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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Anti-fluoride 65 brain-fluoride studies not evidence against fluoridation

Activists like ant-fluoride and anti-vaccination propagandists are very selective about the studies they promote. But their bias often means they get even these ones wrong. FAN’s 65 brain-fluoride studies are an example of this. Image credit: Don’t let confirmation bias narrow your perspective

Anti-fluoride and anti-vaccination activists suffer from a common activist fallacy – they believe their own propaganda. They also have a network of “natural”/alternative health industry internet sites and magazines to disseminate these beliefs and propaganda. A glaring example is a smug article, The End of Fluoridation Is in Sight, published on the Mercola.com alternative health, anti-vaccination site.

The uninformed reader looking at these alternative health industry sources might be excused for thinking that community water fluoridation (CWF) is about to end. That the scientific evidence against it is damning. But, of course, those conclusions are wrong – the science supporting CWF remains strong and the few studies activists use to argue against CWF have big flaws.

Actually, the situation is even worse than that. The studies commonly cited by anti-fluoride activists actually support CWF when they are read properly. Activists are unaware of this because they rarely read the studies they cite – most don’t get past the title, let alone the abstract, and certainly don’t bother with the real content. And they never subject these studies to critical analysis.

The Fluoride Action Network (FAN) has collected  together all the studies they argue show CWF is bad for children’s brains in a single list – “FLUORIDE & IQ: THE 65 STUDIES.” I have completed a detailed analysis of all the 65 studies and my full analysis is available for download as the document Analysis of FAN’s 65 brain-fluoride studies.

In fact, none of these studies in FAN’s list provides any credible evidence that CWF is harmful to child IQ. On the contrary, these studies either assume or provide evidence that fluoride at the concentrations used for CWF is harmless.

I will summarise my findings of these studies in a series of upcoming articles as my health permits (I have just spent a couple of stressful weeks in hospital).

1. Difference studies – a simple comparison of cognitive measures in people living in “low fluoride and “high fluoride” areas. Forty-six studies made in areas of endemic fluorosis – India, China, Mexico, Iran, and Sudan. All these studies implicitly assume no negative health effects at fluoride concentration relevant to CWF
2. Three difference studies relevant to CWF where populations in non-fluoridated and fluoridated areas are compared. All these studies show no effect of CWF on child IQ.
3. Studies which derive relationships of cognitive measurements with fluoride exposure in areas of endemic fluorosis. Six of these studies include enough data for testing if there is a statistically significant effect at concentrations relevant to CWF – there is no effect observed in all these cases.
4. Three studies deriving relationships for cognitive measurements with fluoride exposure in low fluoride areas where concentrations are relevant to CWF. These controversial studies involve considerable statistical manipulations and activists cherry-pick a few statistically significant relationship but ignore the many more non-significant relationships.

Read my article Analysis of FAN’s 65 brain-fluoride studies if you want the detailed analysis. Otherwise, just follow my summaries in future posts.

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Another study used by anti-fluoride activists actually shows community water fluoridation OK

Another study comparing effect in children from nonendemic areas (Dagang) and endemic fluorosis area (Jinghai) about 80km apart in the Tianjin area of China. Hardly sampling the same population.

Anti-fluoride campaigners still use studies from endemic fluorosis area of China in their campaign against community water fluoridation (CWF). This misrepresents the situation. While the control areas they use (non-endemic fluorosis areas where there are no health effects) are relevant to CWF the data from the endemic fluorosis areas where fluoride intake is high are simply not relevant to CWF.

However, some of these studies provide enough information to enable checking for health effects in the control, non-endemic fluorosis areas. I discuss one of these studies below – Cui et al (2018) – and show it finds no health effects at the low fluoride concentration relevant to CWF. The use of this study in anti-fluoride campaigns is therefore misleading.

I also show how even in his misrepresentation of this study the “Research Director” of the Fluoride Action Network (FAN), Chris Neurath, makes basic mathematical mistakes.

The citation for this study is:

Cui, Y., Zhang, B., Ma, J., Wang, Y., Zhao, L., Hou, C., … Liu, H. (2018). Dopamine receptor D2 gene polymorphism, urine fluoride, and intelligence impairment of children in China: A school-based cross-sectional study. Ecotoxicology and Environmental Safety, 165(August), 270–277.

The study used school children (7 to 12 years old) from the districts of Jinghai and Dagang in Tianjin of China (see map above). The endemic fluorosis area had drinking water fluoride concentrations of 1.52–2.49 mg/L and the nonendemic fluorosis area had drinking water fluoride concentrations of 0.20–1.00 mg/L.

Of course, the results for children in the endemic fluorosis area are simply not relevant to CWF where the drinking water concentrations are usually less than 0.8 mg/L.

ONLY THE DATA FROM THE NON-ENDEMIC FLUOROSIS AREA IS RELEVANT TO CWF.

Child IQ values were compared with urinary fluoride levels and regression analysis used to determine if there was any relationship. The children were also tested for the presence of different genes and each of three different genetic groups was considered separately.

Skewed data

The data from both endemic and non-endemic fluorosis areas were combined. That for urinary F was skewed and had to be transformed to provide the normal data distribution required for linear regression analysis. Consequently, the authors report linear regression results for the relationship of child IQ to the logarithm of urinary F [Log(UF)].

No statistically significant relationships were found for two of the genotypes (designated CC & CT) but there was a significant relationship for the genotype designated TT. Less than 14% of the children had this gene.

Figure from Cui et al (2018) showing a negative relationship of child IQ with the logarithm of urinary fluoride. Equation of fitted line is IQ = 117.48 – 9.75*Log(UF). R-squared = 0.142, p = 0.012. 95% CI for coefficient -17.21,-2.29

So, of course, the anti-fluoride campaigners simply go with the results for the children with the TT gene and ignore the results for the other 86% of children.

Nothing new here – they always ignore results that they can not use in their campaigns to confirm their biased presentations.

Analysis of the data for the low fluoride levels relevant to CWF doesn’t support activist claims

Here I will just consider the data relevant to CWF. After digitally extracting the data from the figures in the paper I restricted linear regression analysis to the children with urinary F values of less than 2 mg/L (which is still rather high for areas where CWF is used). The figure below displays that data, together with the results of linear regression analysis. Untransformed values were used because data for urine fluoride concentrations less than 2 mg/ml is normally distributed.

Linear regression analysis for the relationship of child IQ with urinary F. Children with TT gene about 44% of the sample. Children with CC and CT genes about 86% of the sample.

There were no statistically significant (p < 0.05) relationships, either for the TT variant (red triangle) or for the other variants (open circle) (CC & CT combined in this figure).

So, once again we see that if the appropriate data from these studies are used they confirm that there is no relationship of child IQ with measures of fluoride exposure at concentrations relevant to CWF (see also New study touted by anti-fluoridation campaigners actually indicates fluoridation is safe).

FAN’s “Research Director” makes simplistic mistakes

FAN plans to use studies like Ciu et al (2018) in their upcoming case against the US Environmental Protection Agency. Their aim is to attempt to establish cognitive effects as the main harms from CWF and then use studies like these to argue against CWF. Even though studies like this simply establish that there is no harm from fluoride concentration used for CWF. One hopes that the experts testifying for the EPA show how these studies are misrepresented by FAN.

FAN has provided a presentation by their “Research Director,” Chris Nerath, which they claim summarises their arguments. It’s a “pretty” PowerPoint presentation (FAN describes it as “powerful“) and may fool some people, but it just does not stand up to scientific scrutiny.

Quite apart for the misrepresentation of these scientific studies, and use of studies like Cui et al (2018) which are not relevant to CWF, Neurath simply makes basic scientific mistakes.

For example, in his slide 33, he claims that Cui et al (2018) showed a 10 point IQ loss for a 1 mg/L increase in urinary F. But that is simply not true – his mistake is that he ignored the fact that the linear relationship reported by Cui et al 2018) [IQ = 117.48 – 9.75*Log(UF)] is based on log values of urinary F where the value of the coefficient is -9.75. In other words, the 10 point loss is for an increase of urinary by a log value of 1 is equivalent to an increase from a concentration of 1 mg/L [Log(1) = 0] to a urinary F concentration of 10 mg/L ([log(10)=1].

Slide 33 from the presentation by Chris Neurath, FAN’s “Research Director” displaying an embarrassing mathematical mistake.

Let’s do the correct calculation for him. The Cui et al (2018) relationship shows an IQ value 117.48 for a urinary F concentration of 1 mg/L [Log(1)=0] and 114.55 for a urinary F concentration of 2 mg/L [Log(2)=0.301]. So the loss is only 2.9 IQ points.

Neurath thinks it sounds much better for his case to say a loss of 10 IQ points but all he has done is shown either he did not read Cui et al (2018) properly or does not understand a simple mathematical relationship.

However, I should stress Neurath’s argument is irrelevant to CWF, as well as being mathematically wrong because its analysis includes data from endemic fluorosis areas. In fact, there is no statistically significant relationship between child IQ and urinary fluoride either for the overall group or for the separate genetic groups considered.

“Safety threshold”

The graph in Neurath’s slide is adapted from Cui et al (2018) which made an attempt to determine a “safety threshold of urine fluoride levels for IQ
impairment” for the children with the TT gene. They defined this “safety threshold” as the urinary fluoride value corresponding to the mean IQ for the group. This seems arbitrary to me and the authors make no attempt to justify the definition.

They then divided the data into quintiles according to urinary fluoride values. Quintile 4 was the first quintile where the mean IQ value is below the mean IQ for the whole group so they assumed to mean log(UF) for that quintile to represent the “safety threshold.”

It all seems quite hairy to me – but I suppose the method produces a few data points which Neurath was able to plot on a graph and make to appear impressive. But look at the spread of the data (Neurath does not show this) in the graph below where the bars represent the spread of data for each quintile and the dotted line is the mean IQ value for the group. The spread is hardly surprising – the overall data is very scattered and only about 9 data points were used for each quintile.

I frankly think this method of determining a “safety threshold” is meaningless. We could do exactly the same with the data where urinary fluoride is less than 2 mg/L – much more relevant to CWF. This is the result – using quartiles of about 8 data points each.

Quite meaningless.

There are many other misrepresentations and mistakes in Chris Neurath’s Powerpoint presentation and I may return to some of them later. However, let’s hope the court recognises these and rejects FAN’s attempts.

Conclusion

Anti-fluoride activists continually use studies from areas of endemic fluorosis in their campaigns against CWF. However, when the actual data relevant to community water in these studies are considered they usually show no health effect.  There is no doubt that people living in endemic fluorosis areas suffer a range of health problems. But where these studies provide complete data they almost always could be used to support CWF.

Activists like FAN and their “Research Director” simply clutch on to any study they can finds which appears to show harmful effects of fluoride and ignore the fact that they are hardly ever relevant to the fluoride concentration used in CWF. They cherry-pick and ignore, or cover-up, any information not supporting their bias.

This approach is hardly scientific. It is not objective and never undertakes a critical review of the studies used. These activist display a thoughtless approach to scientific research when they opportunistically use scientific studies like this. Their approach is unthinking and it is hardly surprising that they make simple mathematical and statistical errors like the one described here and made by Paul Connett recently (see Anti-fluoridation propaganda now relies on only four studies. 4: Till et al (2020) and Author confirms anti-fluoridation activist misrepresentation of her work).

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When scientists get political: Lead fluoride-IQ researcher launches emotional attack on her scientific critics

age credit: Science and Politics – Skeptically.org

It seems impossible to keep politics out of science. It’s a pity because politics can end up forcing science to produce the results desired by politicians. When this happens the ideal aim of science – the pursuit of objective knowledge – can get lost.

We rightly disapprove of external political and commercial influences on science. But there is another insidious form of politics derived from ego, personal ambition and the promotion of research by institutes and individual researchers. This is very often driven by the competition for research funding – the loudest researcher gets the grant. These days this is a real problem – the classical introverted scientist, no matter how bright, is often at a complete disadvantage when it comes to the fight over research funding.

In my own career, I have seen excellent researchers driven to redundancy simply because they did not have the political skills to fight for research funds. And at the same time, I have seen mediocre scientists, often producing poor quality or even misleading science, get those funds – simply because of their ambition and political skills.

These thoughts came flooding back to me as I read the new opinion piece by Christine Till, the leader of the research group that published several of the recent fluoride-IQ/ADHD and similar papers that I have critiqued here. Papers that have been heavily promoted by the authors and Till’s institute as well as the anti-fluoride/anti-vaccination crowd and, at the same time, extensively critiqued by the scientific community.

The citation  for her article is:

Till, C., & Green, R. (2020). Controversy: The evolving science of fluoride: when new evidence doesn’t conform with existing beliefs. Pediatric Research.

Unfortunately, the article is not a reply to critics or a good faith scientific engagement with the scientific issues. It is simply an attack on those who have made honest and respectful critiques. An attack which attributes unjust motives to her critics and comes close to personal.

Attempt to close down science by personal attacks

I discussed some of these issues before in my articles Scientific integrity requires critical investigation – not blind acceptance and Fluoridation science and political advocacy – who is fooling who?

In this case, I was concerned about the way  Dr William Ghali, one of the promoters of  Christine Till’s work, attacked and attempted to belittle scientific colleagues who were indulging in the normal peer-review process of critiquing published papers which they considered had faults. Nothing new about that scientific critique – it goes on all the time. It is expected by authors and, in the end, it helps to improve the science. I Personally think such critique should be welcomed by researchers.

If the opponents of scientific exchange like Dr Ghali are successful in their attempt to prevent such scientific debate then we are all losers. How can we trust scientific findings that are protected from scrutiny?

This is what is wrong with the opinion piece by Till and Green cited above. Instead of entering into a good-faith scientific exchange with their critics they attribute motives and biases to them. Even accusing them of attempting to prevent the progress of science. They accuse critics of a “tendency to ignore new evidence,” of  “overt cognitive bias” and of promoting  a “polarized fluoride debate.”

But, in fact, these critiques have come because the “new evidence” is not being ignored but is being evaluated. It is being critically considered. The article more or less admits this when it says “critics attacked the methodology of the study [Green et al (2019] and discounted the significance of the results.”

True, the so-called “fluoride debate” is polarised. After all, it is being promoted by anti-fluoride/anti-vaccination activists who are attempting to prevent or remove, a health policy known to benefit children. Till & Green may be unhappy that they have not been able to win over the scientific community with their paper but it is hardly honest to reject the critiques of the paper by calling them “attacks” or by claiming they “ignore” the evidence.

An admission the paper had difficulties

The article admits the  Green et al (2019) paper had difficulties right from the beginning. It took three attempts before a journal would accept it for consideration. Even then it ended up having “several additional rounds of review by the JAMA editors until we eventually reached a compromise.” This gives some substance to my speculation of problems in the review process which lead to the unprecedented publication of an editor’s note – a political action  I have never seen before (see If at first you don’t succeed . . . statistical manipulation might help).

They acknowledge that even their colleagues in environmental epidemiology “were initially sceptical.” And so they should have been – all new research should be reviewed sceptically and critically.

Refusing to engage scientifically

But the annoying thing is that these authors attempt to write off the scepticism and critical review of the wider scientific community as being due to “experts” (yes in quotes), “who held strong beliefs . .” This despite the fact that in the published critiques it is not “strong beliefs” which were presented, but detailed consideration of the methodology and statistical analyses used in the original paper.

All these critiques were made respectfully – and often with thanks to the Green et al (2019) for their new work. Yet Till and Green accuse these reviewers of making “vitriolic comments and claims with little scientific basis” – a comment which is, in itself, disrespectful to those who took time to make their critiques. They resort to smearing two of the reviews (by the UK-based Science Media Centre and Dr Berezow, a specialist from the American Council on Science and Health) by accusations these bodies are “both heavily funded by the pharmaceutical and food and beverage industries.” This funding smear is commonly used by anti-science activists who attempt to discredit scientific findings or analysis but refuse to consider the science itself.

They say of these two reviews that they claim “the results are driven by outliers” – yet a simple search shows that this comment simply does not appear in the cited reviews.  The critique of Dr Berezow from the American Council on Science and Health does not include either of the words “outlier” or “driven.”

The only reference to “outliers” in the Science Media Centre review was by Dr Oliver Jones, Associate Professor of Analytical Chemistry, RMIT University who wrote:

“The authors state that an increase of 1 milligram per liter (1 mg/L) increase in fluoride was associated with a 4.49 point lower IQ score but fluoride intake appears to have been below 1 mg/L for most people in the study, even for those with fluoridated water, and nearly everyone (bar a few outliers) had a fluoride intake of less than 2 mg/L (which multiple previous studies have shown is safe) . There is also a Lot of variation in the data – which makes drawing firm conclusions/ predictions from it difficult.”

A valid criticism which needed a response – not a smear.

My search for the word “driven” produced these two comments:

Dr Joy Leahy, Statistical Ambassador, Royal Statistical Society, wrote:

“if a woman is living in an area with fluoridated water during pregnancy, then her child is likely to grow up drinking this same fluoridated water. Therefore, it is difficult to say whether any association found is driven by the fluoride consumption in pregnancy, or an assumed fluoride consumption in the infant after birth.”

Prof Rick Cooper, Professor of Cognitive Science, Birkbeck, University of London, said:

“a significant decrease in IQ was found only in boys – girls showed a non-significant increase in IQ. The negative effect was driven by a small number of boys whose mothers had extreme levels of fluoride exposure, but even these children had IQ in the normal range.”

These are valid points that again deserve a scientific response yet Till & Green describe them as “vacuous claims exemplify attempts to manipulate the scientific evidence and manufacture doubt.”

We all support using new knowledge to adjust policies

Till & Green attempt to claim the high moral ground by asserting:

“Science advances by continuously challenging old ideas and adjusting our beliefs as new knowledge emerges, even if this new evidence conflicts with conventional wisdom or is inconvenient.”

Of course, this is true and I think it is dishonest of them to pretend this is not also the position of those who critiqued their paper. These reviewers were interested in looking at the new results, evaluating them and seeing how relevant they are. Seeing if they do indeed require us to adopt new thinking.

After all, look at what Dr Berozow, one of the critics they smeared by implying he was influenced by industry funding  and was falling back on “vitriolic comments” and “vacuous claim”, says in introducing his critique:

“The investigation by Green et al into the effect of maternal consumption of fluoride on the IQ of children is important. It is always wise to constantly evaluate and reevaluate long-standing public health practices in the light of new evidence.”

Till & Green are simply resorting to attributing motive and asserting their critics are not open to new knowledge as a way of avoiding facing up to the valid criticisms made by experts who reviewed and critiqued their work.

Confirmation bias – the pot calls the kettle black

We all suffer from confirmation bias and scientists (including Till & Green) are not immune. It is well understood that scientists are the last people to recognise problems in their own work. That is why peer review and open critique of scientific reports is so essential. But, in line with the whole approach of this opinion piece, Till & Green attempt to present a picture that only their critics suffer from this problem. They say:

“We typically fret about subtle biases, like recall bias and unmeasured confounding, but confirmation bias, the tendency to ignore or debunk data that does not conform to what we believe, is arguably a much larger problem.”

I find their attempt to belittle concerns about “unmeasured confounding” rather ironic. After all, this was the problem with Till’s original fluoride-ADHD work (which she used to win research grants for her later fluoride research) that I highlighted in Perrott (2018) Fluoridation and attention deficit hyperactivity disorder – a critique of Malin and Till (2015).

I am aware that Till has read my paper in its pre-publication and published forms but studiously ignores it. For example, the ADHD paper of Riddell et al (2109), which she co-authored, simply does not include Perrott (2018) in its discussion and continues to present Malin & Till (2105) as authoritative despite the obvious flaw that it ignored important confounders, and when these are considered their claim of a relationship between fluoridation and ADHD prevalence proved to be false.

So much for her attribution of confirmation bias to others – when she is obviously guilty of it in this case by ignoring “data that does not conform, to what [she] believes.”

The Till & Green opinion piece is unwise

Till & Green seem to have simply reacted emotionally to the reviews and critiques the Green et al (2019) paper received. They, of course, had the right – even the obligation – to respond scientifically to the reviews. But I believe their response in this article is unwise, maybe even professionally damaging,  and they should not have committed these emotional outbursts to print. After a cooling down period, it is possible they will withdraw the article – and that would be best for them in the end.

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New study touted by anti-fluoridation campaigners actually indicates fluoridation is safe

Children used in this study were from Lintingkou town (a normal-fluoride/control area) and Dakoutun town (a high-fluoride area) in Baodi district of Tianjin, China. The towns are 25 km apart.

Anti-fluoridation activists on social media seem to cite any scientific article about fluoride which they think will show it harmful. They usually rely only on information in the article title or abstract. This means they are often wrong as the articles may not be at all relevant to the low fluoride concentrations used in water fluoridation. Perhaps they should stop for a minute and actually read the articles they cite.

The other day @NYSCOF, the twitter account for the New York State Coalition Opposed to Fluoridation, Inc (a small antifluoridation activist group in New York) promoted a new Chinese study as part of its campaign against community water fluoridation (CWF). It claimed: “Children’s IQ was lower when water and urinary fluoride levels were high compared to a low fluoride group.” But the fact this is a Chinese study should have warned the honest reader that the “high” fluoride group lived in an area of endemic fluorosis and data for them is irrelevant to CWF.

In fact, some of the data in their paper are relevant to CWF – the data for the “low fluoride” control group where children were exposed to drinking water concentrations less than 1 mg/L (CWF aims to maintain a drinking water fluoride concentration of about 0.7 or 0.8 mg/L). It’s worth looking at that data to see if child IQ is related to fluoride exposure at that level.

The take-home message is that it isn’t.

Here is the citation for the new study:

Zhao, Q., Tian, Z., Zhou, G., Niu, Q., Chen, J., Li, P., … Wang, A. (2020). SIRT1-dependent mitochondrial biogenesis supports therapeutic effects of resveratrol against neurodevelopment damage by fluoride. Theranostics, 10(11), 4822–4838.

Two different communities

The children (8-12 year-olds) in this study came from two different communities in the Baodi district of Tianjin, China – see the map above. They are Lintingkou town, where drinking water fluoride concentrations were “normal,” and Dakoutun town, which is in an area of endemic fluorosis and the drinking water fluoride concentrations are high (about 1 to 3.5 mg/L). The towns are about 25 km apart and will clearly have a number of differences which could be relevant to the IQ of children. Possible confounders like this were not considered in the study.

People living in areas of endemic fluorosis suffer a range of health and socioeconomic effects which could influence child IQ

The figure below from the paper illustrates the ranges of drinking water F and urinary F for the children studied (30 in each of the “low” and “high” fluoride groups).

Only the data for the “control” group are relevant to CWF. Unfortunately, the authors chose to plot the IQ data for the two groups on the same graph and concluded that this showed a “fluoride-caused intellectual loss in children” – see their graph below.

But, their conclusion is wrong. When we look at the data for the “control” and “high fluoride” groups separately that simple conclusion is clearly unwarranted.  In fact, there is no statistically significant relationship (p<0.05) of child IQ with urinary F for either the “low” or the “high” group – see the graph below which uses digitally extracted data from the above figure. Data points for the”low” fluoride group are green and those for the “high” fluoride group are red.

This shows how statistical analyses like regression analyses can produce misleading results if the data is not considered properly. It is simply misleading to include two separate populations like this in a regression analysis without considering the whole range of possible confounders.

There is no relationship between child IQ and urinary fluoride in either population. All the regression analysis shows is that there is a difference between the two towns – and that is simply shown by the average values of IQ in those towns. The average child IQ in Lintingkou town is 112.4 while in Dakoutun town it is 98.5.

While these IQ values seem pretty good (usually the average IQ for a population is 100) the lower value for Dakoutun town is not surprising considering that the population living in areas of endemic fluorosis suffer a whole range of health and social problems.

The biochemical data has the same problem

The paper itself is a real hodgepodge of separate studies involving child IQ, levels of mitochondrial biogenesis signalling molecules, experiments with rats and with in vitro cell cultures. I do not have the expertise to critique the biochemical, cell culture and rat behavioural techniques used. However, the presentation of the biochemical data for the children suffers the same problems as the presentation of the IQ data.

The authors claim that there is a significant positive relationship between the silent information regulator 1 (SIRT1) and child urinary F, and significant negative relationships of peroxisome proliferator-activated receptor γ coactivator-1α (PGC-1α) and mitochondrial transcription factor A (TFAM) with child urinary F. But they simply lumped the data for the two towns together. When the data for the two groups are considered separately there are no statistically significant relationships for these biochemical measures in either of the two groups – see figures below. Again, data points for the “low” fluoride group are green and those for the “high” fluoride group are red.

Conclusions

Yet against anti-fluoride campaigners are promoting a study that they probably haven’t even bothered reading. They are using results for an area of endemic fluorosis to argue against CWF. Worse, they are completely ignoring the data in this and similar studies which show no relationship between child IQ and fluoride exposure at fluoride levels relevant to CWF.

Note

The Twitter account @NYSCOF promoting this specific study is very active and is connected with the Fluoride Action Network (FAN) through Carol Kopf –  the media officer for both the New York State Coalition Opposed to Fluoridation, Inc. (NYSCOF) and FAN. Ironically, she uses the slogan “I Am a Force for Science” on her Twitter image.

Sometimes I drop a reply to her posts – in this case pointing out: “And no loss of IQ at F concentrations relevant to community water fluoridation. These studies show CWF safe.”

My comment will not change Carol Kopf’s mind, of course, but others may read it and understand. Mind you, it’s inevitable that other anti-fluoride activists see my comments and react in stupid ways. For example, one of the Fluoride Free NZ leaders, Kane Kitchener, posted this reply:

“Ken, you’ve been exposed too long by Hamilton’s Fluoridated water. Too much reduction in IQ to see it.”

It really is pointless attempting to discuss science with these people.

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No relationship of bone cancer to fluoridation – another new study the anti-fluoride brigade will attempt to ignore

Anti-fluoride activists claim that water fluoridation causes nine cancer proved wrong, yet again. Image credit: Four myths about water fluoridation and why they’re wrong

A new study confirms, yet again, that osteosarcoma, a type of bone cancer, is not associated with community water fluoridation (CWF). This the seventh such study since a 1990 report of an animal study suggested such a link.

The 199o study exposed rats to very high concentrations of fluoride so the results were not relevant to CWF. But, of course, this did not stop anti-fluoride campaigners using the study to argue that CWF causes osteosarcoma.

The citation for this new study is:

Kim, F. M., Hayes, C., Burgard, S. L., Kim, H. D., Hoover, R. N., Osteosarcoma, N., … Couper, D. (2020). A Case-Control Study of Fluoridation and Osteosarcoma. Journal of Dental Research 1.

This was a hospital-based study where patients diagnosed with osteosarcoma were compared with control patients diagnosed with other bone tumours or different conditions. This figure summarises the findings.

The only statistically significant effects show a reduced likelihood of osteosarcoma diagnosis for people living in fluoridated areas – compared with those living in non-fluoridated areas (the red triangles in the figure). These were for people who never drank water and people who had lived in fluoridated areas for 0% to 50% of their lives. It is likely the effects for people who did drink bottles water and those who had lived in fluoridated areas for 50% to 100% or 100% of their lives are not statistically significant because of the smaller numbers involved (The green circles in the figure).

It’s been a bad week for the anti-fluoride crowd – the science keeps proving them wrong. Perhaps that is why they are silent about these new studies.

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New review finds fluoride is not a developmental neurotoxicant at exposure levels relevant to fluoridation

Proper consideration of the best science shows community water fluoridation does not have a negative effect on child IQ. Image credit: Africa Studio / Shutterstock.com

A new extensive review of the scientific literature has concluded that fluoride is not a human developmental neurotoxicant at the current exposure levels in Europe. This is of course just as valid for New Zealand, the USA and other countries which use community water fluoridation (CWF).

Forty-one pages long, it’s a very extensive and detailed review. The full text can be downloaded  and its citation is:

Guth, S., Hüser, S., Roth, A., Degen, G., Diel, P., Edlund, K., … Thomas, H. (2020). Toxicity of fluoride: critical evaluation of evidence for human developmental neurotoxicity in epidemiological studies, animal experiments and in vitro analyses. Archives of Toxicology. 2020 May 8.

The anti-fluoridation crowd won’t be happy with this review. They have tended to have things their own way as they have argued that fluoridation is harmful to child IQ using irrelevant studies from endemic fluorosis areas where people suffer a range of health effect from overexposure to fluoride and other contaminants. Anti-fluoride campaigners have also misrepresented and misused recent studies from areas where fluoride exposure is lower.

So this review is timely because it critically examines all the recent studies and identifies their limitations. It identified 23 relevant epidemiological studies published between January 2012 and August 2019. One of these examined an association between fluoride exposure and school performance. The other 22 examined possible relationships with IQ.

Limitations of fluoride-IQ studies

The authors reported that:

“So far, almost all studies investigating the effect of fluoride intake on intelligence were performed in relatively poor, rural communities, e.g., in China, Iran, and Mongolia, where drinking water may contain comparatively high levels of fluoride (‘exposed population’), whereas the ‘reference populations’ often had access to water that was fluoridated at the recommended level.”

Figure 1: People in endemic fluorosis area sufferer a range of health problems – studies from these areas are not relevant to CWF

This means that anti-fluoride campaigners usually rely on studies which actually show no effect at F intake levels relevant to CWF. They base their arguments on the known negative health effects at high fluoride intake (people in areas of endemic fluorosis suffer a range of health problems) but ignore, or cover-up the fact the data actually does not show any harmful effects at levels similar to that experienced by people in areas of CWF.

Figure 2: Drinking water concentrations reported by Duan et al. (2018) from “high F” and “low F” villages compared with tap water F in areas of CWF

Figure 2 above shows this using data from 26 studies reported in the review of Duan et al. (2018). Here the blue range represents the drinking water concentration range for the control groups where no health problems were reported, or it was assumed none occurred (that is why it was a control group). The green range represents drinking water fluoride concentration common in areas of CWF.

We should be drawing our conclusions about the possible effects of CWF from the blue range of data – not the red range.

Confounding effects

Guth et al (2020) stress that most studies they considered ignored many confounding effects.  For example:

” . .rural regions with unusually high or unusually low fluoride in drinking water may be associated with a less developed health-care system, as well as lower educational and socioeconomic status. Furthermore, in these regions the overall nutritional status and the intake of essential nutrients may be lower and the exposure to environmental contaminants such as lead, cadmium, mercury, or manganese may be higher—factors that are also discussed to have a potential impact on intelligence”

Only two of the studies were from areas using CWF – Broadbent et al (2015) and Green et al (2019) – and their conclusions were different. Guth et al (2020) considered these two studies in detail.

Both studies were limited by the lack of IQ data for mothers – parental IQ is a strong confounder for child IQ studies. But Guth et al (2020) are quite critical of the lack of consideration of confounders in the Green et al (2019) study:

“Green et al. (2019) did not consider breastfeeding and low birth weight as possible confounders (both factors significantly associated with IQ in the study of Broadbent); they considered some of the relevant confounders (city, socioeconomic status, maternal education, race/ethnicity, prenatal secondhand smoke exposure), but did not adjust for others (alcohol consumption and further dietary factors, other sources of fluoride exposure, exact age of children at time point of testing). Furthermore, the study (Green et al. 2019) did not include assessment of children’s postnatal fluoride exposure via, e.g., diet, fluoride dentifrice, and/or fluoride tablets, which is considered to be a noteworthy limitation.”

Problems like poor consideration of confounders, contradictory results and the vague results reported by Green et al (2019) (no overall effect of fluoridation on child IQ, a statistically significant relationship of drinking water F concentration with male child IQ but not with female child IQ) caused Guth et al (2020) to conclude:

“The available epidemiological evidence does not provide sufficient arguments to raise concerns with regard to CWF in the range of 0.7–1.0 mg/L, and to justify the conclusion that fluoride is a human developmental neurotoxicant that should be categorized as similarly problematic as lead or methylmercury at current exposure levels.”

To repeat – this review is very detailed and thorough. Unlike the recent review of Grandjean (2019) (Developmental fluoride neurotoxicity: an updated review) which was superficial and somewhat biased (Grandjean is well known for his opposition to CWF) it made a detailed assessment of problems like the poor consideration of confounders or important risk-modifying factors and the concentration on poor quality studies from areas of endemic fluorosis.

Hopefully, policymakers will read this new review and take its conclusions into account.

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Anti-fluoride campaigners still rely on irrelevant studies

Despite Paul Connett’s claim that one only has to read four studies, anti-fluoride campaigners waste so much time promoting irrelevant studies to support there claims one could say they end up drowning in their own irrelevance. Image Credit: Ian Mcewan Quotations

Anti-fluoride activists simply can’t help it. They will post on social media citations to anything they think shows that fluoride is harmful – even if the studies are completely irrelevant to community water fluoridation (CWF). This despite Paul Connett, director of the Fluoride Action Network (FAN), claiming “You only have to read four studies…” to come to the conclusion that CWF is bad for your health.

Connett claims that he has it all sewed up with these four studies from areas where CWF is used or fluoride exposure values are similar to that for CWF. So I thought this would mean activists would give up citing studies from areas of endemic fluorosis where fluoride exposure is much larger. But no – here we go again with FAN returning to the reliance on endemic fluorosis studies with the claim:

“NEW STUDY: Each 1.0 mg/L increment in [urinary fluoride] concentration corresponded with an increase in the prevalence of psychosomatic problems.”

The local fluoride Free NZ activist group (FFNZ) simply repeats the claim. Anti-fluoride activists have a consistent habit of simply repeating these sort of claims, together with citation, without bothering to actually check what the cited papers say or how relevant the study really is to their cause. These activists seem to make a hobby of this – one can see their work every day on Twitter and Facebook. If nothing else one has to admire their dedication to the cause, if not there understanding of what they cite.

In this case, the study is not at all relevant to CWF. Here is its citation.

Wang, A., Duan, L., Huang, H., Ma, J., Zhang, Y., & Ma, Q. (2020). Association between fluoride exposure and behavioural outcomes of school-age children: a pilot study in China. International Journal of Environmental Health Research, 00(00), 1–10.

Briefly, it reports results for a comparison of six behavioural scores for 325 resident school-age children (7–13 years old) living in Tongxu County of Henan Province in China with a measure of fluoride exposure  (urinary fluoride using a single morning collected sample). There was no statistically significant relationship with of five of these behavioural scores (conduct problems, learning problems, Impulsive-hyperactive, anxiety or ADHD index) with urinary fluoride but there was with one – Psychosomatic problems.

It’s a very weak relationship – one has only to look at how the data is scattered in the figures in the paper to see this:

Notice that the urinary fluoride concentration (Fluoride in the graphs) cover a range much higher than is typical for areas where CWF is used – usually much less than 2 mg/L. Not surprising, as it is from an area of endemic fluorosis. Also noticeable is that some of the high fluoride value data points are outliers which of course will influence the statistical analysis.

Not all the data is available but extraction of the data from the figure for Psychosomatic Problems enabled me to check the effect of outliers at high urinary fluoride concentrations. When only the data for urinary fluoride concentrations below 3 mg/L are considered there is no statistically significant relationship. This is even more true when only the data for urinary fluoride concentrations below 2.5 mg/L is considered. And these concentrations are still higher than found for children living in areas where CWF is used.

Conclusions

This study is completely irrelevant to CWF. In fact, if only the low urinary fluoride concentrations more relevant to CWF are considered the study shows absolutely no negative effect of fluoride on child behaviour. If anything, the study actually could be used to support CWF.

But this does not stop anti-fluoride campaigners from promoting the study on social media as if it supported their arguments. I guess the promotion of irrelevant work like this is simply a result of the way they mine citations – promoting anything that could appear to indicate problems with fluoride -even when the studies are completely irrelevant. It’s also a result of the thoughtless way citations are used and studies are promoted by people who don’t understand or even bother to read the studies they cite and promote.

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