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Guidance for the Clinician in Rendering Pediatric Care

CLINICAL REPORT Organic : Health and Environmental Advantages and Disadvantages

Joel Forman, MD, Janet Silverstein, MD, COMMITTEE ON abstract NUTRITION, and COUNCIL ON ENVIRONMENTAL HEALTH The US market for organic foods has grown from $3.5 billion in 1996 to KEY WORDS $28.6 billion in 2010, according to the Organic Trade Association. Or- organic , produce, meat, dairy, growth hormone, , farming, diet ganic products are now sold in specialty stores and conventional ABBREVIATIONS . Organic products contain numerous marketing claims GH—growth hormone and terms, only some of which are standardized and regulated. NOP— — In terms of health advantages, organic diets have been convincingly USDA US Department of demonstrated to expose consumers to fewer associated This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors with human disease. has been demonstrated to have have filed conflict of interest statements with the American less environmental impact than conventional approaches. However, Academy of Pediatrics. Any conflicts have been resolved through current evidence does not support any meaningful nutritional benefits a process approved by the Board of Directors. The American fi Academy of Pediatrics has neither solicited nor accepted any or de cits from eating organic compared with conventionally grown commercial involvement in the development of the content of foods, and there are no well-powered human studies that directly dem- this publication. onstrate health benefits or disease protection as a result of consuming The guidance in this report does not indicate an exclusive an organic diet. Studies also have not demonstrated any detrimental or course of treatment or serve as a standard of medical care. disease-promoting effects from an organic diet. Although organic foods Variations, taking into account individual circumstances, may be appropriate. regularly command a significant price premium, well-designed farm- ing studies demonstrate that costs can be competitive and yields com- parable to those of conventional farming techniques. Pediatricians should incorporate this evidence when discussing the health and en- vironmental impact of organic foods and organic farming while con- tinuing to encourage all patients and their families to attain optimal nutrition and dietary variety consistent with the US Department of Agri- culture’s MyPlate recommendations. This clinical report reviews the health and environmental issues re- lated to organic food production and consumption. It defines the term www.pediatrics.org/cgi/doi/10.1542/peds.2012-2579 “ ” organic, reviews organic food-labeling standards, describes organic doi:10.1542/peds.2012-2579 and conventional farming practices, and explores the cost and envi- All clinical reports from the American Academy of Pediatrics ronmental implications of organic production techniques. It examines automatically expire 5 years after publication unless reaffirmed, the evidence available on nutritional quality and production contam- revised, or retired at or before that time. inants in conventionally produced and organic foods. Finally, this re- PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). port provides guidance for pediatricians to assist them in advising Copyright © 2012 by the American Academy of Pediatrics their patients regarding organic and conventionally produced food choices. Pediatrics 2012;130:e1406–e1415

e1406 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS

DEFINITION AND REGULATION OF Labeling ingredients or food groups on the ORGANIC FOODS Consumers are confronted with a principal display panel. For example, Definition wide range of food product marketing soup made with at least 70% organic terms, some regulated and some not ingredients and only organic vegetables Organic farming uses an approach to “ (Table 1). The labeling requirements of may be labeled either soup made with growing crops and raising livestock that ” the NOP apply to raw, fresh products organic peas, potatoes, and carrots or avoids synthetic chemicals, hormones, “soup made with organic vegetables.” antibiotic agents, , and processed products that contain and . In the , the organic agricultural ingredients. These labeling requirements are based on Related Terms US Department of Agriculture (USDA) has the percentage of organic ingredients The NOP places no restrictions on the implemented the National Organic Pro- in a product.3 Products labeled “100% use of truthful labeling claims, such as gram (NOP)1 in response to the Organic organic” must contain only organically “no drugs or growth hormones used,” Foods Production Act of 1990.2 The NOP produced ingredients and processing “free range,” or “sustainably har- set labeling standards that have been in aids (excluding water and salt). Prod- vested.”3 The USDA regulates the term effect since October 2002. NOP stand- ucts labeled “organic” must consist of “free range” for poultry products; to ards for organic food production in- at least 95% organically processed use this term, producers must dem- clude many specific requirements for ingredients (excluding water and salt); onstrate that the poultry has been both crops and livestock. To qualify as the remaining 5% of ingredients may allowed “access to the outside.”4 organic, crops must be produced on be conventional or synthetic but must According to Consumers Union’s eval- farms that have not used most synthetic be on the USDA’s approved list. Pro- uation, this means that a poultry pesticides, herbicides, and for cessed products that contain at least product comes from a bird that had at 3 years before harvest and have a suffi- 70% organic ingredients can use the least 5 minutes of access to the out- cient buffer zone to decrease contami- phrase “made with organic ingredients” doors each day.4,5 No standard defi- nation from adjacent lands. Genetic and list up to 3 of the organic nition exists for all other products engineering, ionizing radiation, and sewage sludge is prohibited. Soil fertil- TABLE 1 Commonly Used Food Product Marketing Terms ity and content is managed Term Definition primarily with cultivation practices, 100% organic Must contain only organically produced ingredients and crop rotations, and cover crops sup- processing aids (excluding water and salt). Organic Must consist of at least 95% organically produced ingredients plemented with animal and crop waste (excluding water and salt). Any remaining product .Pests,weeds,anddiseases ingredients must consist of nonagricultural substances are managed primarily by physical, approved on the National List. Made with organic ingredients Must contain at least 70% organic ingredients. mechanical, and biological controls in- Natural A product containing no artificial ingredient or added color and stead of with synthetic pesticides and that is only minimally processed (a process that does not herbicides. Exceptions are allowed if fundamentally alter the raw product). The label must explain substances are on a national approved the use of the term. Free range Producers must demonstrate to the USDA that the poultry has list. Organic livestock must be reared been allowed access to the outside. without the routine use of antibiotic No hormones (pork or poultry) Hormones are not allowed in raising hogs or poultry. Therefore, agents or growth hormones (GHs) and the claim “no hormones added” cannot be used on the labels of pork or poultry unless it is followed by a statement that must be provided with access to the says “Federal regulations prohibit the use of hormones.” outdoors. If an animal is treated for No hormones (beef) The term “no hormones administered” may be approved for disease with antibiotic agents, it cannot use on the label of beef products if sufficient documentation is provided to the USDA by the producer showing no be sold as organic. Preventive health hormones have been used in raising the animals. practices include vaccination and vita- No (red meat and poultry) The terms “no antibiotics added” may be used on labels for min and mineral supplementation. The meat or poultry products if sufficient documentation is fi provided by the producer to the USDA demonstrating that USDA certi es organic products accord- the animals were raised without antibiotics. ing to these guidelines. Organic farmers Certified “Certified” implies that the USDA’s and Inspection must apply for certification, pass a Service and the Agriculture Marketing Service have officially test, and pay a fee. The NOP requires evaluated a meat product. Chemical free This term is not allowed to be used on a label. annual inspections to ensure ongoing There are no restrictions on use of other truthful labeling claims, such as “no drugs or growth hormones used,” or compliance with these standards. “sustainably harvested.”

PEDIATRICS Volume 130, Number 5, November 2012 e1407 Downloaded from www.aappublications.org/news by guest on September 28, 2021 carrying the “free range” label, such increased propensity to purchase or- number of reported in vari- as beef, pork, or eggs; the use of the ganic food is the level of consumer ous articles, the authors grouped the term, however, is allowed. education.14–21 Organic products, how- nutrients into large categories. They The term “natural” or “all natural” is ever, cost up to 40% more. found no significant differences in defined by the USDA for meat and most nutrients, with the exception of poultry and means that the products NUTRITIONAL QUALITY OF ORGANIC higher content in conven- contain no artificial flavoring, color VERSUS CONVENTIONAL FOOD tional produce and higher titratable acidity and phosphorus in organic ingredients, chemical preservatives, Produce or artificial or synthetic ingredients produce.29 Better-quality research that Consumers believe that organic pro- and are “minimally processed.” Mini- accounts for the many duce is more nutritious than conven- mally processed means that the raw variables is needed to elucidate po- tionally grown produce, but the product was not fundamentally al- tential differences in nutrients and the research to support that belief is not tered. Additional USDA definitions of clinical importance of nutrients that definitive. Many studies have demon- other labeling terms can be found in may be different. At this time, however, strated no important differences in publicly available USDA fact sheets.4 there does not appear to be convincing carbohydrate or vitamin and mineral evidence of a substantial difference in The term “raw” milk refers to un- content.22 Some studies have found nutritional quality of organic versus pasteurized milk. All milk certified as lower nitrate content in organic foods conventional produce. organic by the USDA is pasteurized. versus conventionally grown foods, Raw milk can contain harmful bacteria, which is potentially desirable because Milk such as Salmonella species, Escher- of the association of nitrates with in- The composition of dairy products, ichia coli O157:H7, Listeria species, creased risk of gastrointestinal cancer including milk, is affected by many Campylobacter species, and Brucella and, in infants, methemoglobinemia. factors, including differences caused species, and has been repeatedly as- Higher concentrations were by genetic variability and cattle breed; sociated with outbreaks of disease found in organic leafy vegetables, thus, the results of studies assessing caused by these pathogens. The Amer- such as spinach, lettuce, and chard milk composition must be interpreted ican Academy of Pediatrics, US Food versus the same conventionally pro- with caution. In general, milk has the and Drug Administration, and Centers duced vegetables in 21 of 36 (58%) same protein, vitamin, trace mineral for Disease Control and Prevention studies.22 Other studies have found content, and lipids from both organi- advise consumers not to consume raw higher total phenols in organic pro- cally and conventionally reared cows. 6–8 milk. duce versus conventionally grown -soluble antioxidants and vitamins produce and have postulated health present in milk come primarily from SCOPE OF CONSUMER USE, benefits from antioxidant effects.23 the natural components of the diet or PRICES, AND TRENDS IN ORGANIC Several attempts have been made to from the synthetic compounds used to FOOD review the relevant literature and supplement the feed ingested by lac- In 2008, more than two-thirds of US draw conclusions on organic versus tating cows.30 consumers bought some organic prod- conventional foods, but the results are One recent study examined antibiotic ucts, and more than one-quarter bought conflicting.24–28 A large systematic re- and microorganism content, hormone organic at least weekly. The amount of view published in 2009 found that concentrations, and nutritional values US acreage dedicated to organic crops fewer than 20% of 292 articles with of milk in 334 samples from 48 states has doubled since 1997.9 Consumers potentially relevant titles met criteria labeled as organic, not treated with choose organic food in the belief that for quality, leaving only 55 studies to bovine GH (referred to as “GH-free”), or organic foods are more nutritious, have assess. The authors highlighted the conventional. This study found that milk fewer additives and contaminants, and fact that the nutrient content of pro- labeled “conventional” had lower bac- are grown more sustainably.10 Some duce is affected by numerous factors, terial counts than milk that was or- studies11,12 suggest that families with including the geographic location of ganic or GH-free, although this was not children and adolescents or younger the farm, local soil characteristics, clinically significant. Estradiol and pro- consumers in general are more likely climactic conditions that can vary by gesterone concentrations were lower in to buy organic fruits and vegetables season, maturity at time of harvest, conventional milk than in , than are other consumers.13 The factor and storage and time to testing but GH-free milk had progesterone most consistently associated with the after harvest. Because of the large concentrations similar to conventional

e1408 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS milk and estradiol concentrations sim- stomach environment, it must be given 1970s and 1980s using radioimmuno- ilar to organic milk. Macronutrient by injection. GH is species-specific, and assay methods. One study demon- composition was similar, although or- bovine GH is biologically inactive in strated concentrations of estrogens ganic milk had 0.1% more protein than humans. Because of this, any bovine found in meat residues were low and the other 2 milk types.31 GH in food products has no physiologic overlapped with concentrations found Several studies have demonstrated effect on humans, even if it were in untreated cows.34 Gas chromatog- that organic milk has higher concen- absorbed intact from the gastroin- raphy measurements of sex steroids trations of antioxidants and poly- testinal tract. In addition, 90% of bo- progesterone, testosterone, 17β es- unsaturated fatty acids. However, it is vine GH in milk is destroyed during the tradiol, and estrone and their metab- important to recognize that the com- pasteurization process. There is no olites in meat products, fish, poultry, position of milk is strongly related to evidence that the gross composition of milk, and eggs revealed insignificant what the cows eat. This differs by time milk (fat, protein, and lactose) is al- amounts compared with daily pro- of year (outdoors in the summer, in- tered by treatment with bovine GH, nor duction of these steroids in adults and door forage in the winter) and whether is there any evidence that the vitamin children.35 Furthermore, 98% to 99% the farms are high or low input. High- and mineral contents of milk are of endogenous sex steroids are bound input farms supplement the diets of changed by GH treatment.31 by sex-hormone-binding globulin, ren- cattle with proprietary minerals and GH treatment of cows may actually have dering them metabolically inactive as vitamins. Low-input farms use meth- environmental benefits. GH increases only the unbound (free) forms of sex ods similar to those used in organic milk production per cow, which could steroids are metabolically active. Syn- farming but do not follow all the theoretically decrease the number of thetic sex steroids (zeranol, melen- restrictions prescribed by organic cows needed to produce a given gestrol, and trenbolone) commonly farming standards; they use mineral amount of milk, with resultant need for used in animals have lower affinities fertilizers but at lower levels than used fewer cows and, thus, less cultivated to sex-hormone-binding globulin and, by conventional high-input systems. land needed to feed the cows. In ad- therefore, are potentially more meta- One study comparing milk from all 3 dition, fewer cows would result in the bolically active unbound sex steroids. production systems found milk from production of less with re- These hormones do not occur naturally both the low-input organic and low-input sultant reduced methane production in humans, and although the concen- nonorganic systems generally had sig- and less carbon dioxide production, trations of these hormones are low in nificantly higher concentrations of nu- with a resultant salutary effect on cattle, the biological effects in humans, tritionally desirable unsaturated fatty global warming.33 if any, are unknown. acids (conjugated linoleic acid and Ingestion of milk from estrogen-treated omega-3 fatty acids) and fat-soluble Sex Steroids cows appears to be safe for children. antioxidants compared with milk from Estradiol and estrone concentrations in Treatment of cattle with sex steroids the high-input systems; milk derived organic and conventional 1%, 2%, and from cows in both organic certified and increases lean muscle mass, accel- erates the rate of growth, and is an wholemilkwerethesame,althoughthe nonorganic low-input systems was concentrations of sex steroids were significantly higher in conjugated lino- efficient way to increase meat yield. higher as the fat content of the milk leic acid content than was milk from Estrogens are usually given by im- increased and were lower than en- conventional high-input systems.32 plantation of estrogen pellets into the skin on the underside of the ear, and dogenous production rates in humans. Estradiol concentrations in milk ranged HORMONES the ear is discarded during slaughter. Unlike GH, sex steroids are not species- from 0.4 to 1.1 pg/mL, and estrone GH specific and may be given orally concentrations ranged from 2.9 to 7.9 Hormone supplementation of farm without degradation in the stomach. In pg/mL, with the lowest concentrations animals, especially with GH, is one of 1998, the Food and Agriculture Orga- in skim milk and the highest in whole the major reasons consumers state nization of the United Nations and milk.36 they prefer to buy organic foods. Bo- World Health Organization jointly con- Endogenous estradiol concentrations vine GH (ie, recombinant bovine so- cluded that meat from estradiol-trea- are as high as 80 pg/mL in 2- to 4- matotropin) increases milk yield by ted animals was safe on the basis of month-old female infants and 40 pg/mL 10% to 15% and is lipotropic in cows. data obtained from residue levels in in 2- to 4-month-old male infants. Hu- Because GH is degraded in the acidic meat from studies performed in the man milk has estradiol concentrations

PEDIATRICS Volume 130, Number 5, November 2012 e1409 Downloaded from www.aappublications.org/news by guest on September 28, 2021 as high as 39 pg/mL and estrone that higher red meat consumption in used in risk assessments are highly (which has approximately half the adolescence may increase breast overestimated and should be reeval- potency of estradiol) concentrations cancer risk, tracked cases of cancer uated by using current assays.41 It is as high as 1177 pg/mL. Human co- prospectively after the dietary history therefore important to determine the lostrum has even higher estrogen was obtained, it was limited by relative importance of hormone treat- concentrations of 500 pg/mL and 4000 a number of factors, including the ment of animals in the context of other to 5000 pg/mL for estradiol and es- dependence on subjects’ long-term environmental endocrine disrupters trone, respectively. Cow milk, by memory of amount of food eaten through long-term longitudinal studies comparison, has estradiol concen- decades previously, the likelihood that in children. trations of 4 to 14 pg/mL and estrone hormone concentrations in meat were concentrations of 34 to 55 pg/mL.37,38 higher in that period, and the lack NONTHERAPEUTIC USE OF It has been postulated that ingested of direct measurement of hormonal ANTIBIOTIC AGENTS 40 estrogen in food derived from sex- exposure. Longitudinal prospective Conventional animal husbandry fre- hormone-treated animals may play studies are needed to compare the quently includes the administration of a role in earlier development of puberty risk of breast cancer in women who antibiotic agents in nontherapeutic and increasing risk of breast cancer. eat meat from hormone-treated ani- doses to livestock to promote growth However, no studies have supported mals with the risk in women who eat and increase yields. Between 40% and this hypothesis in humans. Studies in meat from untreated animals. 80% of the antimicrobial agents used in animals demonstrating carcinogenic Endocrine disrupters, chemicals that the United States each year are used in and teratogenic effects of estrogens interfere with hormone signaling sys- food animals, three-quarters of which used high doses of estradiol and cannot tems, are pervasive in our environment. is nontherapeutic. Many of these agents be extrapolated to the low doses of Among the most commonly found en- are identical or similar to drugs used in sex steroids found in the food supply. docrine disrupters are bisphenol A, humans.42 Evidence is clear that such Estrogen concentrations in the myo- found in industrial chemicals and nontherapeutic use promotes the de- metrium, breast, and vagina of post- plastics; phthalates, found in personal velopment of drug-resistant organisms menopausal women, although still low, care items such as cosmetics; and in the animals and that these organ- are higher than those found in serum, lavender and tea tree oil, found in many isms then colonize the intestines of and additional studies are needed to hair products, soaps, and lotions; all people living on farms where this determine the significance of these have estrogenic properties. Endocrine practice occurs.43 Evidence is also low concentrations of sex steroids in disrupters are postulated to be in- ample that human disease caused by estrogen-sensitive tissues.39 volved in the increased occurrence of antibiotic-resistant organisms spread An association has been found be- genital abnormalities among newborn through the food chain.44 Because or- tween red meat consumption in high boys and precocious puberty in girls. ganic farming prohibits the non- school girls and the development of Recent literature on sex steroid con- therapeutic use of antibiotic agents, it breast cancer later in life. A 7-year centrations and their physiologic roles could contribute to a reduction in the prospective longitudinal study of 39 268 during childhood indicate that con- threat of human disease caused by premenopausal women 33 to 53 years centrations of estradiol in prepubertal drug-resistant organisms. of age who filled out a comprehensive children are lower than originally SYNTHETIC CHEMICAL EXPOSURE diet history of foods eaten while in high thought and that children are extremely school in the 1960s and 1970s revealed sensitive to estradiol and may respond Pesticides a linear association between each ad- with increased growth and/or breast Pesticides have a host of toxic effects ditional 100 g of red meat consumed in development even at serum concen- that range from acute poisonings to high school per day with the risk of trations below the current detection subtle subclinical effects from long- developing hormone-receptor-positive limits.41 No threshold has been estab- term, low-dose exposure.45 Organo- premenopausal tumors (relative risk, lished below which there are no hor- phosphate pesticides are commonly 1.36; 95% confidence interval, 1.08– monal effects on exposed children. used in agriculture, and poisoning is 1.70; P = .008). Red meat ingestion did Furthermore, the daily endogenous a persistent problem in the agricul- not increase the risk of hormone- production rates of sex steroids in tural setting. From 1998 to 2005, 3271 receptor-negative tumors. Although children estimated by the Food and cases of agricultural occupational this intriguing study, which suggested Drug Administration in 1999 and still acute poisoning were

e1410 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS reported to the California Department consumed conventional produce demon- cross-sectional studies. These studies of Pesticide Regulation and the Na- strated that urinary pesticide residues are limited by a number of factors, tional Institute of Occupational Health’s were reduced to almost nondetectable including difficulties measuring past SENSOR-Pesticides program. This con- levels (below 0.3 μg/L for malathion exposures and the lack of a positive stitutes a rate of 56 cases per 100 000 dicarboxylic acid, for example) when temporal relationship between expo- full-time equivalents, 38 times the rate they were changed to an organic sure and outcome. It is difficult to di- observed in nonagricultural occupa- produce diet for 5 days.58 In addition, rectly extrapolate from these studies tions.46 Chronic exposure among farm residues varied with seasonal intake and draw conclusions about potential workers has been associated with nu- of produce, suggesting that dietary toxicity at the levels of pesticide ex- merous adult health problems, in- intake of organophosphate pesticides posure documented from dietary in- cluding respiratory problems, memory represented the major source of ex- take of conventional produce. Data disorders, dermatologic conditions, de- posure in these young children.59 derived from large prospective cohort pression, neurologic deficits including Although a common practice, rinsing studies may address some of these Parkinson disease, miscarriages, birth conventionally farmed produce reduces shortcomings. defects, and cancer.47–50 Prenatal or- some but not all pesticide residues on ganophosphate pesticide exposure has produce to varying degrees but has ENVIRONMENTAL IMPACT AND been associated with adverse birth not been proven to decrease human PRODUCTION EFFICIENCY OF outcomes, such as decreased birth exposure.60 ORGANIC VERSUS CONVENTIONAL weight and length51 and smaller head Pesticide metabolite concentrations FARMING METHODS circumference.52 A large prospective observed in studies that examined ex- Environmental Impact birth cohort study that measured pes- posure in farming communities as well A major subject in the organic debate ticide exposure in pregnant farm as in residential settings were in the workers in California and followed their is whether organic farming methods same range as those observed in sub- have less impact on the environment, offspring found lower mental de- jects consuming conventional produce velopment index scores at 24 months of can be equally as productive, and can in studies of biological exposure be no more expensive than conven- age53 and attentional problems at 3.5 measures for organic versus conven- tional approaches. A variety of surveys and 5 years of age.54 An analysis of tional produce diets. For instance, the and studies have attempted to com- cross-sectional data from the NHANES median concentration observed for pare these issues for organic and has demonstrated that within the range malathion urinary metabolites in female conventional farming methods. Many of exposure in the general US pop- farm workers whose offspring had believe that organic farming is less ulation, the odds of attention-deficit/ fi signi cantly lower mental development damaging to the environment because hyperactivity disorder for 8- to 15-year- index scores at 24 months of age was organic farms do not use or release old children were increased 55% with μ 53 0.82 g/L, which is close to the me- synthetic pesticides into the environ- a 10-fold increase in urinary concen- dian concentration found in children in ment, some of which have the potential trations of the organophosphate me- the initial conventional diet phase of to harm soil, water, and local terres- tabolite dimethyl alkylphosphate.55 μ the organic diet study of 1.5 g/L, dis- trial and aquatic wildlife.61 In addition, The National Research Council repor- cussed previously.58 Ranges for other it is thought that organic farms are ted in 1993 that the primary form of pesticide metabolites were similar. better than conventional farms at exposure to pesticides in children is Although chronic pesticide exposure sustaining diverse , in- through dietary intake.56 Organic pro- and measurable pesticide metabolite cluding populations of plants, insects, duce consistently has lower levels of concentrations seem undesirable and and animals, because of practices pesticide residues than does conven- potentially unhealthy, no studies to such as crop rotation. When calcu- tionally grown produce,57 and a diet date have experimentally examined the lated either per unit area or per of organic produce reduces human causal relationship between exposure unit of yield, organic farms use less exposure. Several studies have clearly to pesticides directly from conven- energy and produce less waste.62,63 demonstrated that an organic diet tionally grown foods and adverse Organically managed soil has been reduces children’sexposuretopesti- neurodevelopmental health outcomes. demonstrated to be of higher quality cides commonly used in conventional Most of the research implicating and have higher water retention, agricultural production. A small longitu- pesticides in these adverse health which may increase yields for organic dinal cohort of children who regularly outcomes is from case-control or farms in drought years.64

PEDIATRICS Volume 130, Number 5, November 2012 e1411 Downloaded from www.aappublications.org/news by guest on September 28, 2021 Production Efficiency Although costs were higher primarily contributes to the emergence of re- because of increased labor costs (15%), sistant bacteria; thus, organic animal Critics of organic farming methods the return for the organic plots was husbandry may reduce the risk of believe that organic farms require higher because of the higher prices human disease attributable to resistant more land to produce the same commanded at the marketplace.64 organisms. There is sound evidence amount of food as conventional farms. that organic foods contain more vi- One study found a 20% smaller yield tamin C (ascorbic acid) and phos- from organic farms.65 Another study THE DIFFERENCE IN PRICE OF phorus than do conventional foods, from the Danish Environmental Pro- ORGANIC VERSUS CONVENTIONAL but there is no direct evidence that tection Agency found that, area for FOODS this provides meaningful nutritional area, organic farms of potatoes, One major concern with organic food benefits to children eating organic sugar beets, and seed grass produce is its higher price to consumers. Or- foods compared with those who eat as little as half the output as their ganic products typically cost 10% to conventionally grown food products. conventional farm counterparts.66 40% more than similar conventionally Well-designed farming studies dem- produced products.69 A number of It remains controversial whether or- onstrate that comparable yields can factors contribute to these higher ganic farming is able to provide ade- be achieved with organic farming costs, including higher-priced organic quate food supply to sustain the world techniques and that organic farming animal feed, lower productivity, and population. Norman Borlaug, consid- has a lower environmental impact “ higher labor costs because of the in- ered to be the father of the green than do conventional approaches. ” creased reliance on hand weeding. Of revolution and winner of the Nobel However, no well-powered human potential concern is that the higher Peace Prize, believes that organic studies have directly demonstrated price of organically produced fruits farming alone is incapable of feeding health benefits or disease protection and vegetables might lead consumers the world population and needs to be as a result of consuming an organic to eat less of these foods, despite the used in conjunction with genetically diet. Such studies would be difficult fi 67 well-established literature document- modi ed food. On the other hand, to perform and require large pro- ing the health benefits of eating fruits a meta-analysis of 292 studies designed spective cohort populations or, better, fi and vegetables, including lower rates to assess the ef ciency of both organic randomly assigning subjects to inter- of obesity, cardiovascular disease, and conventional farming concluded ventions that increase organic versus and certain types of cancer. Fifty-five that organic methods could produce conventional food intakes. Additional percent of children born in the United enough food on a global per-capita data are needed to identify relation- States are eligible for food packages basis to sustain the current human ships between diet and pesticide ex- under the Special Supplemental Nu- population and potentially an even posure and individual health outcomes. trition Program for Women, Infants, larger population without increasing Pediatricians should incorporate this 68 and Children, and these food pack- the agricultural land base. evidence when discussing the health ages are currently giving families ap- The largest prospective farming study and environmental impact of organic proximately $10 a month to spend on to date is a comparative trial of more foods and organic farming while con- fruits and vegetables, so the money than 20 years’ duration conducted by tinuing to encourage all patients and must be used wisely to maximize researchers from Cornell University. their families to attain optimal nutrition spending capacity for healthy foods. This study, conducted in Pennsylvania, and dietary variety by choosing a diet compared various conventional and high in fresh fruits and vegetables, organic farming approaches in a SUMMARY consistent with the USDA’s MyPlate controlled prospective design in To demonstrate superiority of 1 food recommendations. which confounding influences such as production method over another, it is weather and moisture were similar in important to show an advantage in Key Points the different systems. Over 20 years of terms of improved individual health 1. Nutritional differences between organic observation, the organic fields had or an important societal advantage. and conventional produce appear min- productivity that was generally com- Organic diets have been convincingly imal, but studies examining this have parable to the conventional fields, demonstrated to expose consumers been limited by inadequate controls for while avoiding environmental pollution to fewer pesticides associated with the many subtle potential confounders, with herbicides and pesticides and re- human disease. Nontherapeutic use such as moisture, maturity of the pro- ducing fossil fuel consumption by 30%. of antibiotic agents in livestock duce, and measurement techniques.

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No direct evidence of a clinically rele- 7. Organic farming reduces fossil fuel LEAD AUTHORS vant nutritional difference between or- consumption and reduces environ- Joel Forman, MD ganic and conventional produce exists. mental contamination with pesti- Janet Silverstein, MD cides and herbicides. 2. Organic produce contains fewer COMMITTEE ON NUTRITION, pesticide residues than does con- 8. Large prospective cohort studies that 2011–2012 ventional produce, and consuming record dietary intake accurately and Jatinder J. S. Bhatia, MD, Chairperson a diet of organic produce reduces measure environmental exposures Steven A. Abrams, MD Mark R. Corkins, MD human exposure to pesticides. It directly will likely greatly enhance Sarah D. de Ferranti, MD remains unclear whether such a re- understanding of the relationship be- Neville Hylton Golden, MD duction in exposure is clinically rel- tween pesticide exposure from con- Janet Silverstein, MD evant. ventional foods and human disease and between consumption of meat FORMER COMMITTEE MEMBERS 3. Organic animal husbandry that pro- Stephen R. Daniels, MD, PhD hibits the nontherapeutic use of an- from hormone-treated animals and Frank R. Greer, MD tibiotic agents has the potential to the risk of breast cancer in women. Marcie B. Schneider, MD reduce human disease caused by Nicolas Stettler, MD Dan W. Thomas, MD drug-resistant organisms. Advice for Pediatricians 4. There is no evidence of clinically LIAISONS relevant differences in organic 1. Encourage patients and their families Laurence Grummer-Strawn, PhD – Centers for to eat an optimally health-promoting Disease Control and Prevention and conventional milk. – diet rich in fruits, vegetables, whole Van S. Hubbard, MD, PhD National Institutes of a. There are few, if any, nutritional Health grains, and low-fat or fat-free milk differences between organic and Valérie Marchand, MD – Canadian Pediatric and dairy products. Society conventional milk. There is no ev- – 2. When approached by families inter- Benson M. Silverman, MD US Food and Drug idence that any differences that Administration may exist are clinically relevant. ested in consuming organic foods, Valery Soto, MS, RD, LD – US Department of b. There is no evidence that organic review key facts presented in this Agriculture milk has clinically significant report to address the full range of relevant nutrition, human health, STAFF higher bacterial contamination lev- Debra L. Burrowes, MHA els than does conventional milk. environmental, and cost issues. c.Thereisnoevidencethatconven- Be explicit about areas in which COUNCIL ON ENVIRONMENTAL HEALTH – tional milk contains significantly scientific evidence is strong as well EXECUTIVE COMMITTEE, 2011 2012 increased amounts of bovine GH. as those in which it is uncertain. Jerome A. Paulson, MD, Chairperson Alice Cantwell Brock-Utne, MD Any bovine GH that might remain 3. When advice is sought by families Heather Lynn Brumberg, MD, MPH in conventional milk is not biolog- concerned with the potential Carla C. Campbell, MD, MS ically active in humans because of health impact of pesticide residues Bruce Perrin Lanphear, MD, MPH structural differences and suscep- in food, direct them toward reli- Kevin C. Osterhoudt, MD, MSCE Megan T. Sandel, MD tibility to digestion in the stomach. able resources that provide infor- Leonardo Trasande, MD, MPP 5. Organic farming approaches in mation on the relative pesticide Robert O. Wright, MD, MPH practice are usually more expen- content of various fruits and vege- sive than conventional approaches, tables. Two such examples include: FORMER COMMITTEE MEMBERS Helen J. Binns, MD, MPH but in carefully designed experi- a. Consumer Reports article (Sep- Joel Forman, MD mental farms, the cost difference tember 2008) “Fruits and Vegeta- can be mitigated. bles,WhentoBuyOrganic” (http:// LIAISONS – www.consumerreports.org/health/ Peter C. Grevatt, PhD US Environmental Pro- 6. The price differential between organic tection Agency and conventional food might be re- healthy-living/diet-nutrition/healthy- Mary Ellen Mortensen, MD, MS – Centers for duced or eliminated as organic farm- foods/organic-foods/overview/when- Disease Control and Prevention ing techniques advance and as the to-buy-organic.htm) and Walter Rogan, MD – National Institutes of Health – prices of petroleum products, such b. Environmental Working Group’s Sharon Ann Savage, MD National Cancer Institute as pesticides and herbicides, as well “Shopper’s Guide to Pesticides” STAFF as the price of energy, increase. (http://www.foodnews.org). Paul Spire

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1. US Department of Agriculture, Agricultural regular apples. Am J Agric Res Econ. 2001; Bristol, United Kingdom: ; Marketing Service. National organic pro- 26(2):404–416 2000. Available at: www.soilassociation.org/ gram. Available at: www.ams.usda.gov/ 13. Magnusson MK, Arvola A, Hursti UK, Åberg LinkClick.aspx?fileticket=cY8kfP3Q%2BgA% AMSv1.0/nop. Accessed May 15, 2011 L, Sjödén PO. Choice of organic foods is 3D&tabid=388. Accessed May 15, 2011 2. Organic Foods Production Act of 1990. related to perceived consequences for 26. Magkos F, Arvaniti F, Zampelas A. Organic Available at: www.ams.usda.gov/AMSv1.0/ human health and to environmentally food: nutritious food or food for thought? A getfile?dDocName=STELPRDC5060370&acct= friendly behaviour. Appetite. 2003;40(2): review of the evidence. Int J Food Sci Nutr. nopgeninfo. Accessed May 15, 2011 109–117 2003;54(5):357–371 3. US Department of Agriculture, Agriculture 14. Dimitri C, Oberholtzer L. Marketing U.S. 27. Bourn D, Prescott J. A comparison of the Marketing Services, National Organic Pro- Organic Foods: Recent Trends From Farms nutritional value, sensory qualities, and gram. Organic labeling and marketing in- to Consumers. Economic Information Bul- food safety of organically and convention- formation. October 2002; updated April 2008. letin No. EIB-58. Washington, DC: US De- ally produced foods. Crit Rev Food Sci Nutr. Available at: www.ams.usda.gov/AMSv1.0/ partment of Agriculture, Economic 2002;42(1):1–34 getfile?dDocName=STELDEV3004446. Accessed Research Service; 2009 28. Woese K, Lange D, Boess C, Bogl KW. A May 15, 2011 15. Dettmann RL, Dimitri C. Who’s buying or- comparison of organically and conven- 4. US Department of Agriculture, Food Safety ganic vegetables? Demographic character- tionally grown foods—results of a review and Inspection Service. Meet and poultry la- istics of U.S. consumers. J Food Prod of the relevant literature. J Sci Food Agric. beling terms fact sheet. Available at: www.fsis. Marketing. 2010;16(1):79–91 1997;74(3):281–293 usda.gov/factsheets/meat_&_poultry_labeling_ 16. Zepeda L, Li J. Characteristics of organic 29. Dangour AD, Dodhia SK, Hayter A, Allen E, terms/index.asp#4. Accessed May 15, 2011 food shoppers. J Agric Appl Econ. 2007;39 Lock K, Uauy R. Nutritional quality of or- 5. Consumers Union of United States Inc. The (1):17–28 ganic foods: a systematic review. Am J Clin Consumers Union Guide to Environmental 17. Krystallis A, Fotopoulos C, Zotos Y. Organic Nutr. 2009;90(3):680–685 Labels. Available at: www.greenerchoices.org/ consumers’ profile and their willingness to 30. Butler G, Nielsen JH, Slots T, et al. Fatty acid eco-labels/label.cfm?LabelID=111. Accessed pay (WTP) for selected organic food prod- and fat soluble antioxidant concentrations May 15, 2011 ucts in Greece. J Int Consum Marketing. in milk from high- and low-input conven- 6. American Academy of Pediatrics. Appendix 2006;19(1):81–106 tional and organic systems: seasonal VIII: prevention of disease from potentially 18. O’Donovan P, McCarthy M. Irish consumer variation. J Sci Food Agric. 2008;88(8): contaminated food products. In: Pickering preference for organic meat. Br Food J. 1431–1441 LK, Baker CJ, Kimberlin DW, Long SS, eds. 2002;104(3–5):353–370 31. Vicini J, Etherton T, Kris-Etherton P, et al. Red Book: 2009 Report of the Committee on 19. Cicia G, Del Giudice T, Scarpa R. Consumers’ Survey of retail milk composition as af- Infectious Diseases. 28th ed. Elk Grove perception of quality in organic food: fected by label claims regarding farm- Village, IL: American Academy of Pediatrics; a random utility model under preference management practices. J Am Diet Assoc. 2009:857–859 heterogeneity and choice correlation from 2008;108(7):1198–1203 7. US Food and Drug Administration. The rank-orderings. Br Food J. 2002;104(3): 32. Butler G, Coloumb M, Rehberger B, dangers of raw milk: unpasteurized milk 200–213 Sanderson R, Eyre M, Leifert C. Conjugated can pose a serious health risk. Available 20. Fotopoulos C, Krystallis A. Purchasing linoleic acid isomer concentrations in milk at: www.fda.gov/Food/ResourcesForYou/ motives and profile of the Greek organic from high- and low-input management Consumers/ucm079516.htm. Accessed August consumer: a countrywide survey. Br Food J. systems. J Sci Food Agric. 2009;89(4): 11, 2011 2002;104(9):730–765 697–705 8. Centers for Disease Control and Pre- 21. Magnusson M, Arvola A, Hursti U, Aberg L, 33. Capper JL, Castañeda-Gutiérrez E, Cady vention. Raw milk questions and answers. Sjoden P. Attitudes towards organic foods RA, Bauman DE. The environmental im- Available at: www.cdc.gov/foodsafety/ among Swedish consumers. Br Food J. pact of recombinant bovine somatotro- rawmilk/raw-milk-questions-and-answers. 2001;103(3):209–226 pin (rbST) use in dairy production. html. Accessed August 11, 2011 22. Williams CM. Nutritional quality of organic Proc Natl Acad Sci USA. 2008;105(28): 9. US Department of Agriculture. Emerging food: shades of grey or shades of green? 9668–9673 issues in the US organic industry economic Proc Nutr Soc. 2002;61(1):19–24 34. Tsujioka T, Ito S, Ohga A. Female sex steroid research service. June 2009. Available at: 23. Asami DK, Hong YJ, Barrett DM, Mitchell AE. residues in the tissues of steers treated www.ers.usda.gov/publications/eib55/eib55. Comparison of the total phenolic and with progesterone and oestradiol-17 β. Res pdf. Accessed May 15, 2011 ascorbic acid content of freeze-dried and Vet Sci. 1992;52(1):105–109 10. Shepherd R, Magnusson M, Sjödén PO. air-dried marionberry, strawberry, and 35. Hartmann S, Lacom M, Steinhart H. Natural Determinants of consumer behavior re- corn grown using conventional, organic, occurrence of steroid hormones in food. lated to organic foods. Ambio. 2005;34(4–5): and sustainable agricultural practices. J Food Chem. 1998;62(1):7–20 352–359 Agric Food Chem. 2003;51(5):1237–1241 36. Pape-Zambito DA, Roberts RF, Kensinger RS. 11. Thompson GD, Kidwell J. Explaining the 24. Worthington V. Nutritional quality of or- Estrone and 17beta-estradiol concen- choice of organic produce: cosmetic ganic versus conventional fruits, vegeta- trations in pasteurized-homogenized milk defects, prices, and consumer preferences. bles, and grains. J Altern Complement Med. and commercial dairy products. J Dairy Am J Agric Econ. 1998;80(2):277–287 2001;7(2):161–173 Sci. 2010;93(6):2533–2540 12. Loureiro LL, McCluskey JJ, Mittelhammer 25. Soil Association. Organic farming, food quality 37. Wolford ST, Argoudelis CJ. Measurement of RC. Preferences for organic, eco-labeled, or and human health: a review of the evidence. estrogens in cow’s milk, human milk, and

e1414 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS

dairy products. J Dairy Sci. 1979;62(9): health study. Am J Epidemiol. 2007;165(4): 60. Krol WJ, Arsenault TL, Pylypiw HM, Jr; 1458–1463 364–374 Incorvia Mattina MJ. Reduction of pesticide 38. Schams D, Karg H. Hormones in milk. Ann N 50. Engel LS, O’Meara ES, Schwartz SM. Ma- residues on produce by rinsing. J Agric Y Acad Sci. 1986;464:75–86 ternal occupation in agriculture and risk of Food Chem. 2000;48(10):4666–4670 39. Andersson AM, Skakkebaek NE. Exposure to limb defects in Washington State, 1980– 61. Oquist KA, Strock JS, Mulla DJ. Influence of exogenous estrogens in food: possible im- 1993. Scand J Work Environ Health. 2000;26 alternative and conventional farming pact on human development and health. (3):193–198 practices on subsurface drainage and wa- Eur J Endocrinol. 1999;140(6):477–485 51. Whyatt RM, Rauh V, Barr DB, et al. Prenatal ter quality. J Environ Qual. 2007;36(4):1194– 40. Linos E, Willett WC, Cho E, Colditz G, Frazier insecticide exposures and birth weight and 1204 LA. Red meat consumption during ado- length among an urban minority cohort. 62. Stolze M, Piorr A, Haring AM, Dabbert S. En- lescence among premenopausal women Environ Health Perspect. 2004;112(10): vironmental impacts of organic farming in and risk of breast cancer. Cancer 1125–1132 Europe. Organic Farming in Europe: Eco- Epidemiol Biomarkers Prev. 2008;17(8): 52. Berkowitz GS, Wetmur JG, Birman-Deych E, nomics and Policy. Vol. 6. Stuttgart, Germany: – 2146 2151 et al. In utero pesticide exposure, maternal University of Hohenheim; 2000. Available at: 41. Aksglaede L, Juul A, Leffers H, Skakkebaek paraoxonase activity, and head circumfer- http://orgprints.org/8400/1/Organic_Farming_ NE, Andersson AM. The sensitivity of the ence. Environ Health Perspect. 2004;112(3): in_Europe_Volume06_The_Environmental_ child to sex steroids: possible impact of 388–391 Impacts_of_Organic_Farming_in_Europe.pdf. exogenous estrogens. Hum Reprod Update. 53. Eskenazi B, Marks AR, Bradman A, et al. Accessed May 15, 2011 2006;12(4):341–349 Organophosphate pesticide exposure and 63. Hansen B, Alroe HJ, Kristensen ES. 42. Shea KM; American Academy of Pediatrics neurodevelopment in young Mexican- Approaches to assess the environmental Committee on Environmental Health; American children. Environ Health Per- impact of organic farming with particular American Academy of Pediatrics Committee spect. 2007;115(5):792–798 regard to . Agric Ecosyst Environ. on Infectious Diseases. Nontherapeutic use 54. Marks AR, Harley K, Bradman A, et al. 2001;83(1–2):11–26 of antimicrobial agents in animal agricul- Organophosphate pesticide exposure and 64. Pimentel D, Hepperly P, Hanson J, Douds D, ture: implications for pediatrics. Pediatrics. Seidel R. Environmental, energetic, and 2004;114(3):862–868 attention in young Mexican-American chil- dren: the CHAMACOS study. Environ Health economic comparisons of organic and 43. Levy SB, FitzGerald GB, Macone AB. Changes Perspect. 2010;118(12):1768–1774 conventional farming systems. Bioscience. in intestinal flora of farm personnel after 2005;55(7):573–582 introduction of a tetracycline-supplemented 55. Bouchard MF, Bellinger DC, Wright RO, fi feed on a farm. N Engl J Med. 1976;295(11): Weisskopf MG. Attention-de cit/hyperactivity 65. Mäder P, Fliessbach A, Dubois D, Gunst L, 583–588 disorder and urinary metabolites of organ- Fried P, Niggli U. Soil and bio- diversity in organic farming. Science. 2002; 44. Hamer DH, Gill CJ. From the farm to the ophosphate pesticides. Pediatrics. 2010;125 – kitchen table: the negative impact of anti- (6). Available at: www.pediatrics.org/cgi/ 296(5573):1694 1697 microbial use in animals on humans. Nutr content/full/125/6/e1270 66. Danish Environmental Protection Agency, Rev. 2002;60(8):261–264 56. National Research Council. Pesticides in the The Bichel Committee. Report from the 45. American Academy of Pediatrics, Council Diets of Infants and Children. Washington, main committee. Conclusions and recom- on Environmental Health. Pesticide expo- DC: National Academies Press; 1993 mendations of the committee. Section 8.7.1. sure in children. Pediatrics. 2012; in press 57. Baker B, Benbrook C, Groth E, III, Benbrook K. 1999. Available at: http://www2.mst.dk/ 46. Calvert GM, Karnik J, Mehler L, et al. Acute Pesticide residues in conventional, in- common/Udgivramme/Frame.asp?http://www2. pesticide poisoning among agricultural tegrated pest management (IPM)-grown and mst.dk/udgiv/Publications/1998/87-7909-445- workers in the United States, 1998–2005. organic foods: insights from three U.S. data 7/html/helepubl_eng.htm. Accessed May 15, Am J Ind Med. 2008;51(12):883–898 sets. Food Addit Contam. 2002;19(5):427–446 2011 47. Blair A, Freeman L. Epidemiologic studies of 58. Lu C, Toepel K, Irish R, Fenske RA, Barr DB, 67. Borlaug NE. Ending world hunger. The cancer in agricultural populations: obser- Bravo R. Organic diets significantly lower promise of biotechnology and the threat of vations and future directions. J Agromed. children’s dietary exposure to organo- antiscience zealotry. Plant Physiol. 2000;124 2009;14(2):125–131 phosphorus pesticides. Environ Health (2):487–490 48. Daniels JL, Olshan AF, Savitz DA. Pesticides Perspect. 2006;114(2):260–263 68. Badgley C, Moghtader J, Quintero E, et al. and childhood cancers. Environ Health 59. Lu C, Barr DB, Pearson MA, Waller LA. Di- Organic agriculture and the global food Perspect. 1997;105(10):1068–1077 etary intake and its contribution to longi- supply. Renewable Agric Food Syst. 2007;22 49. Kamel F, Tanner CM, Umbach DM, et al. tudinal organophosphorus pesticide (2):86–108 Pesticide exposure and self-reported exposure in urban/suburban children. En- 69. Winter CK, Davis SF. Organic foods. JFood Parkinson’s disease in the agricultural viron Health Perspect. 2008;116(4):537–542 Sci. 2006;71(9):R117–R124

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