MethylmercuryMethylmercury PoisoningPoisoning inin HighHigh--EndEnd FishFish Consumers:Consumers: AA RiskRisk CommunicationCommunication ChallengeChallenge

EdwardEdward GrothGroth III,III, PhDPhD GrothGroth ConsultingConsulting ServicesServices Pelham,Pelham, NYNY 1080310803 USAUSA May,May, 20092009 TopicsTopics toto bebe covered:covered:

¾ BackgroundBackground && contextcontext ¾ MercuryMercury inin USUS fishfish andand seafoodseafood ¾ SummarySummary ofof 2424 casecase historieshistories ¾ IsIs itit reallyreally methylmercurymethylmercury poisoning?poisoning? ¾ DoseDose--responseresponse issuesissues ¾ FishFish involvedinvolved inin thesethese casescases ¾ HowHow prevalentprevalent aa problem?problem? ¾ ResearchResearch needsneeds ¾ RiskRisk communicationcommunication aspectsaspects ContextContext

¾ AmericansAmericans areare eatingeating moremore fish,fish, whichwhich benefitsbenefits publicpublic healthhealth significantly,significantly, overalloverall ¾ ButBut itit alsoalso increasesincreases thethe likelihoodlikelihood ofof exposureexposure toto methylmercury,methylmercury, fromfrom eatingeating fishfish ¾ RiskRisk isis greatergreater forfor peoplepeople whowho eateat aa lotlot ofof fishfish ¾ TheThe type(stype(s)) ofof fishfish consumedconsumed alsoalso mattermatter ¾ MethylmercuryMethylmercury exposureexposure inin generalgeneral andand extremeextreme highhigh--endend exposureexposure areare eacheach likelylikely toto increaseincrease ifif moremore AmericansAmericans eateat moremore fishfish ConventionalConventional HgHg Wisdom:Wisdom:

¾¾ CriticalCritical effecteffect == developmentaldevelopmental neurotoxicityneurotoxicity ¾¾ PopulationsPopulations atat riskrisk == fetusesfetuses (i.e.(i.e. womenwomen ofof childbearingchildbearing age)age) andand youngyoung childrenchildren ¾¾ NoNo appreciableappreciable riskrisk toto otherother populationspopulations ¾¾ BenefitsBenefits (lower(lower risksrisks ofof CHDCHD && stroke)stroke) farfar outweighoutweigh HgHg risksrisks forfor generalgeneral populationpopulation ThisThis perspectiveperspective isis reflectedreflected asas recentlyrecently asas inin thethe 20062006 NAS/IOMNAS/IOM reportreport onon benefitsbenefits andand risksrisks ofof fishfish && seafoodseafood consumptionconsumption BasisBasis forfor C.W.:C.W.:

¾¾ EpidemiologyEpidemiology fromfrom incidentsincidents inin JapanJapan andand Iraq,Iraq, mostmost studiesstudies 3030--4040 yearsyears agoago ¾¾ FoundFound clearclear--cutcut neurotoxicneurotoxic effectseffects inin adultsadults onlyonly atat highhigh dosesdoses (blood(blood HgHg >> ~200~200 ppb)ppb) ¾¾ SomeSome effectseffects inin childrenchildren @@ >> 5050 ppbppb ¾¾ AmountsAmounts ofof MeHgMeHg fromfrom fishfish inin ““normalnormal dietdiet”” believedbelieved toto bebe belowbelow thethe levellevel ofof concern,concern, exceptexcept forfor potentialpotential forfor fetalfetal exposureexposure KeyKey questions:questions:

¾¾ DoDo wewe needneed toto revisitrevisit andand updateupdate thisthis riskrisk assessment?assessment? ¾¾ IfIf so,so, howhow mightmight wewe approachapproach thatthat task?task? ¾¾ WhatWhat aboutabout ““abnormalabnormal”” (high(high--fish)fish) diets?diets? ¾¾ OnOn whatwhat issuesissues dodo wewe needneed betterbetter data?data? ¾¾ GivenGiven whatwhat wewe knowknow andand dondon’’tt know,know, whatwhat adviceadvice shouldshould wewe givegive consumers?consumers? AA FewFew BasicBasic PrinciplesPrinciples ofof EnvironmentalEnvironmental HealthHealth RiskRisk isis aa ContinuumContinuum SensitivitySensitivity toto toxictoxic effectseffects variesvaries alongalong aa distributiondistribution

Number of individuals affected

Dose SensitiveSensitive subpopulationsubpopulation

NumberNumber affectedaffected

DoseDose FishFish consumptionconsumption andand methylmercurymethylmercury exposureexposure FishFish consumptionconsumption

¾¾ LongLong--termterm trendtrend ofof increasingincreasing perper capitacapita consumptionconsumption inin USUS ¾¾ RecentRecent yearsyears at/nearat/near allall--timetime highhigh ¾¾ PatternsPatterns ofof consumptionconsumption alsoalso changingchanging ¾¾ MoreMore freshfresh andand frozenfrozen steakssteaks andand filletsfillets ¾¾ MoreMore (mostly(mostly imported)imported) shrimpshrimp ¾¾ LessLess cannedcanned andand breaded/processedbreaded/processed fishfish USUS PerPer capitacapita fishfish consumption,consumption, pounds/year,pounds/year, 19901990--20062006 (NMFS)(NMFS)

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 ConsumptionConsumption ofof selectedselected items,items, pounds/person/year,pounds/person/year, 19901990--20062006

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 PerPer capitacapita consumption,consumption, cannedcanned fish,fish, pounds/year,pounds/year, 19901990--20062006

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 TopTop 1010 SeafoodsSeafoods,, 20052005--20072007 USUS consumptionconsumption inin poundspounds perper capitacapita perper yearyear (NFI)(NFI)

Rank 2005 2006 2007 . Species Lbs Species Lbs Species Lbs 1 Shrimp 4.10 Shrimp 4.40 Shrimp 4.10 2 Tuna, can 3.10 Tuna, can 2.90 Tuna, can 2.70 3 Salmon 2.43 Salmon 2.03 Salmon 2.36 4 Pollock 1.47 Pollock 1.64 Pollock 1.73 5 Catfish 1.03 Tilapia 1.00 Tilapia 1.14 6 Tilapia 0.85 Catfish 0.97 Catfish 0.88 7 Crab 0.64 Crab 0.66 Crab 0.68 8 Cod 0.57 Cod 0.51 Cod 0.47 9 Clams 0.44 Clams 0.44 Clams 0.45 10 Flatfish 0.37 Scallops 0.31 Flatfish 0.32 Total, Top 10 15.0 14.9 14.8 WhereWhere’’ss thethe mercury?mercury?

¾¾ AmongAmong popularpopular fishfish andand seafoodseafood choices,choices, howhow muchmuch doesdoes eacheach varietyvariety contributecontribute toto potentialpotential methylmercurymethylmercury exposure?exposure? ¾¾ WhichWhich fishfish areare likelylikely toto contributecontribute mostmost toto methylmercurymethylmercury intake,intake, amongamong peoplepeople whowho eateat aa greatgreat dealdeal ofof fish?fish? MethylmercuryMethylmercury Exposure:Exposure: SourceSource StrengthsStrengths

¾¾ ContributionsContributions ofof differentdifferent fishfish andand seafoodseafood itemsitems toto totaltotal amountamount ofof mercurymercury inin thethe USUS fish/seafoodfish/seafood supply,supply, calculatedcalculated using:using: A:A: 20062006 USUS marketmarket datadata fromfrom NMFSNMFS B:B: MercuryMercury contentcontent fromfrom FDAFDA databasedatabase HgHg InputInput == (%(% ofof market)market) xx (Hg(Hg ppm)ppm) RelativeRelative HgHg ContributionsContributions

¾ HgHg inputsinputs calculatedcalculated forfor 5151 typestypes ofof fishfish andand shellfishshellfish forfor whichwhich therethere areare bothboth NMFSNMFS marketmarket datadata andand FDAFDA HgHg datadata ¾ ResultsResults areare notnot preciseprecise indicatorsindicators ofof exposure,exposure, butbut provideprovide relativerelative comparisonscomparisons ¾ ResultsResults cancan bebe rankedranked andand comparedcompared variousvarious waysways (e.g.,(e.g., percentpercent ofof totaltotal Hg)Hg) AA KeyKey Fact:Fact:

¾The weighted average methylmercury concentration in the US seafood supply is 0.086 ppm ColorColor--codingcoding fishfish forfor methylmercurymethylmercury contentcontent

¾ GREENGREEN == veryvery lowlow == << 0.0430.043 ppmppm ¾ BLUEBLUE == belowbelow averageaverage == 0.0440.044 -- 0.0860.086 ppmppm ¾ BLACKBLACK == aboveabove averageaverage == 0.0870.087 -- 0.1720.172 ppmppm ¾ ORANGEORANGE == moderatelymoderately highhigh == 0.1730.173 -- 0.3440.344 ppmppm ¾ REDRED == highhigh == 0.3450.345 -- 0.6880.688 ppmppm ¾ VIOLETVIOLET == veryvery highhigh == >> 0.6880.688 ppmppm Note:Note: DifferentDifferent breakpointsbreakpoints thanthan FDAFDA hashas usedused TopTop 1010 SeafoodsSeafoods,, 20052005--20072007 USUS consumptionconsumption inin poundspounds perper capitacapita perper yearyear (NFI)(NFI)

Rank 2005 2006 2007 . Species Lbs Species Lbs Species Lbs 1 Shrimp 4.10 Shrimp 4.40 Shrimp 4.10 2 Tuna, can 3.10 Tuna, can 2.90 Tuna, can 2.70 3 Salmon 2.43 Salmon 2.03 Salmon 2.36 4 Pollock 1.47 Pollock 1.64 Pollock 1.73 5 Catfish 1.03 Tilapia 1.00 Tilapia 1.14 6 Tilapia 0.85 Catfish 0.97 Catfish 0.88 7 Crab 0.64 Crab 0.66 Crab 0.68 8 Cod 0.57 Cod 0.51 Cod 0.47 9 Clams 0.44 Clams 0.44 Clams 0.45 10 Flatfish 0.37 Scallops 0.31 Flatfish 0.32 Total, Top 10 15.0 14.9 14.8 TopTop 1010 HgHg SourcesSources

Market Fish Share (%) ppm Hg Percent Hg

Tuna, all types 16.44 next slide 37.37 Haddock & Hake 4.86 0.170 9.73 Swordfish 0.44 0.976 5.06 Catfish 5.71 0.068 4.66 Cod 3.36 0.115 4.55 American lobster 1.22 0.310 4.46 Pollock 7.32 0.049 4.23 Shrimp 22.21 0.012 3.14 Salmon 6.83 0.028 2.25 Sea Bass 0.51 0.301 1.81

Total 77.26 Tuna,Tuna, byby typetype

Type Market % ppm Hg % Hg

Canned albacore 3.81 0.353 15.85

Canned light 11.41 0.118 15.86

Fresh/Frozen 1.22 0.384 5.66

Totals 16.44 37.37

(Insufficient supply data to specify contributions by tuna type to fresh/frozen category, e.g., bluefin, albacore, bigeye, etc.) CommentsComments onon TopTop 1010

¾ SwordfishSwordfish isis thethe onlyonly VioletViolet (very(very highhigh Hg)Hg) fishfish amongamong thethe TopTop 1010 sourcessources ¾ TwoTwo GreenGreen (very(very lowlow Hg)Hg) andand twotwo BlueBlue (below(below averageaverage Hg)Hg) itemsitems unlikelyunlikely toto bebe hazards;hazards; inin TopTop 1010 duedue toto hugehuge volumevolume consumedconsumed ¾ TwoTwo BlackBlack andand twotwo OrangeOrange itemsitems couldcould leadlead toto excessiveexcessive exposureexposure ifif eateneaten frequentlyfrequently ¾ TunaTuna (two(two RedRed,, oneone BlackBlack)) isis overwhelminglyoverwhelmingly thethe largestlargest sourcesource ¾ TopTop 1010 accountaccount forfor moremore thanthan ¾¾ ofof allall mercurymercury OtherOther ItemsItems ofof InterestInterest

Fish Market % ppm Hg % Hg Rank

Gulf Tilefish 0.01 1.450 0.171 40 Shark 0.07 0.988 0.815 21 King mackerel 0.05 0.730 0.430 29 Orange roughy 0.20 0.550 1.296 16 Marlin 0.02 0.489 0.115 42 Grouper 0.27 0.460 1.463 13 Bluefish 0.06 0.337 0.240 35 Snapper 0.86 0.137 1.388 15 Anchovies 3.06 0.050 1.803 11 Squid 1.92 0.070 1.583 12 Clams 2.04 0.023 0.553 28 Scallops 1.46 0.023 0.396 30 InterpretingInterpreting thesethese data:data:

¾ TunaTuna contributescontributes 66 timestimes asas muchmuch mercurymercury toto potentialpotential USUS exposureexposure asas dodo swordfish,swordfish, shark,shark, GulfGulf tilefishtilefish andand kingking mackerelmackerel combinedcombined.. ¾ AmericansAmericans eateat 2929 timestimes asas muchmuch tunatuna asas theythey eateat ofof thethe fourfour highesthighest--mercurymercury fishfish combinedcombined ¾ LobsterLobster,, seasea bassbass,, codcod,, haddockhaddock andand hakehake areare moremore importantimportant sourcessources thanthan manymany varietiesvarieties withwith higherhigher mercurymercury levels,levels, duedue toto marketmarket shareshare ¾ TwoTwo--thirdsthirds ofof thethe marketmarket isis inin thethe GreenGreen andand BlueBlue categories,categories, i.e.,i.e., lowlow mercurymercury MercuryMercury IntensityIntensity ofof CategoriesCategories

Weighted Intensity Category Mean Hg % Market % Hg Index .

Very Low 0.018 42.86 9.074 0.21

Below Avg 0.056 24.13 15.984 0.66

Above Avg 0.129 22.51 34.303 1.52

Mod. High 0.289 2.81 9.565 3.43

High 0.375 5.57 24.599 4.57

Very High 0.964 0.57 6.475 10.83 MercuryMercury IntensityIntensity IndicesIndices

¾ Are ratios, % mercury / % of market ¾ Indicate the relative mercury dose a consumer ingests by eating an item from each category ¾ Span a range of over 50-fold; i.e., fish in the VioletViolet category deliver over 50 times as much mercury, on average, as fish or shellfish in the GreenGreen category ““TroubleTrouble”” Scenarios:Scenarios:

WaysWays toto getget excessiveexcessive mercurymercury doses:doses: A.A. EatEat veryvery highhigh HgHg fishfish moremore oftenoften thanthan rarelyrarely B.B. EatEat moderatelymoderately highhigh oror highhigh HgHg fishfish fairlyfairly often,often, i.e.i.e. onceonce aa weekweek oror moremore C.C. EatingEating above average HgHg fishfish veryvery often,often, i.e.i.e. twicetwice aa weekweek oror more,more, withwith occasionaloccasional mealsmeals fromfrom categoriescategories inin AA oror BB ThereThere areare largelarge numbersnumbers ofof AmericansAmericans (though(though aa smallsmall percentage)percentage) withwith eacheach ofof thesethese consumptionconsumption patternspatterns CaseCase HistoriesHistories ofof methylmercurymethylmercury poisoningpoisoning inin peoplepeople whowho eateat aa lotlot ofof fishfish

OverOver TheThe LimitLimit ¾¾ II wrotewrote itit forfor thethe MercuryMercury PolicyPolicy ProjectProject ¾¾ PrimaryPrimary goal:goal: ToTo putput aa humanhuman faceface onon abstractabstract riskrisk conceptsconcepts ¾¾ Sources:Sources: PublishedPublished casecase reports,reports, aa fewfew inin scientificscientific journals,journals, mostmost inin otherother mediamedia ¾¾ II readilyreadily foundfound 2424 casescases ofof highhigh--endend fishfish eaterseaters withwith methylmercurymethylmercury poisoningpoisoning ¾¾ OnceOnce II hadhad thesethese data,data, II subjectedsubjected themthem toto somesome scientificscientific analysisanalysis CriteriaCriteria forfor InclusionInclusion

¾¾ SymptomsSymptoms consistentconsistent withwith methylmercurymethylmercury poisoningpoisoning ¾¾ PatientPatient oftenoften consumedconsumed highhigh--HgHg fishfish ¾¾ MeHgMeHg toxicitytoxicity diagnoseddiagnosed byby aa physicianphysician ¾¾ SomeSome supportingsupporting datadata (e.g.,(e.g., bloodblood Hg)Hg) ¾¾ PatientPatient stoppedstopped eatingeating highhigh--HgHg fishfish andand symptomssymptoms resolvedresolved ¾¾ MostMost ofof thethe casescases meetmeet allall thesethese criteriacriteria WeaknessesWeaknesses inin thethe datadata

¾¾ MostMost casescases notnot peerpeer--reviewedreviewed (only(only 44 ofof 2424 publishedpublished inin scientificscientific journals)journals) ¾¾ SymptomsSymptoms areare generallygenerally subjectivesubjective ¾¾ WideWide rangerange inin severityseverity ofof symptomssymptoms ¾¾ ExposureExposure datadata (blood,(blood, hairhair Hg)Hg) unavailableunavailable inin somesome cases,cases, qualitativequalitative inin somesome othersothers ¾¾ FishFish intakeintake basedbased onon patientpatient recallrecall ¾¾ SomeSome patientspatients lostlost toto followfollow--upup FarFar fromfrom ideal:ideal:

¾¾ IndividualIndividual casecase historieshistories areare thethe ““lowestlowest”” formform ofof epidemiologicalepidemiological evidenceevidence ¾¾ SomeSome ofof thesethese casescases areare fairlyfairly anecdotal,anecdotal, limitinglimiting confidenceconfidence inin theirtheir reliabilityreliability ¾¾ But:But: LimitedLimited datadata areare nonethelessnonetheless data.data. WhatWhat cancan wewe learnlearn fromfrom thesethese cases?cases? ¾¾ SomeSome provocativeprovocative observationsobservations emergeemerge fromfrom studystudy ofof thisthis limitedlimited datadata setset CriticalCritical Questions:Questions:

¾¾ WhoWho isis atat risk?risk? ¾¾ IsIs itit reallyreally methylmercurymethylmercury poisoning?poisoning? ¾¾ WhatWhat dosesdoses areare associatedassociated withwith harm?harm? ¾¾ WhatWhat fishfish diddid thethe casescases eat?eat? ¾¾ HowHow manymany otherother casescases mightmight therethere be?be? ¾¾ WhatWhat researchresearch isis needed?needed? ¾¾ WhatWhat adviceadvice shouldshould suchsuch highhigh--endend fishfish consumersconsumers bebe getting?getting? WhoWho isis atat risk?risk?

¾¾ CasesCases werewere generallygenerally middlemiddle--agedaged adults,adults, agesages 4040 toto 6666 atat diagnosisdiagnosis ¾¾ FourFour casescases werewere childrenchildren ¾¾ 2020 ofof 2424 casescases ateate commerciallycommercially--caughtcaught fish;fish; 44 werewere sportsport anglersanglers ¾¾ TheThe 1616 adultsadults inin thethe formerformer groupgroup werewere allall healthhealth--consciousconscious individuals,individuals, tryingtrying toto eateat aa healthyhealthy diet,diet, equallyequally divideddivided byby gendergender

AA minorityminority ofof aa minorityminority

¾¾ NotNot ““typicaltypical”” Americans;Americans; realreal ““fishfish loverslovers”” ¾¾ MostMost probablyprobably areare aboveabove thethe 9999th,, somesome aboveabove 99.999.9th percentilepercentile ofof fishfish consumersconsumers ¾¾ WithinWithin thatthat ““extremeextreme”” group,group, theythey preferprefer toto eateat higherhigher--mercury,mercury, predatorypredatory fish:fish: TunaTuna,, swordfishswordfish,, halibuthalibut,, seasea bassbass,, othersothers ¾¾ SomeSome maymay alsoalso bebe moremore sensitivesensitive thanthan averageaverage toto toxictoxic effectseffects HowHow dodo wewe knowknow itit’’ss methylmercurymethylmercury poisoning?poisoning? SymptomsSymptoms seenseen inin cases:cases: Symptoms,Symptoms, continuedcontinued MethylmercuryMethylmercury poisoning?poisoning?

¾¾ SymptomsSymptoms matchmatch classicclassic symptomssymptoms ¾¾ DiagnosedDiagnosed byby aa physicianphysician basedbased onon symptomssymptoms andand elevatedelevated blood/hairblood/hair HgHg ¾¾ WhenWhen stoppedstopped eatingeating highhigh--HgHg fish,fish, bloodblood HgHg droppeddropped && symptomssymptoms resolvedresolved ¾¾ NoNo evidenceevidence forfor otherother causescauses detecteddetected inin oftenoften--extensiveextensive diagnosticdiagnostic processprocess ¾¾ BottomBottom line:line: ItIt isis whatwhat itit appearsappears toto bebe HowHow suresure areare we?we?

¾¾ AbsoluteAbsolute proofproof isis nevernever possiblepossible ¾¾ SeeSee detailsdetails inin thethe 2424 individualindividual casescases describeddescribed inin OverOver TheThe LimitLimit ¾¾ SomeSome casescases areare aa bitbit questionablequestionable ¾¾ ButBut thethe majoritymajority areare quitequite unequivocal:unequivocal: therethere isis virtuallyvirtually nono doubtdoubt thatthat thethe personperson gotgot mercurymercury poisoningpoisoning fromfrom eatingeating largelarge amountsamounts ofof fishfish withwith elevatedelevated HgHg contentcontent DoseDose--responseresponse issues:issues:

¾ NoNo quantitativequantitative bloodblood levellevel availableavailable inin 33 casescases withwith thethe mostmost severesevere symptomssymptoms ¾ SixSix casescases withwith thethe mildestmildest symptoms,symptoms, nono bloodblood HgHg availableavailable inin 4,4, averageaverage 88 ppbppb inin otherother twotwo ¾ But:But: NoNo symptomssymptoms inin oneone patientpatient withwith highesthighest quantifiedquantified bloodblood HgHg (228(228 ppb)ppb) ¾ ModerateModerate toto severesevere symptomssymptoms inin 66 casescases withwith bloodblood HgHg levelslevels ofof 5858--125125 ppbppb ¾ And:And: SimilarSimilar moderatemoderate toto severesevere symptomssymptoms inin 88 otherother casescases withwith bloodblood HgHg ofof 1212--3838 ppbppb DoseDose--responseresponse && gender:gender:

2424 cases:cases: 2020 adults,adults, 44 childrenchildren

¾¾ MildMild symptoms:symptoms: 66 cases,cases, 55 malesmales andand oneone child,child, gendergender notnot specifiedspecified ¾¾ ModerateModerate symptoms:symptoms: 1414 casescases •• 55 malesmales (3(3 adults,adults, 22 children),children), avgavg bHgbHg 68.468.4 ppbppb •• 99 femalesfemales (8(8 adults,adults, 11 child),child), avgavg bHgbHg 44.2544.25 ppbppb ¾¾ SevereSevere symptoms:symptoms: 33 cases,cases, allall malesmales Interpretations:Interpretations:

¾¾ AA smallsmall datadata set,set, butbut widewide differencesdifferences inin individualindividual sensitivitysensitivity toto toxictoxic effectseffects areare stillstill evidentevident ¾¾ SensitiveSensitive individualsindividuals (1/3(1/3 ofof cases)cases) showshow symptomssymptoms atat bloodblood HgHg levelslevels longlong judgedjudged withoutwithout appreciableappreciable riskrisk (i.e.,(i.e., 1212--3838 ppb)ppb) ¾¾ MenMen seemseem moremore likelylikely toto experienceexperience eithereither severesevere oror mildmild symptomssymptoms ¾¾ WomenWomen experiencedexperienced moderatemoderate--toto--severesevere symptomssymptoms atat lowerlower dosesdoses thanthan menmen LowLow--dosedose effects?effects?

¾¾ FrankFrank neurotoxicneurotoxic effectseffects associatedassociated inin somesome casescases herehere withwith farfar lowerlower exposureexposure levelslevels thanthan previouslypreviously recognizedrecognized ¾¾ PossiblyPossibly hyperhyper--sensitivesensitive individualsindividuals ¾¾ ClinicalClinical toxicitytoxicity maymay bebe veryvery rarerare atat thesethese doses,doses, oror perhapsperhaps justjust rarelyrarely diagnoseddiagnosed ¾¾ ButBut adverseadverse effectseffects atat lowlow dosesdoses areare notnot entirelyentirely unprecedentedunprecedented oror unexpectedunexpected LowLow--dosedose effectseffects

¾¾ CartaCarta etet al.,al., 20052005 (Italy):(Italy): ¾¾ 2222 menmen whowho frequentlyfrequently ateate tuna,tuna, hadhad anan averageaverage bloodblood HgHg levellevel ofof 41.541.5 ppbppb ¾¾ 2222 controls,controls, hadhad averageaverage bHgbHg ofof 2.62.6 ppbppb ¾¾ NeurobehavioralNeurobehavioral teststests ofof vigilance,vigilance, handhand tremor,tremor, psychomotorpsychomotor functionfunction ¾¾ CasesCases performedperformed significantlysignificantly worseworse onon threethree functionalfunctional teststests (&(& worseworse onon allall 10)10) LowLow--dosedose effects,effects, contcont’’dd

¾¾ YokooYokoo etet al.,al., 20032003 (Brazil):(Brazil): ¾¾ BatteryBattery ofof neurobehavioralneurobehavioral andand cognitivecognitive teststests givengiven toto 129129 AmazonianAmazonian villagersvillagers ¾¾ Adults,Adults, classifiedclassified byby exposureexposure basedbased onon hairhair HgHg levellevel (mean(mean 4.24.2 ++ 2.42.4 ppm,ppm, rangerange 0.560.56 --13.613.6 ppm)ppm) ¾¾ DoseDose--relatedrelated effectseffects ofof HgHg onon finefine motormotor speed,speed, dexterity,dexterity, concentrationconcentration andand somesome aspectsaspects ofof verbalverbal learninglearning && memorymemory ExposureExposure inin thisthis group:group:

¾¾ MeanMean hairhair mercurymercury ofof 4.24.2 ppmppm vs.vs. meanmean ofof aboutabout 11 ppmppm forfor USUS adultsadults ¾¾ FourFour casescases inin OverOver TheThe LimitLimit hadhad hairhair HgHg levelslevels ofof 9,9, 12,12, 1313 andand 6868 ppmppm ¾¾ I.e.,I.e., testedtested AmazonAmazon villagersvillagers havehave mercurymercury exposuresexposures notnot unlikeunlike AmericansAmericans whowho eateat aa lotlot ofof relativelyrelatively highhigh--HgHg fishfish LowLow--dosedose effects,effects, contcont’’dd

¾¾ OkenOken etet al.,al., 2005,2005, 20082008 (Boston):(Boston): ¾¾ CognitiveCognitive andand neurobehavioralneurobehavioral teststests inin infantsinfants && 33--yryr--oldsolds vs.vs. maternalmaternal fishfish intakeintake ¾¾ HighHigh fishfish consumptionconsumption correlatedcorrelated withwith improvedimproved cognitivecognitive performanceperformance ¾¾ But:But: HighHigh mercurymercury exposureexposure correlatedcorrelated withwith decreaseddecreased cognitivecognitive performanceperformance ¾¾ I.e.,I.e., antagonisticantagonistic effectseffects OkenOken etet al.al.’’ss subjects:subjects:

¾¾ ““HighHigh fishfish--eaterseaters”” consumedconsumed onlyonly twotwo fishfish mealsmeals perper weekweek (>(> twicetwice USUS average)average) ¾¾ HighHigh mercurymercury exposureexposure == >> 9090th percentilepercentile w/inw/in group,group, == hairhair HgHg >> 1.21.2 ppmppm ¾¾ 9090th percentilepercentile forfor bloodblood HgHg inin womenwomen inin NortheastNortheast USUS (NHANES)(NHANES) == 5.25.2 ppbppb ¾¾ Inference:Inference: AdverseAdverse HgHg effectseffects onon thethe fetalfetal brainbrain maymay occuroccur @@ >> 55 ppbppb maternalmaternal bHgbHg ConfirmingConfirming StudiesStudies

¾ Lederman et al. (2008), New York City; mean maternal blood Hg level 2.29 ppb ¾ Jedrychowski et al. (2006), Krakow, Poland; mean maternal blood Hg 0.75 ppb ¾ Davidson et al. (2008), Seychelles; mean maternal hair Hg 5.7 ppm (NOTE: Previous reports from Seychelles had failed to see effects; confounding by nutritional benefits of fish consumption) Conclusions:Conclusions:

¾¾ WeWe areare approachingapproaching aa pointpoint wherewhere ourour viewview ofof lowlow--dosedose methylmercurymethylmercury effectseffects maymay undergoundergo radicalradical revision,revision, asas occurredoccurred forfor leadlead toxicitytoxicity aroundaround 19791979--80.80. ¾¾ SubSub--clinicalclinical effectseffects measuredmeasured byby sensitivesensitive teststests areare likelylikely toto bebe farfar moremore widespreadwidespread thanthan overtovert illnessillness BACKBACK TOTO OUROUR 2424 CASESCASES…… WhatWhat fishfish diddid theythey eat?eat? (commercially(commercially--caughtcaught fish,fish, 2121 cases)cases)

20 18 16 14 12 10 8 6 4 2 0 Tuna, all Swordfish Halibut Sea Bass Yellowtail King types Mackerel OnlyOnly sixsix FishFish VarietiesVarieties involvedinvolved inin thesethese 2121 casescases

¾¾ TunaTuna (all(all types):types): 1818 cases,cases, 8686 %% ¾¾ SwordfishSwordfish:: 88 cases,cases, 3838 %% ¾¾ HalibutHalibut:: 33 cases,cases, 1414 %% ¾¾ SeaSea bassbass:: 33 cases,cases, 1414 %% ¾¾ YellowtailYellowtail:: 22 cases,cases, 10%10% ¾¾ KingKing mackerelmackerel:: 11 case,case, 55 %% (>(> 100%100% becausebecause manymany casescases ateate moremore thanthan oneone typetype ofof highhigh--mercurymercury fish)fish) Noteworthy:Noteworthy:

¾¾ TwoTwo ofof thethe ““troubletrouble scenariosscenarios”” applyapply herehere ¾¾ SomeSome patientspatients ateate swordfishswordfish,, aa veryvery highhigh HgHg fish,fish, oftenoften ¾¾ ButBut thethe majoritymajority ateate TunaTuna,, seasea bassbass,, halibuthalibut andand yellowtailyellowtail,, allall fishfish withwith lessless extremeextreme HgHg levelslevels ¾¾ TunaTuna waswas aa sourcesource inin aa largelarge majoritymajority ofof thethe casescases andand waswas thethe onlyonly knownknown sourcesource inin 99 casescases (43%)(43%) MercuryMercury LevelsLevels inin CommerciallyCommercially CaughtCaught FishFish InvolvedInvolved inin CasesCases Fish # of Cases ppm Hg Tuna, fresh/frozen 11 0.384 Swordfish 8 0.976 Tuna, canned, type not specified 4 0.118 Tuna, canned, albacore 3 0.353 Tuna, sushi 3 0.10-2.76 Halibut 3 0.220 Sea bass 2 0.301 Yellowtail 2 0.484 Tuna, bluefin 1 ~1.0 Sea bass, Chilean 1 0.600 King mackerel 1 0.730 . Most data from US FDA; tuna sushi, NY Times & Houston Chronicle; bluefin estimated from sushi data; Chilean sea bass, Knobeloch et al. (2005); Yellowtail, FL Fish & Wildlife Commission (2003) Summary:Summary:

¾¾ OneOne--thirdthird ofof casescases (8(8 patients)patients) ateate aa highhigh-- mercurymercury fishfish ((swordfishswordfish)) repeatedlyrepeatedly ¾¾ OneOne childchild casecase ateate somesome kingking mackerelmackerel,, butbut alsoalso ateate aa lotlot ofof cannedcanned tunatuna ¾¾ TheThe largelarge majoritymajority ofof casescases ateate mostlymostly moderatelymoderately highhigh andand highhigh mercurymercury fish:fish: tunatuna (fresh/frozen(fresh/frozen steaks,steaks, canned,canned, andand sushi),sushi), halibuthalibut,, seasea bassbass andand yellowtailyellowtail ¾¾ NineNine casescases (43%)(43%) ateate onlyonly tunatuna IfIf therethere werewere aa signsign aboveabove mymy desk,desk, herehere’’ss whatwhat itit mightmight say:*say:*

** withwith apologiesapologies toto JamesJames CarvilleCarville ItIt’’ss thethe tuna,tuna, stupid!stupid! HowHow manymany casescases mightmight bebe ““outout therethere””??

PossiblePossible sizesize ofof populationpopulation atat riskrisk estimatedestimated byby threethree differentdifferent methods:methods:

¾¾ BackBack--ofof--thethe--envelopeenvelope ¾¾ InferencesInferences fromfrom publishedpublished studiesstudies ¾¾ InferencesInferences fromfrom NHANESNHANES datadata ““ExtremeExtreme”” FishFish EatersEaters

FDA estimates: ¾ Population Average Fish Consumption: Women: 14.3 g/day Men: 18.6 g/day ¾ 99th Percentile of Fish Consumption: Women: 95 g/day Men: 134 g/day If a typical serving is 150-180 grams (more for men), 99th percentile eats fish ~ 4 to 5 times per week BackBack--ofof--thethe--envelopeenvelope

¾¾ Assume:Assume: ExtremeExtreme fishfish--eaterseaters areare aboveabove thethe 9999th percentilepercentile inin fishfish consumptionconsumption ¾¾ Assume:Assume: 0.10.1 toto 1010 percentpercent repeatedlyrepeatedly eateat highhigh--mercurymercury fishfish 3,250,0003,250,000 consumersconsumers xx (0.1(0.1 toto 1010 percent)percent) == 3,2503,250 toto 325,000325,000 possiblepossible casescases LimitationsLimitations ofof BOTEBOTE method:method:

¾ CasesCases mightmight occuroccur belowbelow 9999th percentile;percentile; i.e.,i.e., oursours variedvaried fromfrom <1<1 toto >10>10 fishfish mealsmeals perper weekweek ¾ VeryVery fewfew datadata fromfrom whichwhich toto estimateestimate reliablyreliably howhow manymany peoplepeople repeatedlyrepeatedly eateat higherhigher--HgHg fish;fish; widewide rangerange ofof uncertaintyuncertainty (and(and perhapsperhaps >10%>10% repeatedlyrepeatedly eateat tuna?)tuna?) ¾ ServingServing size,size, specificspecific typetype ofof fishfish alsoalso mattermatter ¾ MethodMethod estimatesestimates onlyonly exposure;exposure; cancan’’tt saysay whatwhat fractionfraction ofof peoplepeople withwith highhigh--endend exposureexposure mightmight experienceexperience symptomssymptoms PublishedPublished StudiesStudies CarringtonCarrington && BolgerBolger (2003)(2003) ¾¾ MaximumMaximum assumedassumed fishfish intakeintake == 1818 ozoz perper weekweek (( == << 99th99th percentile)percentile) ¾¾ EstimatedEstimated 9999th percentilepercentile baselinebaseline bHgbHg inin womenwomen ofof childbearingchildbearing ageage == 16.116.1 ppb,ppb, andand 99.999.9th percentilepercentile bHgbHg == 26.326.3 ppbppb ¾¾ I.e.,I.e., 99.999.9th percentilepercentile consumerconsumer (1(1 inin 1,0001,000 people)people) hashas bloodblood HgHg inin thethe lowlow--midmid rangerange observedobserved inin casescases inin OverOver TheThe LimitLimit RepeatRepeat consumptionconsumption data:data:

¾ Carrington & Bolger also have estimated the frequency of repeat consumption from NHANES data ¾ About 10 percent of women choose the same fish > 80% of the time ¾ Problems: Too few data to estimate freq. of repeat eating of low-market share high mercury fish; & data are just for women InferencesInferences fromfrom C&BC&B model:model:

¾ RoughlyRoughly 11 inin 1,0001,000 consumersconsumers maymay havehave bloodblood HgHg levelslevels inin thethe rangerange associatedassociated withwith toxictoxic symptomssymptoms inin sensitivesensitive individualsindividuals amongamong thethe 2424 casescases (i.e.,(i.e., >> 2020 ppb)ppb) ¾ ForFor aa lowerlower exposureexposure levellevel (e.g.,(e.g., 1515 ppb),ppb), thethe numbernumber possiblypossibly atat riskrisk maymay risesrises toto 22 inin 10001000 ¾ FarFar less)less) thanthan 11 inin 1,0001,000 havehave bHgbHg levelslevels above,above, say,say, 5050 ppbppb Limitations:Limitations:

¾¾ AppliesApplies toto womenwomen ofof childbearingchildbearing ageage ¾¾ ModelModel lackslacks empiricalempirical datadata onon thosethose (rare)(rare) individualsindividuals whowho repeatedlyrepeatedly choosechoose higherhigher-- mercurymercury fishfish ¾¾ ReliedRelied onon NHANESNHANES fishfish consumptionconsumption data;data; NHANESNHANES samplesample isis nationallynationally balanced,balanced, doesdoes notnot includeinclude manymany membersmembers ofof ethnicethnic oror tribaltribal minoritiesminorities withwith highhigh--fishfish dietsdiets PublishedPublished epiepi studiesstudies

¾¾ VeryVery fewfew publishedpublished epidemiologicalepidemiological datadata ¾¾ HightowerHightower && MooreMoore (2003):(2003): 720720 patients,patients, ~100~100 withwith elevatedelevated bloodblood HgHg (>(> 55 ppb),ppb), ~~ 55 hadhad symptomssymptoms (case(case raterate == 0.7%)0.7%) ¾¾ KnobelochKnobeloch etet al.al. (2005),(2005), 20002000 volunteers;volunteers; 77 casescases w.w. elevatedelevated bloodblood HgHg (0.35%);(0.35%); 33 withwith symptomssymptoms (0.15%)(0.15%) ¾¾ NonNon--representativerepresentative populationspopulations inin eacheach case.case. ProjectedProjected incidenceincidence thusthus << 0.1%0.1% InferencesInferences fromfrom NHANESNHANES

¾¾ MeasuredMeasured bloodblood HgHg inin 5,2145,214 womenwomen andand children,children, 19991999--20042004 ¾¾ NoNo adultadult men,men, nono olderolder women,women, notnot fullyfully balancedbalanced regionallyregionally oror ethnicallyethnically ¾¾ MaximumMaximum bloodblood HgHg levellevel inin thethe NHANESNHANES samplesample waswas 3333 ppbppb ¾¾ WhatWhat doesdoes thisthis telltell us?us? LevelsLevels aboveabove 3333 ppb?ppb?

¾¾ AnalysisAnalysis ofof statisticalstatistical powerpower ofof sample:sample: ¾¾ ConsiderConsider aa highhigh bloodblood HgHg level,level, defineddefined herehere (arbitrarily)(arbitrarily) asas >> 3333 ppb.ppb. ¾¾ TheThe NHANESNHANES samplesample includedincluded nono oneone withwith aa levellevel thatthat highhigh ¾¾ HowHow manymany peoplepeople inin thethe USUS populationpopulation ofof 325325 millionmillion couldcould havehave levelslevels higherhigher thanthan that,that, andand NHANESNHANES wouldwould stillstill bebe unlikelyunlikely toto includeinclude atat leastleast oneone ofof them?them? Probabilities:Probabilities:

¾¾ AssumeAssume forfor thisthis exerciseexercise thatthat thethe NHANESNHANES samplesample waswas randomrandom andand representativerepresentative ofof thethe USUS asas aa wholewhole ¾¾ IfIf thethe incidenceincidence ofof bHgbHg >> 3333 ppbppb werewere 11 inin 1,0001,000 people,people, thethe probabilityprobability thatthat NHANESNHANES wouldwould includeinclude zerozero isis (0.999)(0.999)5214 == 0.00540.0054 ¾¾ IfIf thethe incidenceincidence ofof bHgbHg >> 3333 ppbppb werewere 11 inin 10,00010,000 people,people, thethe probabilityprobability thatthat NHANESNHANES wouldwould includeinclude zerozero isis (0.9999)(0.9999)5214 == 0.590.59 WithWith 95%95% Confidence:Confidence:

¾¾ IfIf thethe incidenceincidence werewere 11 inin 1,7421,742 people,people, thethe probabilityprobability thatthat NHANESNHANES wouldwould notnot includeinclude anyany isis 0.05.0.05. ¾¾ I.e.,I.e., wewe cancan bebe 95%95% confidentconfident thatthat therethere areare nono moremore thanthan 186,567186,567 (325,000,000(325,000,000 ÷÷ 1,742)1,742) peoplepeople inin thethe USUS withwith bloodblood HgHg >> 3333 ppb.ppb. ¾¾ Or,Or, 0.060.06 percentpercent ofof thethe populationpopulation oror lessless areare likelylikely toto havehave levelslevels aboveabove 3333 ppb.ppb. Comments:Comments:

¾ ThisThis conclusionconclusion isis notnot veryvery reassuringreassuring ¾ ThisThis analysisanalysis dealtdealt withwith bloodblood HgHg levelslevels aboveabove 3333 ppbppb (max(max observedobserved inin NHANESNHANES sample)sample) ¾ TheThe samesame probabilitiesprobabilities applyapply toto 3434 ppb,ppb, 8484 ppbppb andand 134134 ppb,ppb, say,say, butbut wewe knowknow thethe incidenceincidence decreasesdecreases sharplysharply asas bloodblood HgHg levellevel increasesincreases ¾ CasesCases suggestsuggest thatthat symptomssymptoms maymay occuroccur atat 3333 ppbppb oror lessless inin somesome sensitivesensitive patientspatients ¾ SubSub--clinicalclinical effectseffects onon cognitivecognitive processesprocesses andand finefine--motormotor coordinationcoordination areare alsoalso aa concernconcern TriangulationTriangulation

¾¾ C&BC&B modelmodel suggestssuggests 0.10.1 percentpercent ofof USUS womenwomen couldcould havehave bHgbHg >> 2626 ppbppb ¾¾ NHANESNHANES analysisanalysis suggestssuggests 0.060.06 percentpercent couldcould havehave bHgbHg >> 3333 ppbppb ¾¾ NeitherNeither predictspredicts frequencyfrequency ofof symptomssymptoms ¾¾ PublishedPublished studiesstudies suggestsuggest symptomssymptoms inin 0.150.15 –– 0.70.7 percentpercent ofof twotwo highlyhighly selectedselected populations;populations; generalgeneral incidenceincidence isis surelysurely less,less, butbut cancan’’tt saysay howhow muchmuch lessless BottomBottom lines:lines: ¾¾ NoneNone ofof thesethese estimationestimation methodsmethods isis veryvery preciseprecise oror satisfactorysatisfactory ¾¾ ButBut theythey convergeconverge aroundaround aa possiblepossible incidenceincidence ofof aboutabout 0.060.06 toto 0.10.1 percentpercent ¾¾ I.e.,I.e., fromfrom 200,000200,000 toto 300,000300,000 AmericansAmericans maymay havehave elevatedelevated bloodblood HgHg (>(> ~25~25 ppb)ppb) ¾¾ IncidenceIncidence ofof elevatedelevated bloodblood HgHg doesdoes notnot predictpredict thethe incidenceincidence ofof toxictoxic symptomssymptoms ¾¾ ActualActual numbernumber ofof casescases couldcould thereforetherefore bebe (much)(much) smallersmaller (tens(tens ofof thousands?)thousands?) Comments:Comments:

¾¾ TheThe needneed toto narrownarrow thesethese uncertaintiesuncertainties byby focusedfocused researchresearch isis urgenturgent ¾¾ Meanwhile,Meanwhile, however,however, wewe maymay wishwish toto actact asas ifif therethere couldcould bebe fromfrom severalseveral thousandthousand toto aa fewfew hundredhundred thousandthousand possiblepossible casescases ofof methylmercurymethylmercury poisoningpoisoning amongamong highhigh-- endend USUS fishfish consumersconsumers ResearchResearch needs:needs:

¾¾ MoreMore casecase historieshistories needneed toto bebe publishedpublished inin medicalmedical journalsjournals (I(I’’dd welcomewelcome referrals)referrals) ¾¾ FocusedFocused studiesstudies usingusing sensitivesensitive outcomeoutcome measuresmeasures forfor methylmercurymethylmercury effectseffects onon thethe CNSCNS shouldshould bebe donedone onon peoplepeople whowho eateat aa greatgreat dealdeal ofof fishfish (adults(adults && kids)kids) ¾¾ SimilarSimilar studiesstudies shouldshould bebe donedone onon aa largelarge crosscross--sectionsection ofof thethe population,population, stratifiedstratified byby HgHg exposureexposure MoreMore researchresearch needs:needs:

¾¾ BetterBetter datadata areare neededneeded onon highhigh--HgHg fishfish consumption:consumption: HowHow manymany peoplepeople eateat suchsuch fishfish repeatedly,repeatedly, andand howhow muchmuch dodo theythey eateat modmod--highhigh,, highhigh andand veryvery highhigh HgHg fish?fish? ¾¾ BetterBetter datadata neededneeded onon HgHg levelslevels inin somesome fish,fish, includingincluding lowlow andand belowbelow averageaverage HgHg fish,fish, recommendedrecommended asas safersafer choiceschoices (FDA(FDA datadata quitequite sparsesparse inin manymany respects)respects) AdviceAdvice forfor ConsumersConsumers whowho eateat aa lotlot ofof fishfish

¾ Who:Who: PopulationPopulation needingneeding adviceadvice isis notnot justjust mothersmothers--toto--be;be; anyoneanyone elseelse whowho eatseats aa lotlot ofof thethe wrongwrong fishfish (>(> twicetwice aa week)week) maymay bebe atat riskrisk tootoo ¾ WhatWhat fish:fish: ItIt’’ss notnot justjust veryvery highhigh HgHg fish;fish; highhigh andand moderatelymoderately highhigh fishfish alsoalso areare clearlyclearly aa problemproblem ifif eateneaten often,often, andand aboveabove averageaverage HgHg fishfish cancan alsoalso contributecontribute significantlysignificantly toto riskrisk ofof excessexcess exposureexposure ifif eateneaten inin largelarge amountsamounts WhichWhich fishfish toto choose?choose?

¾ Fish and shellfish in the GreenGreen and BlueBlue categories are unlikely to lead to excess exposure no matter how much one eats ¾ These two “safe” categories account for 67 percent of the market ¾ So, motivated consumers can easily find low-mercury choices TopTop 1010 SeafoodsSeafoods,, 20052005--20072007 USUS consumptionconsumption inin poundspounds perper capitacapita perper yearyear (NFI)(NFI)

Rank 2005 2006 2007 . Species Lbs Species Lbs Species Lbs 1 Shrimp 4.10 Shrimp 4.40 Shrimp 4.10 2 Tuna, can 3.10 Tuna, can 2.90 Tuna, can 2.70 3 Salmon 2.43 Salmon 2.03 Salmon 2.36 4 Pollock 1.47 Pollock 1.64 Pollock 1.73 5 Catfish 1.03 Tilapia 1.00 Tilapia 1.14 6 Tilapia 0.85 Catfish 0.97 Catfish 0.88 7 Crab 0.64 Crab 0.66 Crab 0.68 8 Cod 0.57 Cod 0.51 Cod 0.47 9 Clams 0.44 Clams 0.44 Clams 0.45 10 Flatfish 0.37 Scallops 0.31 Flatfish 0.32 Total, Top 10 15.0 14.9 14.8 People who eat a lot of fish need more & better information about the mercury content of the fish they are likely to eat a lot of TheThe idealideal messagemessage (conveyed(conveyed inin ““oneone voicevoice””):):

““EatEat lotslots ofof lowlow-- mercurymercury fishfish”” HardHard toto getget thisthis right:right:

¾¾ ConflictingConflicting messagesmessages fromfrom variousvarious expertexpert sourcessources and/orand/or interestedinterested parties:parties: ¾¾ NotNot right:right: ““BenefitsBenefits outweighoutweigh risks,risks, dondon’’tt worryworry aboutabout mercury.mercury.”” (False(False tradetrade--off)off) ¾¾ NotNot right:right: ““EatEat lotslots ofof fish.fish.”” (Fails(Fails toto makemake importantimportant riskrisk--relatedrelated distinctions.)distinctions.) ¾¾ NotNot right:right: ““ToTo avoidavoid mercurymercury risk,risk, dondon’’tt eateat fish.fish.”” (Dismisses(Dismisses benefits.)benefits.) CommunicationCommunication challengeschallenges

¾ AmericansAmericans consumeconsume aa greatgreat dealdeal ofof tunatuna ¾ SomeSome peoplepeople alsoalso eateat otherother moderatelymoderately highhigh,, highhigh,, oror veryvery highhigh HgHg fishfish repeatedlyrepeatedly ¾ NeedNeed toto adviseadvise thosethose consumersconsumers asas aa distinctdistinct subsub--populationpopulation atat significantsignificant riskrisk ¾ TheyThey needneed moremore andand betterbetter adviceadvice aboutabout thethe mercurymercury contentcontent ofof allall popularpopular fishfish andand shellfishshellfish varieties,varieties, andand improvedimproved guidanceguidance toto choosechoose lowlow-- mercurymercury itemsitems One idea about what consumer advice might look like ConsumerConsumer AdviceAdvice

IfIf youyou eateat fishfish twicetwice aa weekweek oror lessless,, choosechoose fishfish asas follows:follows: GreenGreen oror BlueBlue:: AsAs oftenoften asas youyou likelike Black:Black: UpUp toto onceonce perper weekweek OrangeOrange oror RedRed:: UpUp toto once/2once/2 weeksweeks VioletViolet:: UpUp toto onceonce perper monthmonth ConsumerConsumer Advice,Advice, contcont’’dd

IfIf youyou eateat fishfish 33--44 timestimes aa week,week, choosechoose fishfish asas follows:follows: GreenGreen oror BlueBlue:: AsAs oftenoften asas youyou likelike Black:Black: UpUp toto onceonce inin twotwo weeksweeks OrangeOrange//RedRed:: UpUp toto onceonce perper monthmonth VioletViolet:: UpUp toto onceonce perper 33 monthsmonths MPPMPP Advice,Advice, contcont’’dd

IfIf youyou eateat fishfish 55 timestimes aa weekweek oror moremore,, choosechoose fishfish asas follows:follows: GreenGreen:: AsAs oftenoften asas youyou likelike BlueBlue:: UpUp toto onceonce aa weekweek Black:Black: UpUp toto onceonce aa monthmonth OrangeOrange//RedRed:: UpUp toto onceonce inin threethree monthsmonths VioletViolet:: OnceOnce oror twicetwice aa yearyear ModesModes ofof AdviceAdvice

¾ GovernmentGovernment advisoriesadvisories ¾ NGONGO && privateprivate sectorsector reportsreports && webweb ¾ PointPoint ofof salesale informationinformation ¾ MediaMedia articlesarticles

EffortEffort isis neededneeded toto improveimprove informationinformation throughthrough allall thesethese modesmodes && mediamedia