Underutilized and Under Threat: Environmental Policy as a Tool to Address Diabetes Risk


Purpose of Review

Diabetes is a burgeoning threat to public health in the USA. Importantly, the burden of diabetes is not equally borne across society with marked disparities based on geography, race/ethnicity, and income. The etiology of global and population-specific diabetes risk remains incompletely understood; however, evidence linking environmental toxicants acting as endocrine-disrupting chemicals (EDCs), such as particulate matter and arsenic, with diabetes suggests that environmental policies could play an important role in diabetes risk reduction.

Recent Findings

Evidence suggests that disproportionate exposures to EDCs may contribute to subgroup-specific diabetes risk; however, no federal policies regulate EDCs linked to diabetes based upon diabetogenic potential. Nevertheless, analyses of European Union data indicate that such regulation could reduce diabetes-associated costs and disease burden.


Federal laws only regulate EDCs indirectly. The accumulating evidence linking these chemicals with diabetes risk should encourage policymakers to adopt stricter environmental standards that consider both health and economic impacts.

This is a preview of subscription content, log in to check access.

Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    American Diabetes Association. Standards of medical care in diabetes—2018. Diabetes Care. 2018;41(Suppl 1):S1–S153.

    Google Scholar 

  2. 2.

    Centers for Disease Control and Prevention. National Diabetes Statistics, 2017 Washington, DC: Centers for Disease Control and Prevention; 2017 [Available from: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf.

  3. 3.

    American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033–46.

    Article  PubMed Central  Google Scholar 

  4. 4.

    International Diabetes Federation. IDF Diabetes Atlas, 8th edition: International Diabetes Federation; 2017 [Available from: https://www.idf.org/e-library/epidemiology-research/diabetes-atlas/134-idf-diabetes-atlas-8th-edition.html.

  5. 5.

    •• Heindel JJ, Blumberg B, Cave M, Machtinger R, Mantovani A, Mendez MA, et al. Metabolism disrupting chemicals and metabolic disorders. Reprod Toxicol. 2016. This paper is the most comprehensive review to date of evidence linking endocrine-disrupting chemicals to metabolic disease.

  6. 6.

    Mimoto MS, Nadal A, Sargis RM. Polluted pathways: mechanisms of metabolic disruption by endocrine disrupting chemicals. Curr Environ Health Rep. 2017;4(2):208–22.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Neel BA, Sargis RM. The paradox of progress: environmental disruption of metabolism and the diabetes epidemic. Diabetes. 2011;60(7):1838–48.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Zoeller RT, Brown TR, Doan LL, Gore AC, Skakkebaek NE, Soto AM, et al. Endocrine-disrupting chemicals and public health protection: a statement of principles from the Endocrine Society. Endocrinology. 2012;153(9):4097–110.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    •• Ruiz D, Becerra M, Jagai JS, Ard K, Sargis RM. Disparities in environmental exposures to endocrine-disrupting chemicals and diabetes risk in vulnerable populations. Diabetes Care. 2018;41(1):193–205. This paper reviews evidence suggesting that exposure to environmental toxicants may be a contributor to diabetes disparities

    Article  PubMed  Google Scholar 

  10. 10.

    Brook RD, Sun Z, Brook JR, Zhao X, Ruan Y, Yan J, et al. Extreme air pollution conditions adversely affect blood pressure and insulin resistance: the Air Pollution and Cardiometabolic Disease Study. Hypertension. 2016;67(1):77–85.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Brook RD, Xu X, Bard RL, Dvonch JT, Morishita M, Kaciroti N, et al. Reduced metabolic insulin sensitivity following sub-acute exposures to low levels of ambient fine particulate matter air pollution. Sci Total Environ. 2013;448:66–71.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    To T, Zhu J, Villeneuve PJ, Simatovic J, Feldman L, Gao C, et al. Chronic disease prevalence in women and air pollution—a 30-year longitudinal cohort study. Environ Int. 2015;80:26–32.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Park SK, Adar SD, O'Neill MS, Auchincloss AH, Szpiro A, Bertoni AG, et al. Long-term exposure to air pollution and type 2 diabetes mellitus in a multiethnic cohort. Am J Epidemiol. 2015;181(5):327–36.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Thiering E, Cyrys J, Kratzsch J, Meisinger C, Hoffmann B, Berdel D, et al. Long-term exposure to traffic-related air pollution and insulin resistance in children: results from the GINIplus and LISAplus birth cohorts. Diabetologia. 2013;56(8):1696–704.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Coogan PF, White LF, Jerrett M, Brook RD, Su JG, Seto E, et al. Air pollution and incidence of hypertension and diabetes mellitus in black women living in Los Angeles. Circulation. 2012;125(6):767–72.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Krämer U, Herder C, Sugiri D, Strassburger K, Schikowski T, Ranft U, et al. Traffic-related air pollution and incident type 2 diabetes: results from the SALIA cohort study. Environ Health Perspect. 2010;118(9):1273–9.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Weinmayr G, Hennig F, Fuks K, Nonnemacher M, Jakobs H, Möhlenkamp S, et al. Long-term exposure to fine particulate matter and incidence of type 2 diabetes mellitus in a cohort study: effects of total and traffic-specific air pollution. Environ Health. 2015;14(1):1.

    CAS  Article  Google Scholar 

  18. 18.

    Pope CA 3rd, Turner MC, Burnett RT, Jerrett M, Gapstur SM, Diver WR, et al. Relationships between fine particulate air pollution, cardiometabolic disorders, and cardiovascular mortality. Circ Res. 2015;116(1):108–15.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Brook RD, Cakmak S, Turner MC, Brook JR, Crouse DL, Peters PA, et al. Long-term fine particulate matter exposure and mortality from diabetes in Canada. Diabetes Care. 2013;36(10):3313–20.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Shunthirasingham C, Gawor A, Hung H, Brice KA, Su K, Alexandrou N, et al. Atmospheric concentrations and loadings of organochlorine pesticides and polychlorinated biphenyls in the Canadian Great Lakes Basin (GLB): spatial and temporal analysis (1992–2012). Environ Pollut. 2016;217:124–33.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Kirkley AG, Carmean CM, Ruiz D, Ye H, Regnier SM, Poudel A, et al. Arsenic exposure induces glucose intolerance and alters global energy metabolism. Am J Physiol Regul Integr Comp Physiol 2017:ajpregu 00522 2016.

  22. 22.

    Douillet C, Currier J, Saunders J, Bodnar WM, Matousek T, S M. Methylated trivalent arsenicals are potent inhibitors of glucose stimulated insulin secretion by murine pancreatic islets. Toxicol Appl Pharmacol. 2013;267(1):11–5.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Fu J, Woods CG, Yehuda-Shnaidman E, Zhang Q, Wong V, Collins S, et al. Low-level arsenic impairs glucose-stimulated insulin secretion in pancreatic beta cells: involvement of cellular adaptive response to oxidative stress. Environ Health Perspect. 2010;118(6):864–70.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Diaz-Villasenor A, Burns AL, Salazar AM, Sordo M, Hiriart M, Cebrian ME, et al. Arsenite reduces insulin secretion in rat pancreatic beta-cells by decreasing the calcium-dependent calpain-10 proteolysis of SNAP-25. Toxicol Appl Pharmacol. 2008;231(3):291–9.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Diaz-Villasenor A, Sanchez-Soto MC, Cebrian ME, Ostrosky-Wegman P, Hiriart M. Sodium arsenite impairs insulin secretion and transcription in pancreatic beta-cells. Toxicol Appl Pharmacol. 2006;214(1):30–4.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Maull EA, Ahsan H, Edwards J, Longnecker MP, Navas-Acien A, Pi J, et al. Evaluation of the association between arsenic and diabetes: a National Toxicology Program workshop review. Environ Health Perspect. 2012;120(12):1658–70.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Sung TC, Huang JW, Guo HR. Association between arsenic exposure and diabetes: a meta-analysis. Biomed Res Int. 2015;2015:368087.

    PubMed  PubMed Central  Google Scholar 

  28. 28.

    Wang W, Xie Z, Lin Y, Zhang D. Association of inorganic arsenic exposure with type 2 diabetes mellitus: a meta-analysis. J Epidemiol Community Health. 2014;68(2):176–84.

    Article  PubMed  Google Scholar 

  29. 29.

    Wu H, Bertrand KA, Choi AL, Hu FB, Laden F, Grandjean P, et al. Persistent organic pollutants and type 2 diabetes: a prospective analysis in the nurses’ health study and meta-analysis. Environ Health Perspect. 2013;121(2):153–61.

    PubMed  Google Scholar 

  30. 30.

    Turyk M, Anderson H, Knobeloch L, Imm P, Persky V. Organochlorine exposure and incidence of diabetes in a cohort of Great Lakes sport fish consumers. Environ Health Perspect. 2009;117(7):1076–82.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Rignell-Hydbom A, Lidfeldt J, Kiviranta H, Rantakokko P, Samsioe G, Agardh CD, et al. Exposure to p,p′-DDE: a risk factor for type 2 diabetes. PLoS One. 2009;4(10):e7503.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Lee DH, Steffes MW, Sjodin A, Jones RS, Needham LL, Jacobs DR Jr. Low dose of some persistent organic pollutants predicts type 2 diabetes: a nested case-control study. Environ Health Perspect. 2010;118(9):1235–42.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Lee DH, Lind PM, Jacobs DR Jr, Salihovic S, van Bavel B, Lind L. Polychlorinated biphenyls and organochlorine pesticides in plasma predict development of type 2 diabetes in the elderly: the prospective investigation of the vasculature in Uppsala Seniors (PIVUS) study. Diabetes Care. 2011;34(8):1778–84.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Starling AP, Umbach DM, Kamel F, Long S, Sandler DP, Hoppin JA. Pesticide use and incident diabetes among wives of farmers in the Agricultural Health Study. Occup Environ Med. 2014;71(9):629–35.

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Bertazzi PA, Consonni D, Bachetti S, Rubagotti M, Baccarelli A, Zocchetti C, et al. Health effects of dioxin exposure: a 20-year mortality study. Am J Epidemiol. 2001;153(11):1031–44.

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Consonni D, Pesatori AC, Zocchetti C, Sindaco R, D'Oro LC, Rubagotti M, et al. Mortality in a population exposed to dioxin after the Seveso, Italy, accident in 1976: 25 years of follow-up. Am J Epidemiol. 2008;167(7):847–58.

    Article  PubMed  Google Scholar 

  37. 37.

    Spanakis EK, Golden SH. Race/ethnic difference in diabetes and diabetic complications. Curr Diab Rep. 2013;13(6):814–23.

    Article  PubMed  Google Scholar 

  38. 38.

    Resnik DB, Roman G. Health, justice, and the environment. Bioethics. 2007;21(4):230–41.

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Centers for Disease Control and Prevention. CDC identifies diabetes belt 2011 [Available from: https://www.cdc.gov/diabetes/pdfs/data/diabetesbelt.pdf.

  40. 40.

    Barker LE, Kirtland KA, Gregg EW, Geiss LS, Thompson TJ. Geographic distribution of diagnosed diabetes in the U.S.: a diabetes belt. Am J Prev Med. 2011;40(4):434–9.

    Article  PubMed  Google Scholar 

  41. 41.

    • Revesz R. Environmental law and policy; Foundation Press 2015. This book provides a comprehensive examination of US environmental law.

  42. 42.

    Environmental Protection Agency. How EPA regulates drinking water contaminants 2017 [Available from: https://www.epa.gov/dwregdev/how-epa-regulates-drinking-water-contaminants - make.

  43. 43.

    •• Landrigan PJ. The power of environmental protection: arsenic in drinking water. Lancet Public Health. 2017;2(11):e488–e9. This manuscript argues for the potential benefits of environmental policies in reducing human exposures.

    Article  PubMed  Google Scholar 

  44. 44.

    •• Nigra AE, Sanchez TR, Nachman KE, Harvey D, Chillrud SN, Graziano JH, et al. The effect of the Environmental Protection Agency maximum contaminant level on arsenic exposure in the USA from 2003 to 2014: an analysis of the National Health and Nutrition Examination Survey (NHANES). Lancet Public Health. 2017;2(11):e513–e21. Comparing those consuming public water to those consuming well water, this paper points to important inefficiencies in environmental policy that influence exposure to diabetes-associated chemicals.

    Article  PubMed  Google Scholar 

  45. 45.

    Callan ST, Thomas JM. Environmental economics and management. 6th edition ed. Mason, OH: South-Western Cengage Learning; 2013.

    Google Scholar 

  46. 46.

    Pettit HE. Shifting the experiment to the lab: does EPA have a mandatory duty to require testing for endocrine disruption effects under the toxic substances control act? Environmental Law. 2000;30(2):413–46.

    Google Scholar 

  47. 47.

    Environmental Protection Agency. What is superfund? 2017 [Available from: https://www.epa.gov/superfund/what-superfund.

  48. 48.

    Environmental Protection Agency. Arsenic: policy and guidance 2017 [Available from: https://clu-in.org/contaminantfocus/default.focus/sec/arsenic/cat/Policy_and_Guidance/.

  49. 49.

    Mercury-Containing and Rechargeable Battery Management Act, (1996).

  50. 50.

    Environmental Protection Agency. Bisphenol A action plan 2010 [Available from: https://www.epa.gov/sites/production/files/2015-09/documents/bpa_action_plan.pdf.

  51. 51.

    Environmental Protection Agency. Assessing and managing chemicals under TSCA: polybrominated diphenyl ethers (PBDEs) 2017 [Available from: https://www.epa.gov/assessing-and-managing-chemicals-under-tsca/polybrominated-diphenyl-ethers-pbdes.

  52. 52.

    Environmental Protection Agency. Polybrominated diphenyl ethers (PBDEs) action plan 2009 [Available from: https://www.epa.gov/sites/production/files/2015-09/documents/pbdes_ap_2009_1230_final.pdf.

  53. 53.

    Franco SJ. Age-adjusted percentage of adults aged ≥ 20 years with diabetes, by race and Hispanic ethnicity—National Health and Nutrition Examination Survey, United States, 1999–2002 and 2009–2012. 2015.

  54. 54.

    Chow EFH, Gonzalez V, McIver L. The disparate impact of diabetes on racial/Ethinc minority populations. Clinical Diabetes. 2012;30(3):130–3.

    Article  Google Scholar 

  55. 55.

    Hunt BR, Whitman S, Henry CA. Age-adjusted diabetes mortality rates vary in local communities in a metropolitan area: racial and spatial disparities and correlates. Diabetes Care. 2014;37(5):1279–86.

    Article  PubMed  Google Scholar 

  56. 56.

    Indian Health Service. Factsheet: disparities: US Department of Health and Human Services; 2017 [Available from: https://www.ihs.gov/newsroom/factsheets/disparities/.

  57. 57.

    Rabi DM, Edwards AL, Southern DA, Svenson LW, Sargious PM, Norton P, et al. Association of socio-economic status with diabetes prevalence and utilization of diabetes care services. BMC Health Serv Res. 2006;6:124.

    Article  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Brulle RJ, Pellow DN. Environmental justice: human health and environmental inequalities. Annu Rev Public Health. 2006;27:103–24.

    Article  PubMed  Google Scholar 

  59. 59.

    Environmental Protection Agency. Summary of Executive Order 12898—federal actions to address environmental justice in minority populations and low-income populations 1994 [Available from: https://www.epa.gov/laws-regulations/summary-executive-order-12898-federal-actions-address-environmental-justice.

  60. 60.

    Environmental Protection Agency. Carbon pollution emission guidelines for existing stationary sources: electric utility generating units. Federal Register. 2015;80 FR 64661.

  61. 61.

    Kassotis CD, Klemp KC, Vu DC, Lin CH, Meng CX, Besch-Williford CL, et al. Endocrine-disrupting activity of hydraulic fracturing chemicals and adverse health outcomes after prenatal exposure in male mice. Endocrinology. 2015;156(12):4458–73.

    CAS  Article  PubMed  Google Scholar 

  62. 62.

    Kassotis CD, Bromfield JJ, Klemp KC, Meng CX, Wolfe A, Zoeller RT, et al. Adverse reproductive and developmental health outcomes following prenatal exposure to a hydraulic fracturing chemical mixture in female C57Bl/6 mice. Endocrinology. 2016;157(9):3469–81.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  63. 63.

    Fontenot BE, Hunt LR, Hildenbrand ZL, Carlton DD Jr, Oka H, Walton JL, et al. An evaluation of water quality in private drinking water wells near natural gas extraction sites in the Barnett Shale formation. Environ Sci Technol. 2013;47(17):10032–40.

    CAS  Article  PubMed  Google Scholar 

  64. 64.

    Bureau of Land Management. Oil and gas, hydraulic fracturing on federal and Indian lands: rescission of a 2015 rule. Federal Register. 2017:82 FR 34464.

  65. 65.

    Bureau of Safety and Environmental Enforcement. Oil and gas and sulphur operations on the outer continental shelf—oil and gas production safety systems—revision. Federal Register. 2017:82 FR 61703.

  66. 66.

    Beauchamp TL, Childress JF. Principles of biomedical ethics. 6th ed. New York: Oxford University Press; 2009. xiii, pp.417

  67. 67.

    Diamanti-Kandarakis E, Bourguignon JP, Giudice LC, Hauser R, Prins GS, Soto AM, et al. Endocrine-disrupting chemicals: an Endocrine Society scientific statement. Endocr Rev. 2009;30(4):293–342.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  68. 68.

    Gore AC, Chappell VA, Fenton SE, Flaws JA, Nadal A, Prins GS, et al. EDC-2: the Endocrine Society’s second scientific statement on endocrine-disrupting chemicals. Endocr Rev. 2015;36(6):E1–E150.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  69. 69.

    •• Trasande L, Lampa E, Lind L, Lind PM. Population attributable risks and costs of diabetogenic chemical exposures in the elderly. Journal of Epidemiology and Community Health. 2017;71(2):111–4. This analysis of data from the European Union suggests that reducing exposures to diabetes-associated chemicals may reduce both rates of disease and associated healthcare costs.

    Article  PubMed  Google Scholar 

Download references


This work was supported by the University of Chicago, the American Diabetes Association (1-17-JDF-033 to RMS), the National Institute of Diabetes and Digestive and Kidney Diseases (P30-DK-092949 to Dr. Jagai via pilot funding from the Chicago Center for Diabetes Translational Research), and the National Institute of Environmental Health Sciences (P30-ES-027792 supporting Dr. Sargis via the ChicAgo Center for Health and EnvironmenT (CACHET)). The authors graciously acknowledge the assistance of Samuel M. Fuchs for assistance with the generation of Fig. 1, Milestones in United States Environmental Policy.

Author information



Corresponding author

Correspondence to Robert M. Sargis.

Ethics declarations

Conflict of Interest

Sabina Shaikh, Jyotsna S. Jagai, Colette Ashley, and Shuhan Zhou declare that they have no conflict of interest.

Robert M. Sargis reports honoraria from CVS.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Economics and Policy in Diabetes

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Shaikh, S., Jagai, J.S., Ashley, C. et al. Underutilized and Under Threat: Environmental Policy as a Tool to Address Diabetes Risk. Curr Diab Rep 18, 25 (2018). https://doi.org/10.1007/s11892-018-0993-5

Download citation


  • Diabetes
  • Pollution
  • Toxicant
  • Endocrine-disrupting chemical
  • Environmental policy
  • Environmental justice