2007 and was finished in
March 2010.

Environmental exposure details and child health information was

collected via questionnaires and analyses of prenatal urine and serum
for the content of phthalate metabolites and other biomarkers.

Questionnaires

Self-administered questionnaires were used to collect information on,

for example, lifestyles, socio-economic status, living conditions, diet
and medical history at different time points. For this thesis we have
used questionnaire data from the time of enrollment (median week 10
of pregnancy) and from two time points during the infancy period (6
and 12 months of age). Questionnaires included background
information such as the health of the child and the family (e.g., asthma,
allergy, croup, otitis media, wheezing), home environmental
characteristics (e.g., flooring material type in bedroom, living location,
dwelling types), mother’s background information (e.g., education,
marital status) and lifestyle of the family (e.g., smoking).

Biomarkers in prenatal urine and serum

Prenatal urine (N=2,325) and blood (serum) (N=2,355) were sampled

at enrollment in early pregnancy and stored frozen in a biobank for
later chemical analyses at the department of occupational and
environmental medicine at Lund University, Lund, Sweden. Samples
were taken at the first visit at the antenatal center (i.e., at enrollment)
which happened in week 3 to 27 of pregnancy (median week 10, and
96% of the samples were taken before week 13 of pregnancy).

Urine samples were collected at home in supplied glass containers and

transferred into polypropylene tubes without any other assisting
equipment for easy transportation. Urine samples were analyzed for
19
metabolites of phthalates and phthalate replacement as shown in Table
2. Aliquots of 0.2 mL of urine were mixed with 0.1 mL of ammonium
acetate (1 M; pH 6.5) and 0.01 mL β-glucoronidase (E-coli), and
thereafter incubated at 37°C for 30 min. Then 0.05 mL of a 50:50 (v:v)
water and acetonitrile solution of labeled (3H or 13C) internal
standards of all analyzed compounds were added and the samples were
analyzed by liquid chromatography-tandem mass spectrometry (LC-
MS/MS; Paper II). DIDP/DPHP will be listed together as these two
metabolites have the same retention time and behave similarly on the
mass spectrometer (Gries et al., 2012). The concentrations of phthalate
metabolites may be affected by urine concentration depending on the
fluid balance. One common approach to compensate for this involves
measurement of the creatinine concentration in the sample (Blount et
al., 2000). Because of this reason, creatinine concentration was also
measured and adjusted for in biostatistical analyses.

Table 2. Metabolites from phthalates and phthalate alternative (DINCH)

compounds that were analyzed in prenatal urine in the SELMA study
Parent
Metabolite
Parent Compound Compound Metabolite
CAS NO
CAS NO
Di-ethyl phthalate (DEP) 84-66-2 Mono-ethyl phthalate MEP 2306-33-4
Di-n-butyl phthalate (DBP) 84-74-2 Mono-butyl phthalate MBP 131-70-4
Butyl-benzyl phthalate (BBzP) 85-68-7 Mono-benzyl phthalate MBzP 2528-16-7
Mono-ethyl-hexyl phthalate MEHP 4376-20-9
Mono-ethyl-hydroxy-hexyl phthalate MEHHP 40321-99-1
Di-ethyl-hexyl phthalate (DEHP) 117-81-7 Mono-ethyl-oxo-hexyl phthalate MEOHP 40321-98-0
Mono-ethyl-carboxy-pentyl phthalate MECPP 40809-41-4
Mono-carboxy-methyl-hexyl phthalate MCMHP 82975-93-7
Mono-hydroxy-iso-nonyl phthalate MHiNP 936021-98-6
Di-iso-nonyl phthalate (DiNP) 68515-48-0 Mono-oxo-iso-nonyl phthalate MOiNP 936022-00-3
Mono-carboxy-iso-octyl phthalate MCiOP 936022-02-5
Di-2-propylheptyl phthalate (DPHP) 53306-54-0 Mono-hydroxy-iso-nonyl phthalate MHiDP NA
Di-iso-decyl phthalate (DiDP) 26761-40-0 Mono-carboxy-iso-nonyl phthalate MCiNP NA
Di-iso-nonyl-cyclohexane-di-carboxylate (DiNCH) 166412-78-8 Mono-oxo-iso-nonyl cyclohexanecarboxylic acid MOiNCH NA

Serum samples were analyzed using liquid chromatography-tandem-

mass-spectrometry (LC/MS/MS). A detailed description of the method
is presented in Lindh et al. (2012). Aliquots of 100 μl serum were added
to 25 μl of a water:acetonitrile (50:50) solution containing labeled
internal standards. Proteins were precipitated by acetonitrile and
vigorously shaking for 30 minutes. The samples were then centrifuged
and the supernatant analyzed using a LC (UFLCXR, SHIMADZU
Corporation, Kyoto, Japan) connected to a hybrid triple quadrupole
linear ion trap mass spectrometer (QTRAP 5500, AB Sciex, Foster City,
CA, USA).

20
In these serum samples, cotinine levels were measured. Cotinine is
commonly used as a biomarker for tobacco smoke exposure. If cotinine
levels were below 0.2 ng/mL, subjects were categorized as non-smoker;
if cotinine levels were greater than 15 ng/mL, subjects were considered
as active smokers; and while in between, subjects were considered as
passive smokers (Jefferis et al., 2010).

Biostatistical analyses and modeling

Univariate analyses were performed, and we examined the following

characteristics for each variable: the distribution (summary of the
frequency of individual values or ranges of values for a variable) and
the central tendency (mean, median, geometric mean (GM)) and a 95%
confidence interval (CI).

To take individual differences in urine dilution into consideration,

creatinine corrections were applied in two different ways. To be able to
compare urine metabolite levels with other studies, traditional
creatinine adjustments were applied to individual metabolite
concentrations (Table 2). In the Least square geometric mean (LSGM)
models, we used creatinine as a co-factor since creatinine may be
related to individual characteristics. Due to skewness, all urinary levels
of metabolites were log-transformed (10-log) to improve the
approximation of a normal distribution.

Distributions of urinary EDCs levels were also expressed using

geometric means estimated in LSGM. With this method, it was possible
to adjust for potential confounders (Vaillant et al., 2007). The specific
adjustment variables used in each analysis are further described below
and in the papers. LSGM was calculated in PROC GLM in SAS version
9.3 of the SAS System for Windows. Copyright © 2012, SAS Institute
Inc. Cary, NC, USA.

Correlation analysis (Pearson) was applied to identify the correlation

between phthalates (log transformed and creatinine adjusted
concentrations). It was calculated in PROC CORR in SAS version 9.3 of
the SAS System for Windows. Copyright © 2012, SAS Institute Inc.
Cary, NC, USA. Urinary creatinine concentration was used to adjust for
urinary dilution across different individuals.

21
Associations between different environmental and health effects were
estimated by crude and adjusted odds ratios (ORs and aORs). Logistic
regression analysis was carried out using SPSS for Windows (V.19.0;
IBM Corp, Armonk, NY, USA) for Paper I and PROC LOGISTIC in SAS
version 9.3 of the SAS System for Windows. Copyright © 2012, SAS
Institute Inc. Cary, NC, USA.

To avoid confounding, different adjustments were made in different

bio-statistical analyses. Generally, this was done by including potential
confounders in multivariate models and analyses. The selection of
potential confounders – to be included in the models - were generally
done by including variables that were significantly (p<0.05) associated
with outcome variable and/or the exposure. Here is an overview of
adjustments in the final models:

 Paper I relates to the association between PVC flooring in the

home in childhood and health outcome in children. The variables
adjusted for in paper I were age and sex of the child, allergies
(asthma, eczema, and/or rhinitis) in the family (father, mother,
and siblings), smoking in the family (father, mother, siblings,
and others), single parent households where the child live with
one adult only, and housing types (multifamily house, single-
family house), which were collected at the baseline (DBH I).
 Paper II relates to PVC flooring as a source for phthalate uptake
in pregnant women. The variables adjusted for in paper II were
mother’s age, mother’s smoking status, mother’s education level,
and creatinine in urine (mmol/L).
 Paper III relates to time trends in urinary levels of phthalate
metabolites in pregnant women. The variables adjusted for in
paper III were mother’s age, education, body weight, and
smoking, as well as season for sampling, and creatinine in urine
(mmol/L).
 Paper IV relates to the association between prenatal phthalate
exposure and airway problems in children. The factors adjusted
for were age of the mother, education level of the mother, history
of asthma in the family, sex of the child, smoking for the mother
during early pregnancy (serum levels of cotinine in early
pregnancy), and creatinine in urine (mmol/L).

22
Because of potential correlations between different phthalate
metabolites that occur together, traditional regression methods may
suffer from collinearity effects, when compounds are investigated one
by one. Such correlation can be because the same metabolites share
various sources (e.g., consumer products and articles). In order to solve
this problem, we used weighted quantile sum (WQS) regression, which
is a recently proposed method by Carrico et al. (2015). The benefit of
using WQS is that while considering the correlation between
compounds, generalized inference about the mixture effect can be
made and individual chemicals with the most significant contributions
can be identified. WQS regression was used in paper IV. The analysis
was conducted using PROC GLM in SAS version 9.3 of the SAS System
for Windows. Copyright © 2012, SAS Institute Inc. Cary, NC, USA.

Ethical approval

The DBH-study was approved by the medical ethics committee at

Örebro University, Sweden, (DBH I) and Uppsala University (DBH IV).
Regional Ethical Review Board, Uppsala, Sweden, approved the
SELMA study. Signed informed consents were obtained.

Result and discussion

PVC flooring in home as a source for human uptake of phthalates

Polyvinyl chloride, commonly abbreviated as PVC, is the world’s third

most widely produced synthetic plastic polymer (Allsopp et al., 2000).
The pure PVC is rigid, but with the help of plasticizers such as
phthalates, PVC can be made soft and flexible for use in products such
as cable insulation, toys, floorings and many other applications (Latini
et al., 2010).

Most PVC floorings are manufactured by combining phthalates with

PVC powder to form a liquid paste known as “plastisol” (KEMI, 2015a).
The flooring normally comprises a foam core and a decorative and
protective layer (KEMI, 2015a). PVC flooring is known for its easy
installation, easy care, easy cleaning, and durability at lower price point
(The European Council of Vinyl Manufacturers, n.d.). While lower
quality PVC flooring may last less than 10 years, higher quality PVC

23
flooring can be warrantied for up to 30 years or more (The European
Council of Vinyl Manufacturers, n.d.).

The Swan is the official Nordic ecolabel, which was introduced by the
Nordic Council of Ministers. As per its document about floor covering,
wood flooring and plastic flooring are the most popular flooring types
in Sweden (The Swan ecolabel, 2014). In 2012, 5.7 million plastic
flooring were sold in Sweden, however, most of the production of the
flooring industry has shut down in Sweden and just one large flooring
manufacture remains (KEMI, 2015a). Our data in DBH and SELMA
shows that approximately 30 - 40% of the homes (between 2000 and
2010) have PVC flooring in at least one of the bedrooms of the home
(paper I and paper II).

One major question often posed relates to the importance of PVC

materials in the home, such as PVC flooring, for human uptake of
phthalates. In the SELMA study we have data from the time of
enrollment of the pregnant women, which allows us to closely examine
the indoor environment as a possible major update pathway. Data were
collected pertaining to the type of flooring in the home of the families
via the use of questionnaires, in parallel with prenatal urine that was
analyzed for phthalate metabolites.

The association between type of flooring in the home and urinary levels
of phthalate metabolites were analyzed for pregnant women in a cross-
sectional design including 1,658 women for which we had data for all
included variables for the biostatistical modeling.

With a compound-by-compound approach, urinary metabolite levels

of DBP (MBzP), BBzP (MBzP), and DEHP (MECPP) were significantly
higher overall when PVC flooring were used in the home, compared to
other flooring materials, as reported in paper II. Such significant
differences in phthalate metabolite levels were found even when
adjusting for potential confounders using LSGM regression. Data
showed that the more rooms with PVC-flooring in home, the higher
LSGM levels of phthalate metabolites in the pregnant women (Figure
3). Regarding the other phthalates, DEP, DINP, DIDP and DINCH, no
significant difference in metabolite levels could be found in relation to
the use of PVC flooring in home.

24
Figure 3. Least square geometric mean levels (95% CI) of MnBP, MBzP, and
MECPP in urine (log scale) in relation to flooring material in 1,658 homes.
Adjustments made for mother’s age, mother smoking status, education,
dwelling type, marital status and creatinine. Adjusted overall significance
for trends is marked with a p-value (*<0.05, **<0.01, ***<0.001).

As pointed out earlier one problem is that different metabolites are

correlated as shown in Table 3. One reason for such correlations could
be that metabolites are sharing sources. For example, MBzP were
significantly correlated with metabolites from DEHP (p<0.001), as well
as from MBP (p<0.001), and MBP and MBzP was also significantly
associated (p<0.001). To consider such correlations, the material was
analyzed with WQS regression.

When all examined 14 phthalate metabolites were analyzed in a WQS

model together with potential confounders, and with PVC flooring as
dependent variable, we found significant associations (p<0.0001).
From the WQS analyses, we found that PVC flooring in the home was
related to urinary levels of the MBzP metabolite and MOiNCH
metabolite. MBzP and MOiNCH contributed more than 80% and 10%
respectively to the model, whereas the contributions from DEHP
metabolites were less than 5% (Figure 4).

25
Our results show that analyses with a traditional logistic regression
model with a compound by compound approach, and with a mixture
model conducted in a WQS regression model revealed similar results
regarding PVC flooring as a determinant for urinary levels of MBzP.
The importance for DEHP metabolites, however, was disappearing and
the DINCH metabolite appeared in the WQS analyses.
Table 3. Correlations between urinary levels of phthalates and phthalate
alternative metabolites expressed as Pearson correlation coefficient and
significance level (p-value) calculated on log transformed urinary
concentrations controlled for creatinine (N=1,658).
MEP MBP MBzP MEHP MEHHP MEOHP MECCP MCMHP MHiNP MOiNP MCiOP MHiDP MCiNP
1
DEP MEP
0.13 1
DBP MBP
***
0.06 0.54 1
BBzP MBzP
** ***
0.09 0.37 0.34 1
MEHP
*** *** ***
0.10 0.40 0.35 0.83 1
MEHHP
*** *** *** ***
0.09 0.42 0.37 0.83 0.99 1
DEHP MEOHP
*** *** *** *** ***
0.07 0.35 0.32 0.78 0.92 0.93 1
MECCP
*** *** *** *** *** ***
0.07 0.25 0.23 0.68 0.87 0.85 0.85 1
MCMHP
*** *** *** *** *** *** ***
0.07 0.19 0.16 0.32 0.40 0.39 0.39 0.28 1
MHiNP
*** *** *** *** *** *** *** ***
0.08 0.25 0.20 0.39 0.46 0.45 0.45 0.32 0.95 1
DiNP MOiNP
*** *** *** *** *** *** *** *** ***
0.05 0.13 0.09 0.24 0.31 0.30 0.37 0.27 0.91 0.90 1
MCiOP
* *** *** *** *** *** *** *** *** ***
-0.02 0.16 0.13 0.21 0.23 0.23 0.19 0.13 0.21 0.24 0.18 1
DIDP MHiDP
0.36 *** *** *** *** *** *** *** *** *** ***
/
-0.01 0.06 0.07 0.12 0.16 0.15 0.25 0.20 0.47 0.43 0.57 0.13 1
DPHP MCiNP
0.60 ** *** *** *** *** *** *** *** *** *** ***
-0.02 0.16 0.13 0.21 0.23 0.23 0.19 0.13 0.21 0.24 0.18 1.00 0.13
DINCH MOiNCH
0.36 *** *** *** *** *** *** *** *** *** *** *** ***

Our findings regarding PVC flooring as a source for human levels of

MBzP are supported from other studies. Earlier data from the SELMA
study showed in cross-sectional data that PVC-flooring in the home
were related to higher urinary levels of phthalate metabolites in 83
infants (2-6 months of age). Carlstedt et al. (2013) found that urinary
levels of MBzP were significantly (p<0.007) higher among infants with
PVC flooring in their bedroom when compared to other flooring
materials. However, no significant associations were found for DEHP
metabolites in that study. Shu et al. (In Manuscript) found a significant
association between urinary MBzP concentration and soft PVC flooring
in a living room (p<0.0001) and bathroom (p=0.005) in a study on
1,539 Canadian children (2- 3 months of age) in the CHILD study.
Another study from a cohort of 239 children (5 years of age) in New

26
York City found that children from homes with PVC or linoleum
flooring had significantly higher urinary MBzP concentration than
other children Just et al. (2015). To our knowledge, there is no study
focusing on the importance of PVC for uptake of DINCH.

Figure 4. Phthalates and one phthalate alternative (DiNCH) metabolites (in

prenatal urine) that were found to be associated with self-reported PVC
floorings in the home at the time of urine sampling expressed as a
contribution to the model (weight) in percent, estimated by WQS
regression. The models are adjusted for mother’s age, mother smoking
status, education, dwelling type, marital status and creatinine (N=1,658).

This is the first study where the associations between urinary phthalate
metabolite levels and the existence of PVC flooring at home were
examined with both a traditional compound by compound approach,
as well as a mixture (WQS) method. By using WQS method, this
approach addressed issues that arise with the correlated factors.

Our finding that PVC flooring may be a source for uptake of BBzP
metabolites in pregnant women raise concern for several reasons. First,
BBzP is under regulation and is classified as reproduction toxic
category 1B (i.e., substances presumed to have carcinogenic potential
for humans). Furthermore, BBzP cannot be used for any application
within the EU without permission after 2015 (ECHA, 2016). Another
concern is that PVC flooring material is very common in Sweden
(around 30% - 40% of Swedish homes have PVC flooring). However,
while the use of BBzP as a plasticizer is most likely on the decrease,
27
time trend data in human urinary levels of MBzP does not show that
trend (see chapter 4.2 below). It is notable that PVC is not overly
popular in other countries in North America and Europe. However, one
global commonality is the usage of such flooring material in public
facilities such as health care unit, schools, and daycare centers because
of its unique properties such as durability, long lasting, and easy to
clean (The European Council of Vinyl Manufacturers, n.d.).

One limitation with these analyses is that we do not have data on the
age of the PVC flooring. This means that we cannot distinguish between
the PVC floorings with older phthalates such as DEHP and PVC
floorings and newer phthalates, such as DINCH. Since phthalates are
SVOCs, one of many properties of SVOC is that SVOCs tend to be in the
absorbed phase, and not in gas phase. Therefore, while with the unique
properties of added phthalates in the PVC flooring, the high material
phase concentration and low emission rate make the PVC flooring
relatively constant and stable over time. With newly installed PVC
flooring in a home, the emission is slow. Over time the concentration
of emitted phthalate indoors will plateau. Plasticizers such as DEHP
inhibit the degradation of the PVC polymer when they migrate to the
surface. When it is absorbed by other material, PVC discolors and fall
apart. This raises the concern of long-term human phthalate exposure
with intact aged PVC floorings in home.

Time trends for human levels of phthalates

Already in 1986, the U.S. EPA categorized DEHP as a "probable human

carcinogen" (U.S. EPA, 1988). The U.S. Consumer Product Safety
Commission, also in 1986, asked manufacturers to voluntarily remove
or reduce concentrations of DEHP in toys (U.S. EPA, 1988). Starting in
1997, Danish authorities found what they considered to be
unacceptable levels of DINP leaching from various PVC teething rings
imported from China. As a result, these products were voluntarily
withdrawn from the Danish market, pending for further evaluations
(Wilkinson et al., 1999). However, one would suspect the real
substitution of phthalates started several years after the
implementation of the regulations.

28
Since 1999, regulations around phthalates have been closely followed
by the global market. As mentioned earlier, in the European market,
the HMW phthalates (e.g., DiNP, etc.) currently dominate and they
have in several applications replaced the LMW phthalates (e.g., DBP,
BBzP, DEHP) (KEMI, 2015b). Many Swedish companies have replaced
DEHP with DIDP, DINP, and DPHP (KEMI, 2015b). In 2006, the
European Food Safety Authority (EFSA) approved DINCH for a wide
variety of food contact applications. DINCH compounds have been
used to replace DEHP and DINP (Crespo et al., 2007).

Following the substitution of phthalates in PVC and the timeline above,

we can categorize phthalates and phthalate alternatives used as
plasticizers into three groups:

 Old phthalates that have been used for long time, such as DEHP,
DBP, and BBzP;
 Newer phthalates that were introduced (in the late 1990s) in
order to substitute the old phthalates, such as DINP, DIDP, and
DPHP; and,
 Non phthalate compounds (phthalate replacements) were
introduced around 2005, such as DINCH.

One outstanding question in relation to the substitution that has

occurred is whether it impacts for human uptake. Or in other words, if
molecules are replaced in PVC flooring and other soft PVC materials,
can we see any changes of urinary levels over time of metabolites
related to original compounds and their substitutes. This question was
possible to examine by the use of SELMA data since we can analyze
time trends in urinary levels of phthalate metabolites over a period of
2.5 years when the pregnant women were recruited.

The study population for the current analysis is 1,651 women for which
we have data for all included variables in the biostatistical modelling,
where we have used LSGM analyses adjusted for potential confounding
variables.

Temporal trends from LSGM analyses of urinary levels for 14 phthalate

metabolites were observed as shown in Figure 5. The general findings
were that the older phthalates are on a decreasing trend mainly

29
including DEHP metabolites, while the newer phthalates are increasing
including DiNP and DiDP/DPHP metabolites, and the phthalate
replacement is also increasing with an even faster rate, including the
DINCH metabolite MOiNCH. More specifically, we found:

 A statistically significant downward temporal trends (p<0.0001)

in the urinary levels of all DEHP metabolites MEHP, MEHHP,
MEOHP, MEHHP, and MCMHP were found. When we consider
2007 as the baseline year, the levels of all DEHP metabolites
decreased approximately by 16% (p<0.001) on average over the
sampling period (2007-2010);
 A continuous increase in the urinary excretion of DiNP and
DiDP/DPHP metabolites, where the LSGM concentrations
increased by approximately 34-41% when compared with the
first period; and,
 A strong increase in levels of the metabolite from the phthalate
replacement DINCH (MOiNCH), during the 2.5-year period
(p<0.001). Concentrations of MOiNCH metabolite increased
38% (p<0.0001) in 2008, 109% (p<0.0001) in 2009, and 223%
(p<0.0001) in 2010.

When analyzing the metabolites of DEP (MEP), DBP (MBP), and BBzP
(MBzP) we could not find any significant changes during the 2.5-year
period.

Our findings of decreasing and increasing trends are partly supported

by other studies. The phthalate temporal trends identified here are in
part similar to findings from National Health and Nutrition
Examination Survey (NHANES) and the German Environmental
Specimen Bank. Concentrations of MEP, MnBP, MBzP and the DEHP
metabolites were significantly lower in 2009-2010 than in 2001-2002,
and exposure to phthalate-based replacements, such as DiNP,
increased (Zota et al., 2014), while the monitored urinary metabolite
levels of the non-phthalate-based replacement MOiNCH increased
dramatically during 1999-2012 (Schutze et al., 2014).

One rather remarkable finding is that and BBzP metabolite levels in

urine didn´t change significantly over the study period of 2.5 years
since both these compounds are under regulation and on restriction

30
Figure 5. Urinary levels of phthalate metabolites (estimated by LSGM with 95%
CIs) during four periods from 2007 to 2010 in 1,651 pregnant women in the
SELMA study; 271 samples were included from 2007, 683 samples in 2008,
593 samples in 2009 and 104 samples in 2010. The model adjusted for
urinary creatinine, mothers age (years), season (winter vs. summer),
mother’s education (university vs. other), and PVC flooring in a bedroom
(yes vs. no). DEHP metabolites trend (p<0.001) are in red, DiNP
metabolites trend (p<0.01) are in yellow, and the DINCH metabolite trend
(p<0.001) is in blue.

lists. Other studies found the significantly negative temporal trends for
MnBP, and MBzP (Gyllenhammar et al., 2017; Zota et al., 2014). One
reason for this difference could be the use of a shorter sampling period
in our data.

Our findings regarding DEHP, DiNP and DINCH are in line with the
current regulation patterns in Sweden, as reported by KEMI (2011).
The usage of DEHP and DiNP in PVC was changed between 2002 and
2005. The production of DEHP was reduced from 12,272 tons in 1999
to 2,732 tons in 2002, while DiNP increased from 452 tons to 8,246
tons during the same period. This substitution process has continued
throughout the past several years, although to a much lower extent. The
use of DINCH in Sweden increased by 47 times between 2011 and 2012,

31
from 427 tons to 20 077 tons (KEMI, 2014). In 2012, the registered
amount of DINCH according to the product register was only 40
percent lower than the total amount of phthalates recorded (KEMI,
2014). However, KEMI (2011) report that the usage of BBzP in PVC has
reduced from 1,268 in 1994 tons to 19 tons in 2008, which was not
reflected in our time trend data.

The finding that metabolite of older phthalates (used in soft PVC)

decrease in human urine and those metabolites of newer ones increase
indicates that regulations and substitutions of chemicals can have an
impact on human phthalate exposure. However, regarding DBP and
BBzP no changes over time could be seen, but it should be emphasized
that the study period was rather short.

Early life exposure to phthalates and airway problems in children

Asthma is one of the most common chronic diseases in the world,

especially among children. The causes of the increasing asthma
incidence during recent decades remain mainly unknown; however, a
combination of complex environmental and genetic interactions is
considered (Miller and Ho 2008, Bush 2015). During the past decade,
there have been several studies suggesting that the rising trend in
asthma prevalence might have reached a plateau (van Aalderen, 2012).

Epidemiological evidence is suggesting that early life exposure to

several phthalates increases the risk for childhood asthma (Bornehag
et al., 2010; Braun et al., 2013). Bornehag et al. (2010) listed the
conclusion that epidemiological studies provide indications for a
relationship between phthalates exposures and asthma in children.
Braun et al. (2013) concluded in the review that studies suggest fetal
and childhood exposure to some phthalates may perturb normal
development, with several studies consistently reporting increased risk
of allergic diseases with DEHP and BBzP exposure.

However, asthma is difficult to diagnose in during infancy and younger

years since specific tests are limited, the diagnosis is mainly based on
unspecific signs and symptoms. Furthermore, during infancy the
prediction of future asthma disease is even more difficult. Still,
respiratory tract inflammatory responses constitute a major burden of

32
disease during infancy. Assessments of environmental exposures
could, therefore, be extended from relationships with asthma to
include other clinical measures in early life. Wheeze is such a
recognizable clinical symptom that also has been shown to be
associated with the development of asthma later in life (Jackson et al.,
2008). Other inflammatory morbidities and early life conditions
providing relevant proxies of significant airway inflammatory response
may include viral croup and otitis media, which are upper respiratory
tract infections (Cetinkaya et al., 2001; Janson et al., 2007; Moussa et
al., 1996; Nicolai et al., 1996; Van Bever et al., 1999).

The following results from two studies are presented: one relating to
the importance of PVC flooring in childhood and development of
doctor diagnosed asthma during 10 years with data from the DBH-
study (Paper I), and one study on prenatal exposure for phthalates and
the importance for airway symptoms/diseases such as wheezing and
croup in infants in the SELMA study (Paper IV).

PVC flooring and incidence of asthma

In this study, we have used questionnaire data from the DBH-study

including 3,228 children in a longitudinal design. Analyses showed that
children, who had PVC floorings in the bedroom when they were 1-5
years of age (baseline), were more likely to develop doctor-diagnosed
asthma during the following 10-year period compared to children
living without PVC flooring (Figure 6). It should be noted that children
that had asthma already at baseline were excluded from the analyses to
identify incident asthma during the study period.

Subjects who had PVC flooring in the parents’ bedrooms, but not the
child’s bedroom at baseline were at higher risk of developing asthma
compared to subjects who had PVC flooring in child’s bedrooms but not
in parents’ bedroom. One possible explanation of this association with
parents’ bedrooms could be that the flooring in the parents’ bedroom
at the time of the baseline questionnaire in most of the cases represents
the situation during the pregnancy period. This could then indicate the
exposure situation for the pregnant women. For the children who at
baseline had lived in the same location since birth, PVC flooring in the
parents′ bedroom was significantly associated with having doctor-

33
Figure 6. Association between parental reported doctor-diagnosed asthma at
follow-ups (5 and 10 years) and PVC flooring in the home in childhood at
baseline, extracted by rooms and expressed as adjusted odds ratio and 95%
CI.

diagnosed asthma, whereas this association was not seen for the child’s
bedroom.

Our finding regarding a significant association between PVC flooring

and airway diseases in children have also been shown by others. In a
matched pair case-control study, which was based on the Oslo Birth
cohort during a period of 15 months in 1992 and 1993, Jaakkola et al.
(1999) reported that the risk of bronchial obstruction was related to the
presence of PVC flooring (aOR=1.89, 95% CI: 1.13 - 3.14) during the
first two years of children’s life. In a Finnish study of children aged 7 to
12 years, Jaakkola et al. (2000) reported that lower respiratory tract
symptoms persistent wheezing (OR=3.42, 95% CI=1.13, 10.36), cough
(OR=2.41, 95%; CI = 1.04, 5.63), and phlegm (OR = 2.76, 95% CI=1.03,
7.41), were associated with the presence of plastic wall materials,
whereas upper respiratory symptoms were not. In 2008, Jaakkola et al.
(2008) concluded, after reviewed 27 human and 14 laboratory
toxicology studies, that epidemiologic studies in children show
associations between indicators of phthalate exposure in the home and
risk of asthma and allergies. Jaakkola et al. (2004) reported in a cross-
sectional study of 5951 8-12-year-old school children, that risk of
current asthma, wheezing, and allergy were related to recent
renovation and the installation of materials, and that new linoleum
flooring, synthetic carpeting, particleboard, wall coverings, and
34
furniture and recent painting were determinants of one or several of
these three health outcomes. Oie et al. (1999) reported in a Norwegian
matched case-control study following newborns for 2 years (where 172
case children with bronchial obstruction and control series were one-
to-one matched for date of birth) that the presence of PVC materials
increased the risk of bronchial obstruction in children. In a population-
based cross-sectional study involved 2,568 Finish children aged 1 to 7
years, lower respiratory tract symptoms – persistent wheezing, cough,
and phlegm – were associated with the presence of plastic wall
materials (Jaakkola et al., 2000). In the DBH-study with a cross-
sectional design, PVC flooring in the child´s bedroom was associated
with allergic symptoms in children (Bornehag et al., 2004b). In the 5
years follow-up of the DBH-study, Larsson et al. (2010) reported that
parentally reported PVC flooring in the child’s, as well as in the parent’s
bedroom, at baseline when the children were 1–3 years of age was
significantly associated with incident asthma in children 5 years later.
A cross-section study of 2,740 children age 1 to 8 years of age from
Korea reported that a combination of floor moisture and PVC flooring
increased the prevalence rate of wheeze (AOR = 3.0) (Choi et al., 2014).

Prenatal phthalate exposure and croup during infancy

In this study (paper IV) we have used data from the SELMA study
including 1,062 children with data on prenatal phthalate exposure and
parental reports of airway problem when they were 12 months old.
Approximately, 9.5%, 29.6% and 15.4% of the SELMA children were
reported to suffer from croup, wheezing, and otitis media respectively
during their first 12 months of age, and boys were reported to exhibit
more croup, wheeze and otitis media than girls have.

When we analyzed prenatal phthalate exposure, we found significant

associations between prenatal urinary concentration of BBzP and
DEHP metabolites and croup in infants during their first year of life.
We found significant associations even when adjustments were made
for potential confounders (Figure 7). These associations were stronger
for boys when compared with girls (Paper IV). The associations
between prenatal exposure to BBzP and DEHP metabolites and croup
were also seen when the phthalate metabolites concentration was
categorized in quartiles, suggestive of a dose-response relationship.
35
Figure 7: Association between prenatal urinary levels (log-transformed) of 14
phthalate metabolites (analyzed one by one) and parental reports of croup
in children at 12 months of age, expressed as Odds Ratio (95% CI) adjusted
for sex, mothers education, mother´s age, asthma in the family, smoking
and creatinine in urine.

The level of DiNP phthalate metabolite (MHiNP) in prenatal urine was

significantly associated with wheezing, which was only found in girls.
However, this result was not consistent throughout different analyses,
and in the dose-response analysis the trend was not clear.

No significant associations could be found between prenatal phthalate

exposure and otitis media in the children during their first year of life,
and no associations could be found for other phthalate metabolites.

The prevalence of croup (9.5%) during the child´s first year of the
current study is slightly lower than the approximately 15% that were
reported in other studies (Bjornson et al., 2013; Charles et al., 2010;
Everard, 2009). However, this difference could be due to the fact that
children in the referred studies were slightly older; in the range of 6 to
36 months with a peak during the second year of life (Everard, 2009).

Our results indicate that prenatal exposure for phthalates can be a risk
factor for airway inflammatory response to viral infection during
infancy in offspring. However, to our knowledge no other studies have
focused on this issue and the biological mechanisms behind such a
potential association are largely unknown. Reinforcing the importance

36
of our present findings, other studies showed an association between
early life infections or inflammatory responses (including croup) and
asthma later in childhood (Nicolai et al., 1996; Van Bever et al., 1999).
Van Bever et al. (1999) investigated the cumulative incidence of croup
and recurrent croup by using ISAAC questionnaire in a group of 5,756
of 5-8-year-old children in Antwerp, Belgium. Van Bever et al. (1999)
reported croup and recurrent croup are associated with bronchial
asthma, where the association essentially based on the presence of
hyperactive airways.

Even if the picture is quite unclear for croup, more data have found an
association between prenatal exposure for BBzP and asthma and other
allergic problems in children. Compared to children of mothers with
MBzP concentrations in the first tertile, Whyatt et al. (2014) found
relative risk for a history of asthma-like symptoms among those in the
second tertile was 1.25 (95% CI: 0.94, 1.65). Just et al. (2012) reported
that MBzP was associated positively with any report of eczema by 24
months (RR = 1.52; 95% CI: 1.21, 1.91; p < 0.001, n = 113/376) after
adjusting for specific gravity, sex, and race/ethnicity. Ku et al. (2015)
identified that in boys, there was a significant association between the
prevalence of ever wheezing and a maternal MBzP concentration
greater than the 80th percentile (aOR = 4.95; 95% CI: 1.08–22.63). Hsu
et al. (2012) showed that urinary metabolite, MBzP, was found to be
higher in asthmatics compared to that of control subjects.

Overall discussion of the findings

This thesis identified soft PVC used in flooring material as a source for
uptake of BBzP in pregnant women (Paper II), a finding supported by
several other studies. The thesis further revealed that substitution of
phthalates in soft PVC has an impact on urinary levels of such phthalate
metabolites (Paper III), also reported in other studies. Finally, this
thesis showed the use of PVC flooring in childhood to be a risk factor

37
Figure 8: Three papers of the thesis are put into the full chain model following
phthalates (mainly BBzP) from sources over environmental exposures to
human levels and finally to airway problems in children.

for the development of asthma during the following 10 years (Paper I),
and that prenatal exposure for BBzP and DEHP was related to croup in
infants (Paper IV). The finding that the use of PVC can be related to
airway problems in children has been reported by others, and some
studies have also reported prenatal BBzP exposure to be associated to
airway problems in children.

Using the earlier introduced full chain model, we will hereby put the
thesis results into a larger context to discuss how chemicals in a
building material – exemplified here by PVC flooring – can be related
to health outcomes in children (Figure 8). We will focus on BBzP since
this compound has been identified as a critical phthalate in several
aspects in the thesis. The scientific knowledge is consistent with the
basic structure of the full chain model:

38
 Sources: By far, evidence has shown that BBzP is extensively
used as plasticizers in soft PVC such as flooring materials, toys,
etc., to improve the flexibility and workability of the material
(Akovali, 2007; Koch et al., 2005; National Toxicology, 2003;
Wittcoff et al., 2013; Yeang et al., 2010).
 Environmental exposures: Consistent global data have
shown that independent of where a dust sample is collected
indoors, BBzP and other phthalates will be present. Numerous
studies have shown that BBzP and other phthalates can be
identified in both dust and air in homes and other environments
such as day care centers and schools. Sarka Langer et al. (2010)
analyzed dust samples collected from 500 bedrooms and 151
daycare centers of children (ages 3 to 5 years) in Denmark, and
found that BBzP was detected in 82% of the bedrooms and in
96% of the daycare centers. Furthermore, Adibi et al. (2003)
indicated BBzP was 100% detectable in personal air samples of
two populations of pregnant women in New York (N=30) and
Krakow (N=30). Just et al. (2015)found that BBzP was found in
100% of the dust samples from 239 children in New York City.
In the Swedish DBH study, it was found detectable levels of BBzP
in 79% of 346 dust samples (Bornehag et al., 2005).
 Human uptakes (biomarkers): Consistent global data is
showing that metabolites from BBzP and other phthalates can be
identified in the urine of the general population, including
pregnant women, infants, children, and adults. Data from 2,540
NHANES subjects, which focused on the U.S. general population
greater than 6 years of age, found that phthalate metabolites
were 97% detectable (Silva et al., 2004). In Australia, Gomez
Ramos et al. (2016) reported that phthalate metabolites MBzP
were 100% detected in their pooled urine samples where
subjects’ age ranged from 0 to >60. Shu et al. (In Manuscript)
reported that MBzP was detected 70% in urine samples from 3
months old infants in Canada. In Sweden, MBzP was detected in
100% of the urine samples from 83 children age groups of 2 and
6 months (Carlstedt et al., 2013). Despite this, the most common
method of identifying recent exposures to phthalates was using
urine samples (studies have also measured phthalate
metabolites in breast milk). Main et al. (2006) examined 130
39
 breast milk samples, which were collected from a prospective
Danish–Finnish cohort study (1997 – 2001) and found that
MBzP metabolites were detected in 100% of the samples. In a
Swedish study of 42 mothers who delivered their first child at the
University Hospital in Lund, Sweden, it was found that MBzP
metabolite were detected in 100% of the samples (Hogberg et al.,
2008). Phthalates have also been found in cord blood, amniotic
fluid and saliva (Silva et al., 2005; Tranfo et al., 2014). Silva et
al. (2005) showed that saliva contains enzymes capable of
hydrolyzing phthalate di-esters into their respective monoesters,
and that MBzP was 44% detectable in 39 saliva samples and 30%
of 155 serum samples from adults in U.S. Analyses of amniotic
fluid samples (N=70) that were donated by pregnant women
undergoing routine amniocentesis in Italy, showed that MBzP
metabolites were detected in 79% of the samples (Tranfo et al.,
2014).

There is obviously scientific data showing that phthalates can be found

in different building materials and other products (sources), in indoor
air and dust (environmental exposures), and in human fluids mainly
measured in urine (human uptake). To better understand the full
chain, we will further focus our examination on the role of indoor dust
and air.

Leakage of phthalates from PVC to indoor dust

Our finding in paper II that the use of PVC flooring relates to urinary
levels of BBzP metabolites in the pregnant women (Figure 8) can most
likely be explained by leakage of the compound from PVC materials to
the surrounding environment (and therefore found in indoor air and
dust), and then taken up by humans (Bi et al., 2015). The Swedish
DBH-study showed that PVC flooring in the home was significantly
related to levels of BBzP in indoor dust, with the more rooms with PVC
materials on the floors in the home, the higher levels of BBzP in the
indoor dust (Bornehag et al., 2005). Another study from Bulgaria
showed that the use of polishing products was also significantly
associated with the concentration of BBzP in the indoor dust (Kolarik
et al., 2008).

40
Phthalates in indoor air and dust and the relation to human levels

In a study by Adibi et al. (2003) significant correlations were found

between BBzP in personal air samples and urinary levels of MBzP (r =
0.65, p < 0.01), DBP (r = 0.58, p < 0.01), and DEP (p = 0.42, p < 0.05),
where each subject was enrolled during pregnancy at prenatal clinics
in New York and Krakow. Adibi et al. (2008) reported further
significant association between BBzP in indoor air and MBzP in urine
(r = 0.71, p < 0.0001) and between BBzP in personal air and MBzP in
urine (r = 0.48, p < 0.0001) during pregnancy. Beko et al. (2013), found
significant (p<0.001) positive correlations between BBzP in dust
samples and MBzP metabolite in urine samples that were collected
from 431 children between 3 and 6 years of age. Hsu et al. (2012)
reported a significant correlation between BBzP in settled dust
collected from surfaces above the floor and MBzP (p=0.03)
concentration in Danish children (3-9 years old) urine. Furthermore,
BBzP in dust collected from the children's bedrooms and daycare
centers significantly correlated with the concentrations MBzP in the
children's (3-6 years old) urine in data from Denmark (S. Langer et al.,
2013). Finally, a study of 243 children in New York at the age of 5 years
old, found that BBzP in collected indoor air samples was positively
correlated to the urinary metabolite concentrations (Just et al., 2015).

Phthalates in indoor dust and the association to airway problems

With dust samples collected from 346 children’s bedroom, Bornehag et

al. (2004b) indicated cross sectional associations between indoor dust
exposure and allergic outcomes in young children. Cases with
physician-diagnosed rhinitis or eczema had higher BBzP
concentrations in the bedroom dust compared with controls. In
Bulgaria, the concentration of BBzP was higher in the homes of
children (N=102) with wheezing and eczema (both in the preceding 12
months), though not significantly higher (Kolarik et al., 2008). In a
study that sampled settled dust from the homes of 101 children (3-9
years old), in addition to the children’s corresponding urinary
metabolites, Hsu et al. (2012) reported that a significant dose-
dependent effect (P-value for trend <0.05) was found between levels of
BBzP in settled dust and the risk for being diagnosed as “case”, where
cases were children who had at least two or more parent-reported
41
respiratory and allergic diseases (asthma, allergic rhinitis) or
symptoms (wheezing, coughing at night, eczema, sneezing, runny or
stuffy nose) during the preceding 12 months.

The full chain for BBzP

When the data in the current thesis is put into greater perspective by
using the full chain model in described in Figure 8, and in the context
of other available evidence, the following is suggested;

 Phthalates, and especially BBzP, used as plasticizers in PVC

flooring material can leak to the surrounding environment, and
therefore be found in indoor air and dust;
 Phthalates in indoor air and dust can be taken up by humans,
and therefore found as biomarkers in urine and other human
fluids in both pregnant women, infants and adults; and,
 Phthalates exposure – both at given levels in indoor air and dust
and as biomarkers in pregnant women – increase the risk for
airway problems in children.

If early life exposure for phthalates and especially BBzP and DEHP are
risk factors for development of airway diseases in children, it is of
course of the greatest importance to understand which biological
mechanism that can explain such associations. Several phthalates, and
especially BBzP and DEHP have been found to have anti-androgenic
properties, meaning that they may interact with the natural hormone
system in humans and animals with adverse health effects as a possible
result; however, it is not clear if that is a mechanism of relevance for
airway diseases in children. With the current thesis as a ground, we
have no possibility to examine this issue. The result presented in this
thesis, calls for further research into possible biological mechanisms.

The thesis have shown that we can follow at least one phthalate, butyl
benzyl phthalate, from sources to environmental exposures in indoor
air and dust, and further to uptake in humans and measured as urinary
levels, and finally to airway problems in children by the use of a full
chain model. The thesis further reports that substitution of chemicals
in soft PVC where e.g., DEHP have been replaced by other phthalates
such as DiNP and DiNCH can be reflected as changes in urinary levels

42
in pregnant women over time. We have finally reported that exposure
for phthalates in early life may increase the risk for airway disorders in
children, and discussed that indoor air and dust may play a role for
such associations. However, the biological mechanism explaining why
such exposure should be related to airway problems in children is
unclear and was not the focus of this thesis.

Ethics consideration

All participants participated freely and were eligible to withdraw at any

time from the two presented cohort studies. Participants of SELMA
study provided informed consent prior to their participation. Since
DBH study is a questionnaire based study, no consent form was
distributed. However, participants were informed about the study and
freely to participate. Informed permissions were also obtained from
participants for their unborn child (SELMA).

One of the most basic ethical principles of epidemiology is the moral

obligation to cause no harm to participants (Ahrens et al., 2005), and
both DBH and SELMA research teams took participant privacy issues
seriously. Due to the nature of these two studies, follow-up
questionnaires and biological samples collection were required, and
individual personal identifiers were also collected. Hard copy files
containing personal identifiers were stored in a secured, locked
location. Further, digital data is stored in a secured network drive,
which only authorized personnel has the access. Removal of personal
identifiers and generation of random identifiers are done prior to
distribution of data for analysis.

Since 2012, the SELMA study research team has organized annual open
houses with the purpose to better communicate research information
to participants. Such events can bring the individual-level awareness of
environmental chemicals, allowing individuals the opportunity to
discuss and seek the answers for the questions they may have.

A public Health concern

Staggering results between exposure to phthalates and airway health

issues were reported in this thesis. These results should raise concerns
on the impact of phthalates on human health. However, relative to
43
acute occupational toxic exposure, currently reported environmental
exposure levels are low. Observed effect on individual level could be
subtle and not considered as an overt effect. However, these subtle
individual effects can be an indicator of a future risk to overt disease.
Asthma is one of the major non-communicable, chronic diseases, and
it is a common in children and considered a major public health issue.

In U.S., asthma is also one of the leading causes of school absenteeism.

According to the latest WHO report in 2017, approximately 383,000
deaths attribute to asthma in 2015. Preventing the triggering of asthma
can reduce the severity of asthma development. In 2015, U.S. Centers
for Disease Control and Prevention reported that the asthma
prevalence was approximately 8.4% in children and 7.6% in adults, and
subsequent health care and social costs of asthma are substantial.
Suijkerbuijk et al. (2013) recently reported an approximate annual cost
of € 17.3 billion in EU, and EDC-attributable cost was approximately €
1.73 billion in 2007. While this thesis was limited to airway related
health issues, there is a long list of EDC-related health effects. Legler et
al. (2015) reported that phthalate-attributable female adult obesity and
diabetes were approximately € 15.6 and € 607 million, respectively, in
the EU.

Our data indicates that policy can predict exposure. For many long-
term disease (e.g., asthma) that has no current cure, minimizing
exposure of EDCs such as phthalates could decrease the disease
burden.

Conclusion

With data from two Swedish cohort studies, we followed phthalates

from its sources, to human uptakes, to subsequently identify airway
issues in children. During this process, we illustrated the decreasing
trend of phthalates under strict regulations and how uses of its
replacement are increasing. The full chain model in this thesis helped
us to better understanding the life cycle of phthalates. It could be a
fruitful method to contribute to the risk assessment of other EDCs in
the future.

44
Living in a fast-paced life, we have unknowingly exposed ourselves and
our children to chemicals that may harm human health. Our senses are
not geared toward detecting the underlying dangers, but there are
things we can do that can better protect ourselves and our next
generation:

 Suggestion: Increasingly, consumers are exhibiting prudence

and caution when it comes to the food they eat by asking, and in
some cases demanding, to know the ingredients in food
products. Similarly, by raising the same question when it comes
to the products that go into our home whether it contains
phthalate, can make a difference.

As we’ve shown, the ongoing regulations on phthalates have also been

reflected on human uptakes, which means that a small change can
make a difference; we as the end users of these products can also make
small changes in our choices to possibly make a difference in our own
health. We also have responsibility to protect future generations.

45
ACKNOWLEDGEMENTS

My PhD scholarship was financially supported by Karlstad University

and FORMAS (the Swedish Research Council for Environment,
Agricultural Sciences and Spatial Planning).

While my name may be alone on the front cover of this thesis, I am by

no means its sole contributor. Rather, there are a number of people
behind this piece of work who deserve to be both acknowledged and
thanked here: kind participants; committed supervisors; generous
research advisory group members; an inspiring mentor (who lead me
here) and my fantastically supportive family and friends.

I would like to express my deepest gratitude to my co-supervisor

Professor Bo A. Jönsson, who tragically passed away on November 24th,
2016. It was harder for me to carry on without your support, however,
you left me with many great tools. Professor Jönsson was a curious,
diligent, detail oriented scientist, who inspired me scientific thinking,
and provided me unflagging patience and support. It is your shining
example that I try to emulate in all that I do. Thank you Bosse! Your
scientific contribution and smile will be missed.

I am forever indebted to my academic supervisors, Professor Carl-

Gustaf (CG) Bornehag, Professor Eewa Nånberg and Dr. Åke Svensson,
for their enthusiasm, guidance, and unrelenting support throughout
this five years of rocky road. They have routinely gone beyond their
duties to fire fight my worries, concerns, and anxieties, and have
worked to instill great confidence in both myself and my work. CG has
been supportive and has given me the freedom to pursue various
projects without objection. He has also provided insightful discussions
about the research. I hope that I could be as lively, enthusiastic, and
energetic as CG and to someday be able to command an audience as
well as he can. I am also very grateful to Professor Eewa Nånberg for
her scientific advice and knowledge, many insightful discussions and
suggestions both professionally and personally. I also have to thank Dr.
Åke Svensson for always being there and provide me with helpful
advice and suggestions.

46
I will forever be thankful to my former Canadian supervisor (during my
undergraduate and graduate school period), Dr. Tim K. Takaro, who
lead me here. Tim has been helpful in providing advice many times
during my graduate school career. He was and remains my best role
model for a scientist, researcher, mentor, and teacher. I still think
fondly of my time as a research assistant in his lab. His enthusiasm and
quest for knowledge is contagious. Thank you for always being there
for me. You're always there when I need a hand pushing me, helping
me.

I am very grateful to have Dr. Staffan Janson’s support throughout this

process in all aspects. You were my “go-to person” at several critical
period in my life both professionally and personally. Thank you for
your great advice and suggestions.

I would also like to thank Dr. Sverre Wikström, who provided tons of
much needed medical guidance in one of the manuscripts.

Completing this work would have been all the more difficult were it not
for the support I received from physician, nurses, and emergency
attendances at Vancouver General Hospital (VGH), Vancouver, Canada
in 2014 and 2015. As well as the aftercare and support I received from
Landstinget i Värmland, Karlstad, Sweden. Thank you all for the care
and support.

I also thank the wonderful staff in the Public Health as well as in other
departments at Karlstad University for always being so helpful and
friendly. People here are genuinely nice and want to help me out and
I’m glad to have interacted with many. If I have forgotten anyone, I
apologize.

I also thank my friends (too many to list here but you know who you
are!) for providing support and friendship that I needed. I would like
to thank my dearest colleague and friend Dr. Malin Knutz (AKA:
Mother ) for being supportive throughout my time here and for
checking up on me regularly. I think of her and her family as my
“Swedish family”. I will never forget our New York, Copenhagen, and
Spain trips, I’m sure there will be more laughs to come in the future. I
would especially like to thank Pyry Hämäläinen, the “flower boy”,
workout buddy, event planning buddy…, It was such an honored for me
47
to be a part of your wedding day. Thank you for always being there for
me, during the ups and downs. I am very thankful for Dr. Daniel
Nyqvist’s quick advice and suggestions on this thesis with a short
timeline. Thank you Daniel for the memorable trip to China, where I
learned so much about fish . A special appreciation to Jason Curran.
Jason was the one who was there for me during the thesis writing hell
to help me quickly proofread and give suggestions. I truly thank Daniel
Meron, who provided me with the ability to find the “sanctuary” as an
escape from stress out of my control. Thank you for not only teaching
me to swim, but also making me a better person. I would especially like
to thank Jane and Steve. Thank you Jane for giving me those
memorable trips we had, I can’t wait to have more adventures with you
again. Thank you Steve for provide me with this great book cover with
minimum verbal information. You are very talented artist who can read
my mind. 

A special thanks to my family. Words cannot express how grateful I am

to my mother, my father, my sister and my brother-in-law. It has been
quite a difficult couple of years, but we made it through and I’m sure
we are much stronger now in all aspects. To my angel, Bruce. I would
like to express my thanks for being such a good boy always cheering me
up.

48
REFFERENCES

Adibi, J. J., Hauser, R., Williams, P. L., Whyatt, R. M., Calafat, A. M.,
Nelson, H., . . . Swan, S. H. (2009). Maternal urinary metabolites of Di-
(2-Ethylhexyl) phthalate in relation to the timing of labor in a US
multicenter pregnancy cohort study. American Journal of
Epidemiology, 169(8), 1015-1024.

Adibi, J. J., Perera, F. P., Jedrychowski, W., Camann, D. E., Barr, D.,
Jacek, R., & Whyatt, R. M. (2003). Prenatal exposures to phthalates
among women in New York City and Krakow, Poland. Environ Health
Perspect, 111(14), 1719-1722.

Adibi, J. J., Whyatt, R. M., Williams, P. L., Calafat, A. M., Camann, D.,
Herrick, R., . . . Hauser, R. (2008). Characterization of phthalate
exposure among pregnant women assessed by repeat air and urine
samples. Environ Health Perspect, 116(4), 467-473.

Ahrens, W., & Pigeot, I. (2005). Handbook of epidemiology. Berlin:

Springer.

Akovali, G. (2007). Plastics, Rubber and Health. Shrewsbury, UK:

Smithers Rapra Press.

Al-Saleh, I., & Elkhatib, R. (2016). Screening of phthalate esters in 47

branded perfumes. Environmental Science and Pollution Research,
23(1), 455-468.

Allsopp, M., Santillo, D., & Johnston, P. (2000). Hazardous Chemicals

in PVC Flooring. Retrieved from
http://greenpeace.to/publications/pvc_flooring.pdf

Api, A. M. (2001). Toxicological profile of diethyl phthalate: a vehicle

for fragrance and cosmetic ingredients. Food Chem Toxicol, 39(2), 97-
108.

Attina, T. M., & Trasande, L. (2015). Association of Exposure to Di-2-

Ethylhexylphthalate Replacements With Increased Insulin Resistance
in Adolescents From NHANES 2009–2012. J Clin Endocrinol Metab,
100(7), 2640-2650.

Bannai, M., Mazda, T., Ishikawa, Y., & Sasakawa, S. (1987). The effect
of di-(2-ethylhexyl)phthalate, a chemical leached from blood bags, on
platelet adenosine diphosphate aggregability. Chem Pharm Bull
(Tokyo), 35(10), 4328-4331.

49
BASF. (2015). The trusted non-phthalate plasticizer Retrieved from
http://www.plasticizers.basf.com/portal/load/fid255202/Hexamoll%
C2%AE%20DINCH%C2%AE%20-%20the%20trusted%20non-
phthalate%20plasticizer.pdf

Beko, G., Weschler, C. J., Langer, S., Callesen, M., Toftum, J., &
Clausen, G. (2013). Children's phthalate intakes and resultant
cumulative exposures estimated from urine compared with estimates
from dust ingestion, inhalation and dermal absorption in their homes
and daycare centers. PLoS One, 8(4), e62442.

Bertelsen, R. J., Carlsen, K. C., Calafat, A. M., Hoppin, J. A., Haland,

G., Mowinckel, P., . . . Lovik, M. (2012). Urinary Biomarkers for
Phthalates Associated with Asthma in Norwegian Children. Environ
Health Perspect, 121(2), 251-256.

Bi, C., Liang, Y., & Xu, Y. (2015). Fate and Transport of Phthalates in
Indoor Environments and the Influence of Temperature: A Case Study
in a Test House. Environ Sci Technol, 49(16), 9674-9681.

Biesanz, Z. (2007). Dildos, Artificial Vaginas, and Phthalates: How

Toxic Sex Toys Illustrate Broader Problem for Consumer Protection.
Law and Inequality: Journal of Theory and Practice, 25(1), 203-226.

Bjornson, C. L., & Johnson, D. W. (2013). Croup in children. CMAJ:

Canadian Medical Association Journal = Journal De L'association
Medicale Canadienne, 185(15), 1317-1323.

Blount, B. C., Milgram, K. E., Silva, M. J., Malek, N. A., Reidy, J. A.,
Needham, L. L., & Brock, J. W. (2000). Quantitative detection of eight
phthalate metabolites in human urine using HPLC-APCI-MS/MS. Anal
Chem, 72(17), 4127-4134.

Borch, J., Axelstad, M., Vinggaard, A. M., & Dalgaard, M. (2006).

Diisobutyl phthalate has comparable anti-androgenic effects to di-n-
butyl phthalate in fetal rat testis. Toxicol Lett, 163(3), 183-190.

Bornehag, C. G., Lundgren, B., Weschler, C. J., Sigsgaard, T.,

Hagerhed-Engman, L., & Sundell, J. (2005). Phthalates in Indoor Dust
and Their Association with Building Characteristics. Environ Health
Perspect, 113(10), 1399.

Bornehag, C. G., Moniruzzaman, S., Larsson, M., Lindstrom, C. B.,

Hasselgren, M., Bodin, A., . . . Janson, S. (2012). The SELMA study: a
birth cohort study in Sweden following more than 2000 mother-child
pairs. Paediatr Perinat Epidemiol, 26(5), 456-467.

50
Bornehag, C. G., & Nanberg, E. (2010). Phthalate exposure and asthma
in children. Int J Androl, 33(2), 333-345.

Bornehag, C. G., Sundell, J., & Sigsgaard, T. (2004a). Dampness in

buildings and health (DBH): Report from an ongoing epidemiological
investigation on the association between indoor environmental factors
and health effects among children in Sweden. Indoor Air, 14 Suppl 7,
59-66.

Bornehag, C. G., Sundell, J., Weschler, C. J., Sigsgaard, T., Lundgren,

B., Hasselgren, M., & Hagerhed-Engman, L. (2004b). The association
between asthma and allergic symptoms in children and phthalates in
house dust: a nested case-control study. Environ Health Perspect,
112(14), 1393-1397.

Braun, J. M., Sathyanarayana, S., & Hauser, R. (2013). Phthalate

exposure and children's health. Curr Opin Pediatr, 25(2), 247-254.

Calafat, A. M., Needham, L. L., Silva, M. J., & Lambert, G. (2004a).

Exposure to di-(2-ethylhexyl) phthalate among premature neonates in
a neonatal intensive care unit. Pediatrics, 113(5), e429-434.

Calafat, A. M., Slakman, A. R., Silva, M. J., Herbert, A. R., & Needham,
L. L. (2004b). Automated solid phase extraction and quantitative
analysis of human milk for 13 phthalate metabolites. J Chromatogr B
Analyt Technol Biomed Life Sci, 805(1), 49-56.

Carlstedt, F., Jonsson, B. A., & Bornehag, C. G. (2013). PVC flooring is

related to human uptake of phthalates in infants. Indoor Air, 23(1), 32-
39.

Carrico, C., Gennings, C., Wheeler, D., & Factor-Litvak, P. (2015).

Characterization of Weighted Quantile Sum Regression for Highly
Correlated Data in a Risk Analysis Setting. Journal of Agricultural,
Biological, and Environmental Statistics, 20(1), 100-120.

Cate, M. T. (2009). The birth of plastic. ICIS Chemical Business,

275(20), 26-27.

Cetinkaya, F., & Turgut, S. (2001). The relation between recurrent

acute subglottic laryngitis and asthma in children. International
Journal Of Pediatric Otorhinolaryngology, 57(1), 41-43.

Charles, J., Britt, H., & Fahridin, S. (2010). Croup. Aust Fam Physician,
39(5), 269-269.

51
Cheng, Z., Nie, X.-P., Wang, H.-S., & Wong, M.-H. (2013). Risk
assessments of human exposure to bioaccessible phthalate esters
through market fish consumption. Environ Int, 57–58, 75-80.

Choi, H., Byrne, S., Larsen, L. S., Sigsgaard, T., Thorne, P. S., Larsson,
L., . . . Bornehag, C. G. (2014). Residential culturable fungi, (1-3, 1-6)-
beta-d-glucan, and ergosterol concentrations in dust are not associated
with asthma, rhinitis, or eczema diagnoses in children. Indoor Air,
24(2), 158-170.

Cirillo, T., Fasano, E., Castaldi, E., Montuori, P., & Amodio Cocchieri,
R. (2011). Children's exposure to Di(2-ethylhexyl)phthalate and
dibutylphthalate plasticizers from school meals. J Agric Food Chem,
59(19), 10532-10538.

Colacino, J. A., Harris, T. R., & Schecter, A. (2010). Dietary intake is

associated with phthalate body burden in a nationally representative
sample. Environ Health Perspect, 118(7), 998-1003.

Crespo, J. E., Balart, R., Sanchez, L., & López, J. (2007). Substitution
of di(2-ethylhexyl) phthalate by di(isononyl) cyclohexane-1,2-
dicarboxylate as a plasticizer for industrial vinyl plastisol formulations.
Journal of Applied Polymer Science, 104(2), 1215-1220.

Dhanya, C. R., Gayathri, N. S., Mithra, K., Nair, K. V., & Kurup, P. A.
(2004). Vitamin E prevents deleterious effects of di (2-ethyl hexyl)
phthalate, a plasticizer used in PVC blood storage bags. Indian J Exp
Biol, 42(9), 871-875.

Duty, S. M., Calafat, A. M., Silva, M. J., Ryan, L., & Hauser, R. (2005).
Phthalate exposure and reproductive hormones in adult men. Hum
Reprod, 20(3), 604-610.

Eisenberg, M. L., Hsieh, M. H., Walters, R. C., Krasnow, R., &

Lipshultz, L. I. (2011). The relationship between anogenital distance,
fatherhood, and fertility in adult men. PLoS One, 6(5), e18973.

European Chemical Agency, E. (2016). Background document for 1,2-

benzenedicarboxylic acid, dihexyl ester, branched and linear.
Retrieved from
https://echa.europa.eu/documents/10162/13640/7th_recom_final_
backgdoc_benzenedicarboxylic_acid_dihexyl_ester_en.pdf

European Union. (2015). COMMISSION DELEGATED DIRECTIVE

(EU) 2015/863, amending Annex II to Directive 2011/65/EU of the
European Parliament and of the Council as regards the list of restricted

52
substances. Retrieved from http://eur-lex.europa.eu/legal-
content/EN/TXT/?uri=CELEX:32015L0863

Everard, M. L. (2009). Acute bronchiolitis and croup. Pediatr Clin

North Am, 56(1), 119-133, x-xi.

Fierens, T., Servaes, K., Van Holderbeke, M., Geerts, L., De Henauw,
S., Sioen, I., & Vanermen, G. (2012). Analysis of phthalates in food
products and packaging materials sold on the Belgian market. Food
Chem Toxicol, 50(7), 2575-2583.

Foster, P. M. (2006). Disruption of reproductive development in male

rat offspring following in utero exposure to phthalate esters. Int J
Androl, 29(1), 140-147; discussion 181-145.

Fromme, H., Gruber, L., Seckin, E., Raab, U., Zimmermann, S.,
Kiranoglu, M., . . . Hbmnet. (2011). Phthalates and their metabolites in
breast milk--results from the Bavarian Monitoring of Breast Milk
(BAMBI). Environ Int, 37(4), 715-722.

Ge, W. P., Yang, X. J., Wu, X. Y., Wang, Z., Geng, W., & Guo, C. F.
(2016). Phthalate residue in goat milk-based infant formulas
manufactured in China. J Dairy Sci, 99(10), 7776-7781.

Gomez Ramos, M. J., Heffernan, A. L., Toms, L. M., Calafat, A. M., Ye,
X., Hobson, P., . . . Mueller, J. F. (2016). Concentrations of phthalates
and DINCH metabolites in pooled urine from Queensland, Australia.
Environ Int, 88, 179-186.

Graham, P. R. (1973). Phthalate ester plasticizers--why and how they

are used. Environ Health Perspect, 3, 3-12.

Gries, W., Ellrich, D., Kupper, K., Ladermann, B., & Leng, G. (2012).
Analytical method for the sensitive determination of major di-(2-
propylheptyl)-phthalate metabolites in human urine. J Chromatogr B
Analyt Technol Biomed Life Sci, 908, 128-136.

Gyllenhammar, I., Glynn, A., Jonsson, B. A., Lindh, C. H., Darnerud, P.

O., Svensson, K., & Lignell, S. (2017). Diverging temporal trends of
human exposure to bisphenols and plastizisers, such as phthalates,
caused by substitution of legacy EDCs? Environ Res, 153, 48-54.

Hauser, R., Duty, S., Godfrey-Bailey, L., & Calafat, A. M. (2004).

Medications as a source of human exposure to phthalates. Environ
Health Perspect, 112(6), 751-753.

53
Hogberg, J., Hanberg, A., Berglund, M., Skerfving, S., Remberger, M.,
Calafat, A. M., . . . Hakansson, H. (2008). Phthalate diesters and their
metabolites in human breast milk, blood or serum, and urine as
biomarkers of exposure in vulnerable populations. Environ Health
Perspect, 116(3), 334-339.

Hoppin, J. A., Brock, J. W., Davis, B. J., & Baird, D. D. (2002).

Reproducibility of urinary phthalate metabolites in first morning urine
samples. Environ Health Perspect, 110(5), 515-518.

Howdeshell, K. L., Furr, J., Lambright, C. R., Rider, C. V., Wilson, V. S.,
& Gray, L. E., Jr. (2007). Cumulative effects of dibutyl phthalate and
diethylhexyl phthalate on male rat reproductive tract development:
altered fetal steroid hormones and genes. Toxicol Sci, 99(1), 190-202.

Hsu, N. Y., Lee, C. C., Wang, J. Y., Li, Y. C., Chang, H. W., Chen, C. Y.,
. . . Su, H. J. (2012). Predicted risk of childhood allergy, asthma, and
reported symptoms using measured phthalate exposure in dust and
urine. Indoor Air, 22(3), 186-199.

Jaakkola, J. J., & Knight, T. L. (2008). The role of exposure to

phthalates from polyvinyl chloride products in the development of
asthma and allergies: a systematic review and meta-analysis. Environ
Health Perspect, 116(7), 845-853.

Jaakkola, J. J., Oie, L., Nafstad, P., Botten, G., Samuelsen, S. O., &
Magnus, P. (1999). Interior surface materials in the home and the
development of bronchial obstruction in young children in Oslo,
Norway. Am J Public Health, 89(2), 188-192.

Jaakkola, J. J., Parise, H., Kislitsin, V., Lebedeva, N. I., & Spengler, J.
D. (2004). Asthma, wheezing, and allergies in Russian schoolchildren
in relation to new surface materials in the home. Am J Public Health,
94(4), 560-562.

Jaakkola, J. J., Verkasalo, P. K., & Jaakkola, N. (2000). Plastic wall

materials in the home and respiratory health in young children. Am J
Public Health, 90(5), 797-799.

Jackson, D. J., Gangnon, R. E., Evans, M. D., Roberg, K. A., Anderson,

E. L., Pappas, T. E., . . . Lemanske, R. F., Jr. (2008). Wheezing
rhinovirus illnesses in early life predict asthma development in high-
risk children. Am J Respir Crit Care Med, 178(7), 667-672.

Janson, C., Kalm-Stephens, P., Foucard, T., Alving, K., & Nordvall, S.
L. (2007). Risk factors associated with allergic and non-allergic asthma
in adolescents. Clin Respir J, 1(1), 16-22.

54
Jefferis, B. J., Lawlor, D. A., Ebrahim, S., Wannamethee, S. G.,
Feyerabend, C., Doig, M., . . . Whincup, P. H. (2010). Cotinine-assessed
second-hand smoke exposure and risk of cardiovascular disease in
older adults. Heart, 96(11), 854.

Jensen, M. S., Norgaard-Pedersen, B., Toft, G., Hougaard, D. M.,

Bonde, J. P., Cohen, A., . . . Jonsson, B. A. (2012). Phthalates and
perfluorooctanesulfonic acid in human amniotic fluid: temporal trends
and timing of amniocentesis in pregnancy. Environ Health Perspect,
120(6), 897-903.

Johnson, S., Saikia, N., & Sahu, R. (2011). Phthalates in toys available
in Indian market. Bull Environ Contam Toxicol, 86(6), 621-626.

Just, A. C., Miller, R. L., Perzanowski, M. S., Rundle, A. G., Chen, Q.,
Jung, K. H., . . . Whyatt, R. M. (2015). Vinyl flooring in the home is
associated with children/'s airborne butylbenzyl phthalate and urinary
metabolite concentrations. J Expos Sci Environ Epidemiol, 25(6), 574-
579.

Just, A. C., Whyatt, R. M., Miller, R. L., Rundle, A. G., Chen, Q., Calafat,
A. M., . . . Perzanowski, M. S. (2012). Children's urinary phthalate
metabolites and fractional exhaled nitric oxide in an urban cohort. Am
J Respir Crit Care Med, 186(9), 830-837.

Kabasci, S. (2013). Bio-Based Plastics : Materials and Applications:

Wiley.

KEMI, S. C. A. (2011). PVC - Turnover of the biggest thermoplastics.

Retrieved from
http://www3.kemi.se/en/Content/Statistics/Statistics-in-
brief/Statistics-in-brief---Substances-and-substance-groups/PVC/

KEMI, S. C. A. (2015a). Hälsoskadliga kemiska ämnen i byggprodukter

– förslag till nationella regler. Retrieved from
https://www.kemi.se/global/rapporter/2015/rapport-8-15-
halsoskadliga-kemiska-amnen-i-byggprodukter.pdf

KEMI, S. C. A. (2015b). Phthalates which are toxic for reproduction

and endocrine-disrupting – proposals for a phase-out in Sweden.
Retrieved from https://www.kemi.se/global/rapporter/2015/report-
4-15-phatalates.pdf

KEMI, S. C. A. (2017). Tillsyn av sexleksaker - Rapport från ett

tillsynsprojekt 2016. Retrieved from
http://www.kemi.se/global/tillsyns-pm/2017/tillsyn-1-17-tillsyn-av-
sexleksaker.pdf

55
Kim, B. N., Cho, S. C., Kim, Y., Shin, M. S., Yoo, H. J., Kim, J. W., . . .
Hong, Y. C. (2009). Phthalates exposure and attention-
deficit/hyperactivity disorder in school-age children. Biol Psychiatry,
66(10), 958-963.

Koch, H. M., Preuss, R., Drexler, H., & Angerer, J. (2005). Exposure of
nursery school children and their parents and teachers to di-n-
butylphthalate and butylbenzylphthalate. Int Arch Occup Environ
Health, 78(3), 223-229.

Kolarik, B., Naydenov, K., Larsson, M., Bornehag, C. G., & Sundell, J.
(2008). The association between phthalates in dust and allergic
diseases among Bulgarian children. Environ Health Perspect, 116(1),
98-103.

Ku, H. Y., Su, P. H., Wen, H. J., Sun, H. L., Wang, C. J., Chen, H. Y., . .
. Group, T. (2015). Prenatal and postnatal exposure to phthalate esters
and asthma: a 9-year follow-up study of a taiwanese birth cohort. PLoS
One, 10(4), e0123309.

Lai, C. K. W., Beasley, R., Crane, J., Foliaki, S., Shah, J., & Weiland, S.
(2009). Global variation in the prevalence and severity of asthma
symptoms: Phase Three of the International Study of Asthma and
Allergies in Childhood (ISAAC). Thorax, 64(6), 476-483.

Langer, S., Beko, G., Weschler, C. J., Brive, L. M., Toftum, J., Callesen,
M., & Clausen, G. (2013). Phthalate metabolites in urine samples from
Danish children and correlations with phthalates in dust samples from
their homes and daycare centers. Int J Hyg Environ Health, 217(1), 78-
87.

Langer, S., Weschler, C. J., Fischer, A., Bekö, G., Toftum, J., & Clausen,
G. (2010). Phthalate and PAH concentrations in dust collected from
Danish homes and daycare centers. Atmos Environ, 44(19), 2294-
2301.

Larsson, M., Hagerhed-Engman, L., Kolarik, B., James, P., Lundin, F.,
Janson, S., . . . Bornehag, C. G. (2010). PVC--as flooring material--and
its association with incident asthma in a Swedish child cohort study.
Indoor Air, 20(6), 494-501.

Latini, G., Ferri, M., & Chiellini, F. (2010). Materials degradation in

PVC medical devices, DEHP leaching and neonatal outcomes. Curr
Med Chem, 17(26), 2979-2989.

Legler, J., Fletcher, T., Govarts, E., Porta, M., Blumberg, B., Heindel, J.
J., & Trasande, L. (2015). Obesity, diabetes, and associated costs of

56
exposure to endocrine-disrupting chemicals in the European Union. J
Clin Endocrinol Metab, 100(4), 1278-1288.

Lindh, C. H., Rylander, L., Toft, G., Axmon, A., Rignell-Hydbom, A.,
Giwercman, A., . . . Jonsson, B. A. (2012). Blood serum concentrations
of perfluorinated compounds in men from Greenlandic Inuit and
European populations. Chemosphere, 88(11), 1269-1275.

Lopez-Carrillo, L., Hernandez-Ramirez, R. U., Calafat, A. M., Torres-

Sanchez, L., Galvan-Portillo, M., Needham, L. L., . . . Cebrian, M. E.
(2010). Exposure to phthalates and breast cancer risk in northern
Mexico. Environ Health Perspect, 118(4), 539-544.

Maag, J., Lassen, C., Brandt, U. K., Kjølholt, J., Molander, L., &
Mikkelsen, S. H. (2010). Identification and assessment of alternatives
to selected phthalates. Retrieved from
http://www2.mst.dk/udgiv/publications/2010/978-87-92708-00-
7/pdf/978-87-92708-01-4.pdf

Main, K. M., Mortensen, G. K., Kaleva, M. M., Boisen, K. A., Damgaard,

I. N., Chellakooty, M., . . . Skakkebaek, N. E. (2006). Human breast
milk contamination with phthalates and alterations of endogenous
reproductive hormones in infants three months of age. Environ Health
Perspect, 114(2), 270-276.

Meeker, J. D., Hu, H., Cantonwine, D. E., Lamadrid-Figueroa, H.,

Calafat, A. M., Ettinger, A. S., . . . Tellez-Rojo, M. M. (2009). Urinary
phthalate metabolites in relation to preterm birth in Mexico city.
Environ Health Perspect, 117(10), 1587-1592.

Moore, C. (2012). Plastic Ocean: How a Sea Captain's Chance

Discovery Launched a Determined Quest to Save the oceans.

Mortensen, G. K., Main, K. M., Andersson, A. M., Leffers, H., &

Skakkebaek, N. E. (2005). Determination of phthalate monoesters in
human milk, consumer milk, and infant formula by tandem mass
spectrometry (LC-MS-MS). Anal Bioanal Chem, 382(4), 1084-1092.

Moussa, M. A., Skaik, M. B., Yaghy, O. Y., Salwanes, S. B., & Bin-
Othman, S. A. (1996). Factors associated with asthma in school
children. Eur J Epidemiol, 12(6), 583-588.

National Research Council (US) Committee on the Health Risks of

Phthalates. (2008). 2. Phthalate Exposure Assessment in Humans
Phthalates and Cumulative Risk Assessment: The Tasks Ahead.
Washington (DC): National Academies Press (US).

57
National Toxicology, P. (2003, Apr). NTP-CERHR Monograph on the
Potential Human Reproductive and Developmental Effects of Di-n-
Butyl Phthalate (DBP). NTP CERHR MON. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/15995736

Nicolai, T., & Mutius, E. v. (1996). Risk of asthma in children with a

history of croup. Acta Pædiatrica, 85(11), 1295-1299.

Oie, L., Nafstad, P., Botten, G., Magnus, P., & Jaakkola, J. K. (1999).
Ventilation in homes and bronchial obstruction in young children.
Epidemiology, 10(3), 294-299.

Parlett, L. E., Calafat, A. M., & Swan, S. H. (2012). Women's exposure

to phthalates in relation to use of personal care products. J Expo Sci
Environ Epidemiol, 23(2), 197-206.

Potter, N. N., & Hotchkiss, J. H. (1995). Food science (5th ed.):

Springer.

Rakkestad, K. E., Dye, C. J., Yttri, K. E., Holme, J. A., Hongslo, J. K.,
Schwarze, P. E., & Becher, R. (2007). Phthalate levels in Norwegian
indoor air related to particle size fraction. J Environ Monit, 9(12), 1419-
1425.

Rudel, R. A., Gray, J. M., Engel, C. L., Rawsthorne, T. W., Dodson, R.

E., Ackerman, J. M., . . . Brody, J. G. (2011). Food packaging and
bisphenol A and bis(2-ethyhexyl) phthalate exposure: findings from a
dietary intervention. Environ Health Perspect, 119(7), 914-920.

Sathyanarayana, S., Karr, C. J., Lozano, P., Brown, E., Calafat, A. M.,
Liu, F., & Swan, S. H. (2008). Baby care products: possible sources of
infant phthalate exposure. Pediatrics, 121(2), e260-268.

Schutze, A., Kolossa-Gehring, M., Apel, P., Bruning, T., & Koch, H. M.
(2014). Entering markets and bodies: increasing levels of the novel
plasticizer Hexamoll(R) DINCH(R) in 24 h urine samples from the
German Environmental Specimen Bank. Int J Hyg Environ Health,
217(2-3), 421-426.

Sharman, M., Read, W. A., Castle, L., & Gilbert, J. (1994). Levels of di-
(2-ethylhexyl)phthalate and total phthalate esters in milk, cream,
butter and cheese. Food Addit Contam, 11(3), 375-385.

Shu, H., Allen, R., Zeng, L., Lanphear, B., Bornehag, C.G., Brauer, M., .
. . Takaro, T. (In Manuscript). Potential sources of phthalate exposure
at three months of age in the CHILD study

58
Silva, M. J., Barr, D. B., Reidy, J. A., Malek, N. A., Hodge, C. C., Caudill,
S. P., . . . Calafat, A. M. (2004). Urinary levels of seven phthalate
metabolites in the U.S. population from the National Health and
Nutrition Examination Survey (NHANES) 1999-2000. Environ Health
Perspect, 112(3), 331-338.

Silva, M. J., Reidy, J. A., Samandar, E., Herbert, A. R., Needham, L. L.,
& Calafat, A. M. (2005). Detection of phthalate metabolites in human
saliva. Arch Toxicol, 79(11), 647-652.

Silva, M. J., Samandar, E., Preau, J. L., Jr., Needham, L. L., & Calafat,
A. M. (2006). Urinary oxidative metabolites of di(2-ethylhexyl)
phthalate in humans. Toxicology, 219(1-3), 22-32.

Suijkerbuijk, A. W., de Wit, G. A., Wijga, A. H., Heijmans, M.,

Hoogendoorn, M., Rutten-van Molken, M., . . . Feenstra, T. L. (2013).
[Societal costs of asthma, COPD and respiratory allergy]. Ned Tijdschr
Geneeskd, 157(46), A6562.

Swan, S. H., Liu, F., Hines, M., Kruse, R. L., Wang, C., Redmon, J. B., .
. . Weiss, B. (2010). Prenatal phthalate exposure and reduced
masculine play in boys. Int J Androl, 33(2), 259-269.

The European Council of Vinyl Manufacturers. (n.d.). PVC's Physical

Properties. Retrieved from http://www.pvc.org/en/p/pvcs-physical-
properties

The Swan ecolabel. (2014). About Nordic Ecolabelled Floor coverings.

Retrieved from
http://www.svanemerket.no/PageFiles/12197/029_Background_to_
proposed_criteria_version_6.pdf

Tranfo, G., Paci, E., Pigini, D., Bonanni, R. C., Capanna, S., Carolis, C.
D., & Iavicoli, S. (2014). Phthalate Metabolites in Amniotic Fluid and
Maternal Urine Samples. Journal of Environmental Protection,
Vol.05No.14, 8.

U.S. EPA, E. P. A. N. C. f. E. A. (1988). Chemical Assessment Summary:

Di(2-ethylhexyl)phthalate (DEHP); CASRN 117-81-7. Retrieved from
https://cfpub.epa.gov/ncea/iris/iris_documents/documents/subst/0
014_summary.pdf

Vaillant, M., & Olliaro, P. (2007). Geometric least squares means ratios
for the analysis of Plasmodium falciparum in vitro susceptibility to
antimalarial drugs. Malaria Journal, 6, 156-156.

59
van Aalderen, W. M. (2012). Childhood asthma: diagnosis and
treatment. Scientifica (Cairo), 2012, 674204.

Van Bever, H. P., Wieringa, M. H., Weyler, J. J., Nelen, V. J., Fortuin,
M., & Vermeire, P. A. (1999). Croup and recurrent croup: their
association with asthma and allergy. An epidemiological study on 5-8-
year-old children. Eur J Pediatr, 158(3), 253-257.

Wan, H. T., Leung, P. Y., Zhao, Y. G., Wei, X., Wong, M. H., & Wong,
C. K. (2013). Blood plasma concentrations of endocrine disrupting
chemicals in Hong Kong populations. J Hazard Mater, 261, 763-769.

Van Vliet, E. D., Reitano, E. M., Chhabra, J. S., Bergen, G. P., & Whyatt,
R. M. (2011). A review of alternatives to di (2-ethylhexyl) phthalate-
containing medical devices in the neonatal intensive care unit. J
Perinatol, 31(8), 551-560.

WHO. (April 2017). Asthma. Retrieved from

http://www.who.int/mediacentre/factsheets/fs307/en/

Whyatt, R. M., Perzanowski, M. S., Just, A. C., Rundle, A. G., Donohue,

K. M., Calafat, A. M., . . . Miller, R. L. (2014). Asthma in inner-city
children at 5-11 years of age and prenatal exposure to phthalates: the
Columbia Center for Children's Environmental Health Cohort. Environ
Health Perspect, 122(10), 1141-1146.

Wilkinson, C. F., & Lamb, J. C. t. (1999). The potential health effects of

phthalate esters in children's toys: a review and risk assessment. Regul
Toxicol Pharmacol, 30(2 Pt 1), 140-155.

Wittassek, M., Koch, H. M., Angerer, J., & Bruning, T. (2011). Assessing
exposure to phthalates - the human biomonitoring approach. Mol Nutr
Food Res, 55(1), 7-31.

Wittcoff, A. A., Reuben, B. G., & Plotkin, J. S. (2013). Industrial

Organic Chemicals (3rd ed.): Wiley.

Yang, J., Hauser, R., & Goldman, R. H. (2013). Taiwan food scandal:
The illegal use of phthalates as a clouding agent and their contribution
to maternal exposure. Food Chem Toxicol, 58, 362-368.

Yeang, K., & Woo, L. (2010). Dictionary of Ecodesign : An Illustrated

Reference Routledge.

Zhu, J., Phillips, S. P., Feng, Y. L., & Yang, X. (2006). Phthalate esters
in human milk: concentration variations over a 6-month postpartum
time. Environ Sci Technol, 40(17), 5276-5281.

60
Zota, A. R., Calafat, A. M., & Woodruff, T. J. (2014). Temporal Trends
in Phthalate Exposures: Findings from the National Health and
Nutrition Examination Survey, 2001-2010. Environ Health Perspect,
122(3), 235-241.

61
Human health depends on a well-functioning endocrine system to regulate hormone
release for normal bodily functions. Endocrine disrupting chemicals (EDCs) constitutes
a group of chemicals, included in many commonly used products, (e.g., PVC flooring),
with properties proven or suspected to interact with the natural hormone system in
humans and animals.

One type of widely concerning EDC is phthalates. Since phthalates create weak
chemical bonds when they are added into different products, they readily leach into the
surrounding environment. Phthalate metabolites can therefore be frequently measured in
human biological samples. Major public health concerns regarding EDCs over the past
three decades have focused on phthalates resulting in implementation of regulations.

The thesis shows that PVC flooring in the home is a source for human uptake of phthalates,
that replacement of phthalates in soft PVC products have an impact on human uptake of
these chemicals, and that exposure for phthalates in early life increase the risk for airway
disorders in children. This means that regulation and consumers’ product choices can
lead to changes in uptake of EDCs of importance for human health. Philosophically, we
all have a responsibility to protect future generations from dangerous chemicals.

ISBN 978-91-7063-806-0

ISBN 978-91-7063-902-9

ISSN 1403-8099

DOCTORAL THESIS | Karlstad University Studies | 2017:30