Opponents of fluoridation all at sea with new legislation

Image credit: Why Ideology and Science Don’t Mix

Opponents of community water fluoridation (CWF) should be supporting the proposed fluoridation legislation instead of organising opposition to it.

Think about it.

If Fluoride Free NZ (FFNZ) was honest in its claim that they are “New Zealand’s leading advocate for science in the fluoridation debate” (see their press release  Open letter to Hon Andrew little, Minister of Health) then they should be supporting science rather than ideology and insist on the best scientific scrutiny of information relating to fluoridation.

If they honestly accept the claims of those cherry-picked anti-fluoride scientists they are quoting in their social media memes then they should welcome the opportunity to expose the research of those scientists to a proper critical review.

With scientific backers like this, opponents of community water fluoridation should be welcoming the new fluoridation legislation (example of social media memes promoted by the Fluoride Action Network)

And they should welcome the proposal that the proper place for such a scientific review is the office of the Director-general of health which can call on the best scientists for information and review of the evidence. That proposal is an integral part of the draft legislation which requires that the Director-General must consider the scientific evidence related to community water fluoridation before making a direction that CWF be introduced or stopped in a region (see clause 116E : Director-General may direct local authority to add or not to add fluoride to drinking water in the Supplementary Order Paper).

So, it appears strange that instead of welcoming the new legislation FFNZ is mobilising their supporters to oppose it. And their US colleagues at the Fluoridation Action Network are pouring their resources into the FFNZ campaign.

But why? It is ridiculous for pro-science people to campaign to retain the old system where the evaluation of evidence and decisions on CWF were made by scientific and political naive councillors in local bodies. Councillors who could be easily captured by activists and fooled by their misrepresentation of the science., Councillors who are more concerned with their next election or chances of claiming the Mayor’s job than any science. And councillors who are already predisposed to the claims of the activists, who may indeed be activists themselves, who were more concerned with ideological orientation than any science.

If the fluoridation opponents organised by FFNZ are really “leading advocates for science” and want recent research they are promoting to be considered in fluoridation decisions then they would be supporting the new legislation rather than opposing it.

Ideological distortion of science

I really wonder at a group of ideologically motivated people making submissions promoting their understanding (or misunderstanding) of the science to the Parliamentary Health Committee when that committee is simply not tasked with considering the science. Its job is to consider proposals for the reorganisation of the mechanism for making fluoridation decisions – nothing to do with science itself.

Instead of wasting their submissions on this bill, they should be saving them for promotion of their beliefs about what the science claims to the Director-General of Health and his/her staff. Once this bill is passed the Director-General of Health’s office should be a great place for these claims to be properly considered and reviewed.

That would be a vast improvement on the old situation when they took their arguments to scientifically and politically naive local body councils. Or brought in US anti-fluoridation spokesmen to speak to audiences of homoeopaths, head massagers and other alternative health advocates and their followers.

Or perhaps I am the naive one. Perhaps fluoridation opponents prefer to make their arguments to those local body councillors instead of scientifically capable people. Perhaps FFNZ is dishonest to claim they are ““New Zealand’s leading advocate for science in the fluoridation debate.” 

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Update of NZ fluoridation review timely and useful

Image credit: Kurt:S/Flickr (CC BY-SA 2.0).

An updated New Zealand scientific review of community water fluoridation (CWF) finds that CWF in New Zealand is safe and effective. The new review, Fluoridation: an update on evidence, was published by the New Zealand Prime Minister’s Chief Science Advisor Juliet Gerrard FRSNZ HonFRSC. It examines scientific findings published since the last New Zealand fluoridation review in 2014 – Eason et al (2014). Health effects of water fluoridation: A review of the scientific evidence. It states:

“Royal Society Te Apārangi published a comprehensive review in 2014 looking at the health effects of water fluoridation [Eason et al. 2014]. The review found that there were no adverse effects of fluoride of any significance arising from fluoridation at the levels used in Aotearoa New Zealand. We have considered new research on fluoridation and comprehensive reviews published subsequently, and find that the conclusions of the Royal Society Te Apārangi remain appropriate.”

So, in effect, nothing new there as far as conclusions are concerned. New Zealanders should continue to welcome CWF without any fear of negative effects. But some readers may be interested in the details – specifically the review’s conclusions about the new research which anti-fluoride activists have been promoting of late. Opponents of CWF have in the last year or so almost exclusively concentrated their campaigns on claimed harmful neurodevelopmental and cognitive impacts. The review considers this in a section “Could fluoride have possible neurodevelopmental and cognitive health effects?” and concludes:

“Recent studies continue to show that at very high levels and with chronic exposure, fluoride could potentially have negative neurodevelopmental and cognitive impacts. However, this is not a concern at levels used in fluoridation of water supplies in Aotearoa New Zealand.”

In particular, the new review considered the studies opponents of CWF claim show harmful effects at the water fluoride concentrations used in CWF. It found problems with these studies and states:

“The conclusion reached by Royal Society Te Apārangi remains appropriate. While there is some evidence that high fluoride concentrations may have an adverse effect on developing brains, there is no convincing evidence of neurological effects at fluoride concentrations achieved by fluoridation of water supplies in Aotearoa New Zealand.”

The new review could be better

Of course, the review is written for policymakers and politicians who want the conclusions but don’t want to see the detailed evidence. They will have confidence that behind the scenes proper scientific scrutiny was made of the studies discussed. But, as a scientist, I would have liked to see more details about that scrutiny. For example, a lot more could be said about the deficiencies of the Canadian study (Green et al., 2019) than:

“There was significant and valid criticism of aspects of the study by many subject-matter experts when it was released (see for example, ‘expert reaction to study looking at maternal exposure to fluoride and IQ in children’). The study used sub-group analysis to find an association that is not explained in the paper (i.e. why were only boys affected and why verbal IQ was not impacted), the effect appeared to be driven by the minority of participants that had much higher fluoride exposures (i.e. higher than those in Aotearoa New Zealand).”

I find this statement in the review a bit misleading:

“The results found in the study undertaken in Canada [56] are also in contrast to those found in the study undertaken in Aotearoa New Zealand [57], which has the advantage of more accurately reflecting local contextual factors.”

It refers to the Green et al., (2019) and Broadbent et al (2015) studies claiming their results are contradictory. But in terms of their comparison of IQ in fluoridated and unfluoridated areas this table shows their findings were exactly the same – absolutely no difference. (Till et al 2020 used essentially the same Canadian data) I think this comparison should have been made clear in the review because it is important but is most often overlooked because opponents of fluoridation, and the study’s authors,  never consider it. They remain silent about the facts in this table. This is hypocritical considering the attempts anti-fluoridation critics made to discredit the same finding reported by Broadbent et al (2015) when their paper was published.

Fluoridation opponents have instead concentrated on the relationships between maternal urinary fluoride and child IQ outcomes reported by Green et al (2019). However, all those relationships were extremely weak (explaining only a few per cent of the variation) or statistically non-significant.

The bias of the authors of the Green et al (2019) and Till et al (2020) studies is evident not only in their complete absence of discussion of their own results showing no difference between fluoridated and unfluoridated areas. It is also shown by the fact neither Green et al (2019) or Till et al (2020) referred to the findings of Broadbent et al (2015) or include that paper in their discussion or reference list. (Contrast this with the fact Green et al 2019 included four papers published in the journal Fluoride, known for its anti-fluoridation bias and poor quality).

These omissions are serious as Broadbent et al (2015) is the only other study of IQ in areas including CWF. This defect in the papers appears not to have been picked up by the publishing journals’ referees – which brings me to question the quality of the peer review used for these papers.

We really need to have a more extensive critique of these studies with proper consideration of the methodologies used (e.g. measurement of urinary fluoride and cognitive factors), the statistical relevance of the reported relationships and the quality of their literature reviews and discussions.

A timely, authoritative and useful review

This new review is timely. The NZ Parliament will soon pass legislation removing the current local body control of regional fluoridation decisions over to the Director-General of Health. Anti-fluoride activists will actively campaign against this and will be promoting misinformation about the recent research. The new review provides lawmakers and the media with up to date scientific information, presented in a popular format, which will counter the anti-fluoridation campaigners.

The backing of the office of the New Zealand Prime Minister’s Chief Science Advisor provides scientific authority. As do the 12 reputable scientists who provided peer reviews of the document.

The more science-savvy members of the public who want to see evidence rather than simply rely on recommendations will also find the review and its bibliography useful.

At this stage, it is not clear how anti-fluoride organisations will attempt to discredit the new review and its findings. In 2014 they worked hard to discredit the NZ Fluoridation Review prepared by the Royal Society of New Zealand and the Office of the Prime Minister’s Chief Science Advisor (Health effects of water fluoridation: A review of the scientific evidence.) They prepared their own critique (promoted as a critique by “international scientists “but actually written by, and “peer-reviewed” by, the usual small group of anti-fluoride scientists and activists) –  with their report Scientific and Critical Analysis of the 2014 New Zealand Fluoridation Report. I critiqued and analysed the report in “NZ Community Water Fluoridation is Safe and Effective: A critique of Fluoride Free NZ’s criticisms of the NZ Fluoridation Review“ which can be downloaded as a pdf.

Many opponents of CWF may be distracted by other things like the Covid19 vaccination issue at the moment. However, the anti-fluoridation campaign has big financial backers locally and internationally so it is likely they will come up with something a lot more effective than the recent attempt by Fluoride Free NZ to pretend that the new review effectively supports their claims.

I look forward to analysing any substantial critique they can make of the updated NMZ Fluoridation review.

A meme promoted by Fluoride Free NZ seeks to pretend the new fluoridation review supports their claims. It doesn’t.

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Fluoridation contribution to heavy metals in drinking water is too low to measure

Anti-fluoride activists claims of fluoridation chemicals being laced with toxic metals just do not stand up to scrutiny

Anti-fluoridation activists claim fluoridation adds toxic heavy metals to drinking water because the fluoridation chemicals are “waste products” from industry (the phosphate fertiliser industry). Despite the fact that published research shows this not true.

The activists rarely give evidence for their claims but when they do they cite chemical data from certificates of compliance supplied to local bodies by the fluoridation chemical providers. But these activists simply have no concept of what these figures mean and always ignore the huge dilution involved in water treatment.

Example of continually tweeted scaremongering misinformation from the Fluoride Action Network’s press officer.

Anti-fluoride people particularly go on about arsenic yet a 2015 Canadian study showed that the difference in arsenic levels from unfluoridated and fluoridated water treatment plants was infinitesimal. That study is:

Peterson, E., Shapiro, H., Li, Y., Minnery, J. G., & Copes, R. (2015). Arsenic from community water fluoridation: quantifying the effect. Journal of Water and Health.

The data shows that even after treatment the concentration of arsenic due to natural sources is about 0.44 ppb. Fluoridation added a mere 0.07 ppb to this! (ppb = parts per billion = micrograms/litre = μg/L).

See Another defeat for anti-fluoridation claims about arsenic for a discussion of this paper.

The authors point out that all the drinking water systems in their study were compliant with the Canadian drinking water guideline for arsenic of 10 μg/L (10 ppb [parts per billion] – the same as in New Zealand) and the estimated amount attributable to fluoridation from this study is less than 1% of this guideline. Their results were also consistent with other published estimates of the likely contribution of fluoridation chemicals to arsenic in drinking water.

The fluoridation chemicals used in New Zealand have lower levels of impurities than those used in North America so the resulting contamination of drinking water is even lower than in Canada.

Here I look at the heavy metals contaminants in our drinking water and the effect of fluoridation on those levels

What are the concentrations of contaminants in our tap water?

They are very low – in fact, they are regulated to be very low. The regulations set maximum allowable levels (MAV) and providers must keep their contaminant below these MAV levels.

The figure below uses data taken from reports for the Hamilton City Council Water Supply Annual Compliance Report 2018/2019. I have converted the data from units of g/m³ to parts per billion – ppb. I have used data from  a certificate of compliance for the hydrofluorosilicic acid (HFA) supplied to the Hamilton City Council in 2015 (referred to in my article Chemophobic scaremongering: Much ado about absolutely nothing)

I have made this figure tall in an attempt to show the calculated contribution of contaminants concentrations from the fluoride treatment (red) alongside the actual measured levels in the tap water (green). The Y-axis is different for Barium and Aluminium because the concentrations are much higher. Click on the image to see a larger version of the figure

Here are some relevant points about this data:

1: Lead is not included because the amount is below the detection limit. The measured levels of the other contaminants of interest (green) are very low – well below the MAV values.

Waikato River water contains relatively high levels of arsenic – higher than MAV recommendations. But water treatment reduces the levels to well below the MAV level (and in some samples the levels are below the detection limit).

2: The calculated levels for contaminants due to added fluoridation chemicals (HFA – hydrofluorosilicic acid) are extremely low. In fact, in all cases, they are well below the levels that could be detected by the analytical methods used – in most cases far less than 1% of the detectable levels.

This means that the final concentration in drinking water of heavy metals added with the fluoridation chemicals is far too low to even be detected by the sensitive chemical analytical methods used. It is simply misleading for anti-fluoride activists to rave on about the contaminant levels in the concentrated chemicals without taking into account the huge dilution involved.

3: The figure below illustrates that the fluoridation treatment makes only a minuscule (undetectable) contribution of contaminant elements to the tap water.  Well under 1% of the contaminant contribution coming from the source water itself.

Conclusion

Fluoridation chemicals add such a minuscule amount of heavy metals to drinking water that their contribution cannot be detected. The amounts are below the detection limit of the analytical methods used.

The claims of anti-fluoride activists are emotional rather than factual. It is meaningless to publish images of compliance certificates. When they cite chemical data for the fluoridation chemicals used they simply have no concept of what the figures mean and completely ignore the high dilution factor involved in treating drinking water.

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Hip fractures in the elderly and fluoride – contradictory evidence

Room for cherry-picking to confirm a bias. Separate Swedish studies report that fluoride can either prevent or promote the risk of hip fracture in the elderly. Image credit: Are hip fracture patients treated quickly enough?

Anti-fluoride activists are promoting a recent study linking fluoride intake and bone fractures. No surprise there. But they are cherry-picking a single study to support their agenda and scientifically literate people should see the wider picture and not ignore other studies which, on the whole,  convey a different story. This issue illustrates problems with epidemiological studies producing variable results and shows why people should avoid cherry-picking and look at the full range of studies in a field.

Here I consider just two studies on fluoride intake and bone fracture which produced different conclusions. Both studies involved people from Sweden where the natural fluoride levels in drinking water vary across the country.

Drinking water fluoride may protect against hip fractures

First a study from 2013:

Näsman, P., Ekstrand, J., Granath, F., Ekbom, A., & Fored, C. M. (2013). Estimated drinking water fluoride exposure and risk of hip fracture: A cohort study. Journal of Dental Research, 92(11), 1029–1034.

The main findings are illustrated in the figure showing the calculated Hazard Ratios for people of different ages living in areas of Sweden with “very low” (less than 0.3 mg/L), “low” (0.3 – 0.69 mg/L), “medium” (0.7 -1.49 mg/L) or “High” (greater than 1.5 mg/L) fluoride levels in the drinking water. The Hazard Ratio in the figure below is a measure of the number of hip fractures at these levels compared with the number of hip fractures at “Very low” fluoride concentration. The bars represent the 95% confidence intervals. The Hazard Ratios for the “very low” group are 1.0 and Hazard Ratios statistically significantly different to 1 (no effect) are coloured red.

Considering all people there is no statistically significant increase in the number of hip fractures for any level of water fluoride concentration compared with the “very low” levels. The number of hip fractures experienced by people in the two lower age groups (less than 70 years and 70 – 80 years) was significantly lower at higher water fluoride concentrations than at the “very low” concentrations. The authors say:

this “suggests a protective effect of fluoride among the younger (age younger than 80 years): however, the majority of fractures occurred above the age of 80 years (median age at time of fracture, 82.0).”

So a study suggested that the fluoride in Swedish drinking water does not encourage bone fractures and may actually protect against them in the lower age groups.

Fluoride may encourage hip fractures

Now a study from 2021 – the one anti-fluoride activists are promoting (for obvious reasons):

Helte, E., Vargas, C. D., Kippler, M., Wolk, A., Michaëlsson, K., & Åkesson, A. (2021). Fluoride in Drinking Water , Diet , and Urine in Relation to Bone Mineral Density and Fracture Incidence in Postmenopausal Women. Environmental Health Perspectives, 129(April).

Unlike Näsman et al (2013) which used drinking water fluoride concentrations as a measure of fluoride exposure, Helte et al (2021) used urinary fluoride and estimated dietary fluoride intake as measures of fluoride exposure. The Hazard Ratios were calculated from the number of hip fractures in the Tertile 2 groups (0.88 – 1.30 mg/g urinary fluoride or 1.74 – 2.41 mg/day dietary fluoride intake) and Tertile 3 groups (1.30 – 116.51 mg/g urinary fluoride or 2.41 – 11.16 mg/day dietary fluoride intake) compared with hip fractures in the tertile 1 groups (0.14 – 0.88 mg/g urinary fluoride or 0.26 – 1.74 mg/day dietary fluoride intake).

Note: The urinary fluoride units of mg/g represent mg of urinary F/g urinary creatinine. Creatinine levels were used to correct the spot values for dilution.

The Hazard Ratios that statistically significantly different to 1 (no effect) are coloured red in the figure below.

A bit complicated I know, but what the figure shows is no statistically significant increase in hip fracture numbers for the tertile 2 groups compared with the lower F intake tertile one group. But a significant increase in fracture numbers for the tertile 3 groups except for the women exposed to constant water fluoride concentrations since 1982 in the dietary F group.

Hertle et al (2021) also considered other types of fracture. There were no statistically significant increases in fractures in the upper tertiles for either the “all fractures” or “major osteoporotic fractures” classes.

So, a bit of a mixed bag but this paper is currently being promoted by anti-fluoride activists as evidence of a harmful result from community water fluoridation (CWF).

Critically assessing the evidence for bone fractures

It is easy to see why supporters of CWF may cite Näsman et al (2013) as evidence for lack of harm and opponents may cite Helte et al (2021) as evidence of harm from CWF. But neither approach is really scientific. The methodological differences and choice of factors considered can easily explain variable results. One should critically and rationally assess both of these papers, together with the many other papers reporting similar studies, before coming to any conclusion.

On balance, the published studies probably support the findings of Näsman et al (2013) and not Helte et al (2021). In fact, a systematic review and meta-analysis published in 2015 concluded that chronic exposure to fluoride in drinking water was not associated with a significant increase in hip fracture risk. The citation for this review is:

Yin, X.-H., Huang, G.-L., Lin, D.-R., Wan, C.-C., Wang, Y.-D., Song, J.-K., & Xu, P. (2015). Exposure to Fluoride in Drinking Water and Hip Fracture Risk: A Meta-Analysis of Observational Studies. PLOS ONE, 10(5), e0126488. 

It’s worth reproducing one of the figures from that review because it illustrates how epidemiological studies may, individually, support a claim of harm but when considered as a whole these studies do not support the claim. The figure below shows the range of Hazard Ratios obtained by a number of studies.

The lesson here is to be very careful of claims made on the basis of single cherry-picked studies. Especially when those making the claim have a bias they wish to confirm. Every claim should be critically and rationally considered using all the available studies.

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An open letter to Paul Connet and the anti-fluoride movement

Image credit: How to Effectively Share Your Knowledge

Paul Connett and Vyvyan Howard have, through the local Fluoride Free New Zealand activist group, published an open letter addressed to NZ scientists and educators (see An Open Letter To NZ Scientists And Educators). It is strange to encourage scientific exchanges through press releases but if they are seriously interested in an exchange of informed scientific opinion on the research they mention I am all for it.

In fact, I renew my offer to Paul Connett for a new exchange on the new relevant research along the lines of the highly successful scientific exchange we had in 2013/2014 summarised in Conett & Perrott (2014) The Fluoride Debate.

Connett and Howard say they felt “let down” by the reception they received in their 2018 visit. But they should realise this sort of ridicule is inevitable when a supposedly scientific message is promoted by activist fringe groups with known funding by big business (in this case the “natural”/alternative health industry). The science should be treated more respectably and discussed in a proper scientific forum or via a proper scientific exchange rather than political style activist meetings.

It is this sort of respectable, informed and open scientific exchange I am offering to Paul Connett and Vyvyan Hoard.

Connett and Howard argue that there has recently been  “a dramatic change in the quality of these [fluoride] studies.” I agree that new research occurs all the time and there is plenty of scope upgrading of the scientific exchange we had in 2013/2014 to cover that new research. Consideration of the new research requires the objective, critical and intelligent consideration scientists are well used to and this is not helped by activist propaganda meetings. So I encourage Connett and Howard to accept my offer. after all, if they are confident in their own analysis of this research what do they have to lose?

Inaccuracies in “open letter”

One can see an “Open letter” as displaying a willingness to enter into a proper scientific exchange. However, Connett and Vivyan’s open letter includes inaccuracies and misinformation on the new research which simply demonstrates that a one-sided presentation cannot present the research findings properly.

For example, they misrepresent the 2014 New Zealand fluoridation review of Eason et al (2014). Health effects of water fluoridation: A review of the scientific evidence. Even to the extent of mistaking the authors (not Gluckman & Skegg as they claim) and misrepresenting the small mistake made in the summary which was later corrected. That attitude does not bode well for the proper consideration of the research.

Connett and Howard concentrate on new research relating child IQ to fluoride intake but they ignore completely the fact that all the research comparing IQ in fluoridated and unfluoridated areas show absolutely no effect. I have summarised the results for the three papers involve in this table.

Instead, they concentrated on a few extremely weak relationships reported in a few papers. But even here they get this wrong – for example, they say there is “a loss of about 4 IQ points in offspring for a range of 1 mg/liter of fluoride in mother’s urine.” The paper they refer to (Green et al 2019) actually found no statistically significant relationship between child IQ and maternal urinary fluoride for all children considered. The relationship Connett and Howard mention was actually for male children (no relationship for female children or for all children) and was very weak. These sort of weak relationships are commonly found in epidemiological research and are usually meaningless. In this case, Connett and Howard have simply cherry-picked one value and misrepresented it as applying to all children.

Both the Green et al (2019) and Till et al (2020) papers Connett and Howard refer to suffer from selecting a few weak statistically significant relationships and ignoring the larger number of non-significant relationships they found for the data they investigated. Connett and Howard also completely ignored the new studies that don’t fit their claims. For example that of Santa-Marina et al (2019). Fluorinated water consumption in pregnancy and neuropsychological development of children at 14 months and 4 years of age. which showed an opposite positive relationship of child IQ with maternal urinary fluoride. Similar they ignored the large Swedish study of Aggeborn & Öhman (2020). The Effects of Fluoride in the Drinking Water showing no effect of fluoride on IQ but positive effects on oral health and employment possibilities in later life.

In conclusion, I reiterate that genuine open scientific exchanges do not take place via press release and activist meetings. However, the fact that Connett and Howard have issued an “Open Letter” could be interpreted as inviting others to participate in a proper exchange. I endorse that concept and offer Connett and Howard space for a free and open exchange on the new research at this blog site.

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Embarrassing knock-back of second draft review of possible cognitive health effects of fluoride

We have come to expect exaggeration of scientific findings in media reports and institutional press releases. But it can also be a problem is original scientific publications where findings are reported in an unqualified or exaggerated way. Image Credit: Curbing exaggerated reporting

This is rather embarrassing for a US group attempting to get the science right about possible toxic effects of fluoride. It’s also embarrassing for the anti-fluoride activists who have “jumped the gun” and been citing the group’s draft review as if it was reliable when it is not.

The US National Academies of Sciences, Engineering, and Medicine (NAS) have released their peer-review of the revised US National Toxicity Program (NTP) draft on possible neurodevelopmental effects of fluoride (see Review of the Revised NTP Monograph on the Systematic Review of Fluoride Exposure and Neurodevelopmental and Cognitive Health Effects).

This is the second attempt by the NTP reviewers to get acceptance of their draft and it has now been knocked back by the NAS peer reviewers for a second time.

Diplomatic but damning peer-review

Of course, the NAS peer reviewers use diplomatic language but the peer review is quite damning. It criticises the NTP for ignoring some of the important recommendations in the first peer review. One which is quite critical was the lack of response to the request that NTP explains how the monograph can be used (or not) to inform water fluoridation concentrations. The second NAS peer review firmly states that the NTP:

“should make it clear that the monograph cannot be used to draw any conclusions regarding low fluoride exposure concentrations, including those typically associated with drinking-water fluoridation.”

And:

“Given the substantial concern regarding health implications of various fluoride exposures, comments or inferences that are not based on rigorous analyses It seems to me that there is soime internal politicsshould be avoided.”

It seems to me there is some internal politics involved and some of the NTP authors may be promoting their own, possibly anti-fluoride, agenda. Certainly, the revised NTP draft monograph continues to obfuscate this issue. It continues to state that “fluoride is presumed to be a cognitive neurodevelopmental hazard to humans” – a clause which anti-fluoride campaigner consistently quote out of context. Yes, it does state that this is based on findings demonstrating “that higher fluoride exposure (e.g., >1.5 mg/L in drinking water) is associated with lower IQ and other cognitive effects in children.” But this is separated from the other fact that the findings on cognitive neurodevelopment for “exposures in ranges typically found in drinking water in the United States (0.7 mg/L for optimally fluoridated community water systems)” are “are inconsistent, and therefore unclear.”

Monograph exaggerates by enabling unfair cherry-picking

So, you see the problem. The draft NTP monograph correctly refers to IQ and other cognitive effects in children exposed to excessive levels of fluoride. The draft also correctly refers to that lack of evidence for such effects at lower fluoride exposure levels typical of community water fluoridation. But in different places in the document.

The enables activist cherry-picking to support an anti-fluoride agenda and that is a fault of the document itself. It should clearly state that the monograph should not be used to draw any conclusion at these low exposure levels. This is strongly expressed in the peer-reviewers’ comments.

I find the blanket “presumed to be a hazard for humans” quite misleading. For example, no one says that calcium is “presumed to be a cardiovascular hazard to humans.” Or that selenium is “presumed to be a cardiovascular or neurological hazard to humans.” Or what about magnesium – would you accept that it is a “presumed neurological hazard to humans?” Would you accept that iron is a “presumed cardiovascular, cancer, kidney or erectile dysfunction hazard to humans?” Yet all those problems have been reported for humans at high intake levels of these elements.

No, we sensibly accept that various elements and microelements have beneficial, or essential benefits, to humans at reasonable intake levels., Then we sensibly warn that these same elements can be harmful at excessive intake. To proclaim that any of these elements are “presumed” to be hazardous – without clearly saying at excessive intake levels, is simply distorting or exaggerating the data.

What does “presumed” mean?

A lot of readers find the use of “presumed” strange. But it’s meaning is related to the levels of evidence found by reviewers.

No, don’t believe those anti-fluoride activists who falsely claim that “presumed” is the highest level of evidence and that the finding should be treated as factual. They are simply wrong.

Some idea of the word’s use is presented in this diagram from the NTP revised draft monograph.

So “presumed” means that the evidence for the effect is moderate. That the effect is not factual or known. But as further evidence comes in the ranking of fluoride as a hazard may increase, or decline.

As the monograph bases this “presumed” rating solely on evidence from areas of endemic fluorosis where fluoride intake levels are high it is correct to avoid stating the effects as factual. For example, consider these images from areas of endemic fluorosis in China (taken from a slide presentation by Xiang 2014):

Clearly, people in these areas suffer a range of health effects related to the high fluoride intake. The cognitive effects like IQ loss from these areas could result from these other health effects, not directly from fluoride (although excessive fluoride intake leads to the health effects).

So we can “presume” that fluoride (in areas of endemic fluorosis where fluoride intake is excessive) is a “cognitive neurodevelopmental hazard for humans” but we can not factually state that the neurodevelopment effects are directly caused by fluoride. That would require further scientific work to elucidate the specific mechanisms involved in creating that effect.

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Science is often wrong – be critical

Activists, and unfortunately many scientists, use published scientific reports like a drunk uses a lamppost – more for support than illumination

Uncritical use of science to support a preconceived position is widespread – and it really gets up my nose. I have no respect for the person, often an activist, who uncritically cites a scientific report. Often they will cite a report which they have read only the abstract of – or not even that. Sometimes commenters will support their claims by producing “scientific evidence” which are simply lists of citations obtained from PubMed or Google Scholar.

[Yes, readers will recognise this is a common behaviour with anti-fluoride activists]

Unfortunately, this problem is not restricted to activists. Too often I read scientific papers with discussions where authors have simply cited studies that support, or they interpret as supporting, their own preconceived ideas or hypotheses. Compounding this scientific “sin” is the habit of some authors who completely refuse to cite, or even discuss, studies producing evidence that doesn’t fit their scientific prejudices.

Publication does not magically make scientific findings or ideas “true” – far from it. The serious reader of scientific literature must constantly remember that the chances are very high that published conclusions or findings are likely to be false. John Ioannidis makes this point in his article Why most published research findings are false. Ioannidis concentrates on the poor use, or misuse, of statistics. This is a constant problem in scientific writing – and it certainly underlines the fact that even scientists will consciously or unconsciously manipulate their data to confirm their biases. They are using statistical analysis in the way a drunk used a lamppost – for support rather than illumination.

Poor studies often used to fool policymakers

These problems are often not easily understood by scientists themselves but the situation is much worse for policymakers. They are not trained in science and don’t have the scientific or statistical experience required for a proper critically analysis of claims made to them by activists. Yet they are often called on to make decisions which rely on the acceptance, or rejection, of scientific claims (or, claims about the science).

An example of this is a draft (not peer-reviewed) paper by Grandjean et al  – A Benchmark Dose Analysis for Maternal Pregnancy Urine-Fluoride and IQ in Children.

These authors have an anti-fluoride activists position and are campaigning against community water fluoridation (CWF). Their paper uses their own studies which report very poor and rare statistical relationships of child IQ with fluoride intake as “proof” of causation sufficiently strong to advocate for regulatory guidelines. Unsurprisingly their recommended guidelines are very low – much lower than those common with CWF.

Sadly, their sciencey sounding advocacy may convince some policymakers. It is important that policymakers be exposed to a critical analysis of these studies and their arguments. The authors will obviously not do this – they are selling their own biases. I hope that any regulator or policymaker required to make decisions on these recommendations have the sense to call for an independent, objective and critical analysis of the paper’s claims.

[Note: The purpose of the medRxiv preprints of non-peer-reviewed articles is to enable and invite discussion and comments that will help in revising the article. I submitted comments on the draft article over a month ago (Comments on “A Benchmark Dose Analysis for Maternal Pregnancy Urine-Fluoride and IQ in Children”) and have had no response from the authors.  This lack of response to constructive critiques is, unfortunately, common for this group. I guess one can only comment that scientists are human.]

Observational studies – exploratory fishing expeditions

A big problem with published science today is that many studies are nothing more than observational exploratory studies using existing databases which, by their nature, cannot be used to derive causes. Yet that can easily be used to derive statistically significant links or relationships. These can be used to write scientific papers but they are simply not evidence of causes.

Properly designed studies, with proper controls and randomised populations properly representing different groups, may provide reasonable evidence of causal relationships – but most reported studies are not like this. Most observational studies use existing databases with non-random populations where selection and confounding with other factors is a huge problem. Authors are often silent about selection problems and may claim to control for important confounding factors, but it is impossible to include all confounders. The databases used may not include data for relevant confounders and authors themselves may not properly select all relevant confounders for inclusion.

This sort of situation makes some degree of data mining likely., This occurs when a number of different variables and measures of outcomes are considered in the search for statistically significant relationships. Jim Frost illustrated the problems with this sort of approach. Using a set of completely fictitious random data he was able to obtain a statistically significant relationship with very low p values and R-squared values showing the explanation of 61% of the variance (see Jim Frost – Regression Analysis: An Intuitive Guide).

That is the problem with observational studies where some degree of data mining is often involved. It is possible to find relationships wich look good, have low p-values and relatively high R-squared values, but are entirely meaningless. They represent nothing.

So readers and users of science should beware. The findings they are given may be completely false or contradictory. or at least meaningless in quantitative terms (as is the case with the relationships produced by the Grandjean et al 2020 group discussed above).

A recent scientific article provides a practical example of this problem. Different authors used the same surgical database but produced complete opposite findings (see Childers et al: 2020). Same Data, Opposite Results?: A Call to Improve Surgical Database Research). By themselves each study may have looked convincing. Both used the same large database from the same year. Over 10,000 samples were used in both cases and both studies were published in the same journal within a few months. However, the inclusion and exclusion criteria used were different. Large numbers of possible covariates were considered but these differed. Similarly, different outcome measures were used.

Readers interested in the details can read the original study or a Sceptical Scalpel blog article Dangerous pitfalls of database research. However, Childers et al (2020) describe how the number of these sort of observational studies “has exploded over the past decade.” As they say:

“The reasons for this growth are clear: these sources are easily accessible, can be imported into statistical programs within minutes, and offer opportunities to answer a diverse breadth of questions.”

However:

“With increased use of database research, greater caution must be
exercised in terms of how it is performed and documented.”

“. . . because the data are observational, they may be prone to bias from selection
or confounding.”

Problems for policymakers and regulators

Given that many scientists do not have the statistical expertise to properly assess published scientific findings it is understandable for policymakers or regulators to be at a loss unless they have proper expert advice. However, it is important that policymakers obtain objective, critical advice and not simply rely on the advocates who may well have scientific degrees. Qualifications by themselves are not evidence of objectivity and, undoubtedly, we often do face situations where scientists become advocates for a cause.

I think policymakers should consciously seek out a range of scientific expert advice, recognising that not all scientists are objective. Given the nature of current observational research, its use of existing databases and the ease with which researchers can obtain statistically significant relationships I also think policymakers should consciously seek the input of statisticians when they seek help in interpreting the science.

Surely they owe this to the people they represent.

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Even studies from endemic fluorosis areas show fluoride is not harmful at levels used in fluoridation

Most of the claims made by anti-fluoride propagandists are simply wrong. Image source: Fluoridation and the ‘sciency’ facts of critics

Anti-fluoride propagandists continually cite studies from areas of endemic fluorosis in their arguments against community water fluoridation (CWF). But if they critically looked at the data in those papers they might get a shock. Invariably the published data, even from areas of endemic fluorosis, shows fluoride is safe at the concentrations relevant to CWF.

I have completed a detailed analysis of all the 65 studies the Fluoride Action Network (FAN) lists as evidence that community water fluoridation (CWF) is harmful to child IQ. The full analysis is available for download as the document Analysis of FAN’s 65 brain-fluoride studies.

In this article, I discuss the studies in the FAN’s list (see “FLUORIDE & IQ: THE 65 STUDIES”) which report relationships between child IQ and fluoride exposure in areas of endemic fluorosis. There are eleven such studies in the FAN list but only six of them provide sufficient data to enable independent statistical analysis.

While those six studies do show a statically significant (p<0.05) negative relationship of IQ with fluoride intake those results are not relevant to CWF because the fluoride as exposure levels are much higher than ever occurs with CWF.

However, it is possible to investigate if the relationships are significant at lower concentrations more relevant to CWF. I have done this with these six studies and illustrate the result obtained with these graphs below using the data extracted from Xiang et al (2003). (This study is often used by anti-fluoride campaigners).

The red data points in the figures below are for lower concentrations of urinary F or creatinine adjusted urinary F. The range for the red points is still quite a bit larger than urinary F levels measured for children in areas where CWF is used. However, we can see that the relationships at these lower ranges are not statistically significant (results from regression analyses cited in figures).

 

This was also the case with the other studies from FAN’s list which provided sufficient data for regression analyses. I summarise the results obtained for five of these studies in the figure below.

This show that none of the studies found statistically significant relationships with fluoride exposure for the low fluoride concentration relevant to CWF. The situation is basically the same for the sixth study, Mustafa et al (2018), which reports average school subject performances for a range of subjects for children in Khartoum state, Sudan. However, it is hard to know what the safe limit for fluoride exposure is in that climate (for climatic reasons the upper permissible F level in drinking water is set at 0.33 ppm for Khartoum state) and the sample numbers are low. Interested readers should consult my report – Analysis of FAN’s 65 brain-fluoride studies.

Conclusion

Anti-fluoride campaigners often cite FAN’s list (“FLUORIDE & IQ: THE 65 STUDIES”) in their attempts to argue that fluoridation is bad for the child’s brain. But in these series of articles Anti-fluoride 65 brain-fluoride studies not evidence against fluoridation, I have shown that their arguments are false.

In Child IQ in countries with endemic fluorosis imply fluoridation is safe I showed that while IQ and other health problems may occur where fluoride exposure is very high in areas of endemic fluorosis the reports themselves implicitly assume that the low fluoride exposure in the “low fluoride” areas is safe. It is the data from these areas, not the “high fluoride” areas, that are relevant to CWF. So despite the heavy use of these articles by FAN and anti-fluoride activists these studies do not prove what they claim. If anything these studies show CWF is safe.

In this article, I considered a few of these studies which included data relevant to low fluoride exposure. When the low fluoride exposure data (relevant to CWF)  from these studies were statistically analysed none of them showed significant relationships of child IQ to fluoride exposure. That confirms the implicit assumption from these studies that there is no negative effect of fluoride exposure on child IQ at these low levels.

Finally, in Canadian studies confirm findings of Broadbent et al (2015) – fluoridation has no effect on child IQ I summarise results from the only three studies where comparisons of IQ for children living in fluoridated and unfluoridated areas are compared. These studies were made in New Zealand and Canada and the results were the same. No statistically significant differences in child IQ were found.

However, the authors of the Canadian studies ignored this result and instead used questionable statistical methods to search for possible relationships between fluoride exposure and child IQ. Most of the relationships they report were not statistically significant but, nevertheless, they and their supporters have simply ignored this and concentrated on the few statically significant relationships.

Anti-fluoride activists currently rely strongly on these studies and heavily promote them. I will discuss these few studies further in my next article.

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Canadian studies confirm findings of Broadbent et al (2015) – fluoridation has no effect on child IQ

Readers may remember the scathing reaction of anti-fluoride campaigners to the paper of Broadbent et al (2015). This was the first paper to compare child and adult IQ levels for people living in fluoridated and unfluoridated areas.

The anti-fluoride campaigners were extremely rude in their reaction – accusing the authors of fraud and claiming the paper was “fatally flawed.” Interestingly, several scientists known for their anti-fluoride bias also launched attacks – but more respectably as letters to the editor of the journal. For example, see articles by Osmunson et al (2016),  Grandjean (2015),; and Menkes et al (2014).

And why? Simply because Broadbent et al (2015) showed there was no difference in IQ of people living in fluoridated areas. That the studies from areas of endemic fluorosis used by anti-fluoride activists to argue at CWF were just not relevant (see Child IQ in countries with endemic fluorosis imply fluoridation is safe).

But isn’t it strange? Two more recent papers (Green et al 2019 & Till et al 2020) have effectively repeated the work of Broadbent et al (2015). They found the same result – no difference in IQ of children living in fluoridated and unfluoridated areas. And simply no reaction, no condemnation from anti-fluoride activists or the anti-fluoride scientists.

No condemnation because these anti-fluoride critics promote these papers for other reasons. But this underlines how biased the critics of the Broadbent et al (2015) paper were.

I have completed a detailed analysis of all the 65 studies the Fluoride Action Network (FAN) lists as evidence that community water fluoridation (CWF) is harmful to child IQ. The full analysis is available for download as the document Analysis of FAN’s 65 brain-fluoride studies.

In this article, I discuss the studies in the FAN’s list (see “FLUORIDE & IQ: THE 65 STUDIES”) which compare child IQ in areas of “fluoridated” and “unfluoridated” fluoride in Canada. Only two studies – but I include that of Broadbent et al (2015) (which FAN’s list ignores) for completeness. All three studies found no difference in the IQ of children living in fluoridated and unfluoridated areas.

Comparing IQ of children in fluoridated and unfluoridated areas

The table below summarises the results reported by all three studies – Broadbent et al (2015), Green et al (2019), and Till et al (2020).

Table 1: Results from studies comparing IQ of children and adults from fluoridated and fluoridated areas

Notes:
Data from Green et al (2019) for children whose mothers lived in fluoridated or unfluoridated areas during pregnancy.
Data from Till et al (2020) for children either breastfed of formula-fed as babies while living in fluoridated or unfluoridated areas.

There is absolutely no difference in IQ due to fluoridation. Remember, the standard dedication of the values in the table are about 13 to 16 IQ points.

I have presented all the results from these papers graphically below. FSIQ is the normal IQ measurement. VIQ (Verbal IQ) and PIQ (Performance IQ) are subsets of FSIQ.

The only statistically significant differences between fluoridated and unfluoridated areas were for VIQ of breastfed babies (VIQ higher for fluoridated areas) and PIQ of formula-fed babies (PIQ lower for fluoridated areas).

Anti-fluoride campaigners and (biased scientists like Grandjean) love the Green et al (2019) and Till et al (2020) papers because they reported (very weak) negative relationships of some child cognitive measures with fluoride intake ( I discuss this in separate articles). This is largely a result of the statistical methods used – particularly resorting to several different cognitive measures and measures of fluoride exposure, as well as the separation of results according to gender. Reminds me of the old saying that one can always get the results one requires by torturing the data hard enough.

I will return to the statistical problems of these and similar papers in a separate article.

Misrepresentation by anti-fluoride activists

Anti-fluoride campaigners have latched on to the two Canadian studies – often making claims that simply are not supported. But always ignoring the data shown above.

For example – this propaganda poster from FAN promoting the Green et al (2019) study.

This completely misrepresents the results of the study. No difference was found in the IQs of children from fluoridated and unfluoridated areas. These people completely ignore that result while placing unwarranted faith in the weak relationships reported elsewhere in that paper. (In fact, Green et al (2019) found a weak significant relationship only for boys – the relationships for all children and for girls were not significant. See my articles about this statistical torture).

And this FAN propaganda poster promoting the Till et al (2020) study.

Again – completely wrong. There was no difference in IQ of formula-fed babies in fluoridated and unfluoridated areas (see Table 1 above). Even worse – FAN is misrepresenting the statistical relationships reported in this paper as there’s was no statistically significant relationship between child IQ and fluoride exposure for formula-fed our breastfed babies once the influence of outliers and/or confounders were considered.

Misrepresentation by anti-fluoride scientists

It is understandable, I guess, that the authors of the two Canadian papers make a lot of the poor statistical relationships they reported and ignored the fact that they did not see any effect of fluoridation. Perhaps they can be excused some bias due to professional ambition. But this underlines why sensible readers should always critically and intelligently read the papers in this controversial area. One should never rely on the public relations claims of authors and their institutes. But it is sad to see how scientific basis and ambitions can lead scientists to support the claims of political activists. or worse, to attack honest scientists who do post-publication peer review of the studies (see for example When scientists get political: Lead fluoride-IQ researcher launches emotional attack on her scientific critics).

I am also very critical of scientific supporters of these studies who have their own anti-fluoride motivations. Philippe Grandjean, for example, was one of the authors very critical of the Broadbent et al (2015) paper and ignored completely the fact that the Green et al (2019) and Till et al (2020) papers report exactly the same result – no effect of fluoridation on child IQ. Grandjean often makes public comments supporting the claims of anti-fluoride campaigners like FAN. He also behaved in a scientifically unethical way when he refused to allow my critique of the flawed paper by Malin & Till (2015) to be published in Environmental Health – the journal he acts as the chief editor of (see Fluoridation not associated with ADHD – a myth put to rest).

I am repeating myself but it is a matter of “reader beware.” Readers should not simply rely on the scientific “standing” of authors who are only human and suffer from the same biases as others. They should read these papers for themselves and make up their own mind about what the data actually says.

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Child IQ in countries with endemic fluorosis imply fluoridation is safe.

Anti-fluoride activists love to point out that people living in endemic fluorosis areas in countries like China suffer all sorts of health problems, including lower IQ. But studies of these areas show no lowering of IQ in the low fluoride areas relevant to community water fluoridation.

I have completed a detailed analysis of all the 65 studies the Fluoride Action Network (FAN) lists as evidence that community water fluoridation (CWF) is harmful to child IQ. The full analysis is available for download as the document Analysis of FAN’s 65 brain-fluoride studies.

In this article, I discuss the studies in the FAN’s list (see “FLUORIDE & IQ: THE 65 STUDIES”) which compare child IQ in areas of “low” and “high” fluoride in countries like China, Mexico, Iran, Egypt, and India where fluorosis is endemic. In fact, all these studies either assume or provide evidence that fluoride at the concentrations used for CWF is harmless.

IQ differences for “high” and “low” fluoride areas

FAN was really dredging through very poor research to find these studies. In fact, FAN had to go to the trouble of translating many of these studies because they were obscure and not available in English.

Of their 65 studies, 17  do not provide data for fluoride intake or for drinking water fluoride concentrations. Instead, they simply describe the “high” areas as endemic fluorosis areas or areas where people suffer severe dental or skeletal fluorosis. Several of the studies used “control” groups from areas of “slight” fluorosis or dental fluorosis in contrast to skeletal fluorosis.

Another 29 studies did provide water fluoride concentrations for the “low” fluoride and “high” fluoride areas. This data is useful as it enables us to consider how relevant the results are to CWF. I have summarised the data in Figure 1.

The take-home message from Figure 1 is that while these 29 studies do show a decrease in child IQ in areas of “high” fluoride those areas are not relevant to CWF. In fact, the only relevance to CWF are the areas of “low” fluoride where there is the implicit assumption that child IQ is not affected. We can also assume this is the case for the 17 studies which do not provide details of fluoride exposure.

Figure 1: Comparison of water fluoride levels in “high” and “low” fluoride areas of 29 of the FAN studies and in areas where CWF is used.

So these 46 studies heavily promoted by FAN over recent years do not show any harm from CWF – in fact, all these studies implicitly assume there is no negative effect on child IQ at the “low” fluoride levels studied – and these are the areas most relevant to CWF. A simple consideration of the health problems faced by people living in areas of endemic fluorosis should have made it obvious that the data for high fluoride areas is simply not relevant. Consider these figures from Das et al (2016) – one never sees people like this in areas where CWF is used:

Dental fluorosis case found in the study area (age: 12, sex: male). Das et al (2016)

Skeletal fluorosis case found in the study area (age: 17, sex: male). Das et al (2016)

FAN is simply silly to suggest these studies, and especially the results for the “high” fluoride areas, area at all relevant to CWF.

Mind you, Paul Connett, FAN Director, likes to draw attention to one of these studies where he claims the “high” fluoride area has a drinking- water fluoride concentration of 0.81 mg/L which is similar to that for CWF. He is simply dredging the data (and ignoring all the other studies he cites)  to make this claim. The study he refers to was made in an area of iodine deficiency and is extremely weak – simply and half pages in a Chinese newsletter. Have a look for yourself – Lin et al (1991).

In a future article, I will discuss the studies in FAN’s list which compare IQ for children from fluoridated and unfluoridated areas.

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