By Cosby Stone
Whenever I am asked what I do for a living, the phrase "I'm an allergist" is almost immediately followed by "So, where are all of these allergies coming from?"
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By Kara Wada
Blooming spring flowers signal the beginning of spring, but for millions of people, they also signal the onset of the misery: allergy and asthma season. Itchy, watery eyes; sneezing, runny nose; cough and wheezing are triggered by an overreaction of the body to pollen.
Older Than the Dinosaurs, as Wide as the World<p>Fossilized specimens of pollen granules have been found predating dinosaurs and alongside <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098096/" target="_blank">Neanderthals</a>.</p><p>And, sinus and asthma symptoms and treatments are documented throughout history and across the globe. People just didn't know exactly how to treat the symptoms, or exactly what was causing them.</p><p>For example, more than 5,000 years ago, the Chinese used the berries of the horse tail plant, ma huang (<em>Ephedra distachya</em>), to relieve congestion and decrease mucous production associated with "<a href="http://pennstatehershey.adam.com/content.aspx?productId=107&pid=33&gid=000240" target="_blank">plant fever</a>" — a condition affecting people during the fall.</p><p>In Egypt, the "<a href="https://babel.hathitrust.org/cgi/pt?id=coo.31924073200077;view=1up;seq=11" target="_blank">Papyrus Ebers</a>," written around 1650 B.C., recommended more than 20 treatments for cough or difficulty breathing, including honey, dates, juniper and beer.</p><p>Although <a href="https://www.ncbi.nlm.nih.gov/pubmed/6757243" target="_blank">Homer's "Iliad"</a> describes the loud noise of breathing in battle as "asthma," <a href="https://www.atsjournals.org/doi/full/10.1164/ajrccm.184.12.1420b" target="_blank">Aretaeus of Cappadocia</a> of the second century A.D. is credited with the first clinical description more consistent with modern understanding of this condition. He wrote of those who suffered that:</p><blockquote>"They open the mouth since no house is sufficient for their respiration, they breathily standing, as if desiring to draw in all the air which they possibly can inhale… the neck swells with the inflation of the breath, the precordia (chest wall) retracted, the pulse becomes small and dense," and if the symptoms persist, the patient "may produce suffocation after the form of epilepsy."<br></blockquote><p>By the time Columbus landed, indigenous populations in Central and South American were utilizing <a href="https://benthamopen.com/contents/pdf/TONPJ/TONPJ-4-8.pdf" target="_blank">ipecacuanha</a>, a root found in Brazil with expectorant and emetic properties and <a href="https://www.merriam-webster.com/dictionary/balsam" target="_blank">balsam</a>, which is still used in some cold remedies today. <a href="https://www.hindawi.com/journals/emi/2016/4048764/" target="_blank">Coca</a> and tobacco leaves, used medicinally by the Incas, were later exported to Europe for additional experimentation for the treatment of rhinitis and asthma.</p><p>Aside from the "plant fever" described in China, the first written description of seasonal respiratory symptoms is credited to <a href="https://www.ncbi.nlm.nih.gov/pubmed/27840475" target="_blank">Rhazes</a>, a Persian scholar, around 900 A.D. He described the nasal congestion that coincided with the blooming of roses, termed "rose fever."</p>
Symptoms Noticed, but No Cause Identified<p>As scientific advancement was stifled during the Middle Ages, in large part due to the plague, it wasn't until 900 years later, in 1819, that <a href="https://www.bbc.com/news/magazine-28038630" target="_blank">Dr. John Bostock</a> published a description of his own seasonal allergies. But he didn't know what was causing them.</p><p>Having suffered from "<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(01)99507-8/fulltext" target="_blank">summer catarrh</a>" since childhood, Bostock persisted in his study of the condition, despite an initial lackluster response from the medical community.</p><p>In the nine years between his first and second publications, he found only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110966/" target="_blank">28 additional cases</a> consistent with his own seasonal allergy symptoms, which perhaps demonstrates the lower prevalence of the condition at the time. He noted that nobility and the privileged classes were more often afflicted by seasonal allergies. This was thought to be the consequence of wealth, culture and an indoor life.</p><p>Societal changes with their roots in the Industrial Revolution, including increased exposure to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4829390/" target="_blank">air pollution, less time spent outdoors, increased pollen counts and improved hygiene</a>, all likely contributed to the increased prevalence of allergies that we continue to see today. They also helped form the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841828/" target="_blank">hygiene hypothesis</a>, which states that in part decreased exposure to particular bacteria and infections could be leading to the increase in allergic and autoimmune diseases.</p><p>The source of seasonal symptoms at the time was also thought to be caused by the smell of new hay. This led to the coining of the term "<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110966/" target="_blank">hay fever</a>."</p><p>Bostock instead suspected the recurring symptoms were triggered by the summer heat, since his symptoms improved when he spent the summer on the coast. It would later became common for nobility and aristocrats to spend allergy season in coastal or mountain resorts to avoid bothersome symptoms.</p>
Identifying the True Culprit<p>Through methodical study and self-experimentation, <a href="https://hekint.org/2017/01/28/charles-harrison-blackley-the-man-who-put-the-hay-in-hay-fever/" target="_blank">Dr. Charles Blackley</a> identified that pollen was to blame for allergy symptoms. He collected, identified, and described various pollens and then determined their allergic properties by rubbing them into his eyes or scratching them on his skin. He then noted which ones resulted in redness and itching. This same technique is used in skin prick testing by allergists today.</p><p>Inspired by discoveries related to vaccination, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3651049/" target="_blank">Dr. Leonard Noon</a> and John Freeman prepared doses of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3651049/" target="_blank">pollen extracts for injection</a> in an effort to desensitize patients with allergic rhinitis in the early 1900s. This effective treatment, called <a href="https://acaai.org/allergies/allergy-treatment/allergy-immunotherapy" target="_blank">allergy immunotherapy</a>, also known as allergy shots, is still used today.</p><p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667286/" target="_blank">Antihistamines</a> first became available in the 1940s, but they caused significant sedation. The formulations with fewer side effects that are used today have only been available since the 1980s.</p>
Pollen Counts Likely to Grow<p>Though recognized by ancient civilizations, seasonal allergic rhinitis and allergic asthma have only increased in prevalence in recent history and are on the rise, now affecting <a href="https://www.aaaai.org/about-aaaai/newsroom/allergy-statistics" target="_blank">10 to 30 percent of the world's population</a>.</p><p>Fueled by warmer temperatures and increased carbon dioxide levels, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4829390/" target="_blank">pollen seasons are longer, and pollen counts are higher</a>. Many experts believe this will <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4829390/" target="_blank">worsen</a> in the coming years due in large part to climate change.</p>
Like many other plant-based foods and products, CBD oil is one dietary supplement where "organic" labels are very important to consumers. However, there are little to no regulations within the hemp industry when it comes to deeming a product as organic, which makes it increasingly difficult for shoppers to find the best CBD oil products available on the market.
Charlotte's Web<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDcwMjk3NS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY0MzQ0NjM4N30.SaQ85SK10-MWjN3PwHo2RqpiUBdjhD0IRnHKTqKaU7Q/img.jpg?width=980" id="84700" class="rm-shortcode" data-rm-shortcode-id="a2174067dcc0c4094be25b3472ce08c8" data-rm-shortcode-name="rebelmouse-image" alt="charlottes web cbd oil" data-width="1244" data-height="1244" /><p>Perhaps one of the most well-known brands in the CBD landscape, Charlotte's Web has been growing sustainable hemp plants for several years. The company is currently in the process of achieving official USDA Organic Certification, but it already practices organic and sustainable cultivation techniques to enhance the overall health of the soil and the hemp plants themselves, which creates some of the highest quality CBD extracts. Charlotte's Web offers CBD oils in a range of different concentration options, and some even come in a few flavor options such as chocolate mint, orange blossom, and lemon twist.</p>
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By Marlene Cimons
Cristina Stinson never had an allergic reaction to ragweed until after she started working with it. "I think the repeated exposure to the pollen is what did it," she said. It also didn't help that her community is chock-full of it. "There is plenty of ragweed in my neighborhood," she said. "In fact, it grows right outside my door."
A video posted to Facebook on Monday, in which a tree tapped by a frontloader releases a massive cloud of pollen, has gone viral, resonating with viewers in what experts say is an especially bad allergy season, partly because of climate change.
The video was taken by Eric Henderson of Millville, New Jersey, who drove the frontloader that released the pollen cloud, ABC News reported Wednesday. His wife, Jennifer, posted it on Facebook, where it has gotten more than five million views.
By Bill Gottlieb
More than 24 million American children and adults suffer from asthma, which is when the respiratory "pipes" (bronchi) that carry air in and out of the lungs are inflamed and spasm. And every year, the disease sends more than 1.8 million people to the hospital, killing nearly 4,000 with severe, choking asthma attacks.
Fifty percent of people with asthma have attacks triggered by allergens, such as molds, dust mites and animal dander. Of course, you can have allergies without asthma. You can have hay fever (seasonal allergic rhinitis), which is when your immune system mistakes pollen from grass, trees or weeds for a foreign invader and revs up its defenses, triggering sneezing, red and itchy eyes, a stuffed and runny nose, and fatigue.
But whether you have asthma or asthma and allergies or just allergies, you may have noticed your condition is getting worse. The rates of asthma have increased over the past 25 years—the number of people with asthma has increased fourfold and the number of deaths from asthma attacks has doubled. And people with hay fever are noticing that every allergy season seems like the worst ever.
What's happening? Many studies show the increase in allergies could be due to changes in the environment. This slideshow shows six reasons why more people might be feeling the affects of allergies:
Hay fever season and the ragweed allergies it brings may be getting more intense and lasting longer, according to a 2011 study from the U.S. Department of Agriculture (USDA) published in the Proceedings of the National Academy of Sciences of the United States of America. "The main takeaway from the study is that we are seeing a significant increase in the season length of ragweed and this increase is associated with a greater warming at northern latitudes, consistent with projections regarding climate change," said Lewis Ziska, PhD, the lead author of the study and plant physiologist with USDA's Crop Systems and Global Change Lab. (The study found that the length of the ragweed season increased by as much as 27 days between 1995 and 2009 in various areas of the U.S.).
Climate change threatens human health in a number of ways, but allergies may be the most immediate, easy-to-recognize ailment, said Linda Marsa, investigative journalist and author of the book Fevered: Why a Hotter Planet Will Hurt Our Health—And How We Can Save Ourselves. And the problem isn't only longer allergy seasons.
Under normal circumstances, a single ragweed plant creates one million pollen grains. But in an environment with more carbon dioxide (CO2)—the main driver of climate change—plants produce three to four million pollen grains, explained Clifford Bassett, MD, medical director of Allergy & Asthma Care of New York and a member of the public-education committee at the American College of Allergy, Asthma & Immunology. But the problem doesn't stop there. CO2 in the atmosphere is like plant food for weeds, causing them to produce pollen that contains more allergenic proteins than normal, said Marsa.
A study in the journal Environmental Health Perspectives found that triclosan (an antibacterial chemical used in toothpastes and other personal care products) may play a role in worsening allergies. The study researchers looked at 3 years of health data from about 5,000 people and found that urinary levels of triclosan were linked to allergies and hay fever. This finding supports the "hygiene hypothesis"—sanitizing our homes and environments creates a weaker immune system that is less able to respond to bacterial and viral threats.
"Hygiene can protect us from infections," said Erin Rees-Clayton, PhD, a study author and a research investigator at the University of Michigan School of Public Health. "But some of the chemicals in hygiene and cleaning products may have more risks than benefits."
"Asthma prevalence has increased dramatically over the past 30 years, which suggests that some as-yet-undiscovered environmental exposures may be implicated," said study leader Kathleen Donohue, MD, assistant professor of Medicine at Columbia University Medical Center. "Our study indicates that one such exposure may be BPA."
Donohue and her colleagues analyzed health data from 570 pregnant women and their children at ages 3, 5 and 7. They found that exposure to BPA in early childhood—even very low levels of it—increased the risk of asthma in the children.
What are the jobs most likely to give you asthma? That's the question posed by researchers at the Imperial College London, who studied nearly 10,000 people to see which careers were most likely to trigger asthma. Of the 18 asthma-producing occupations, seven of them involved regular use of cleaning products.
That's not too surprising when you consider that 53 percent of cleaning products damage the lungs, according to an analysis by the Environmental Working Group. (And "green" cleaning products are not necessarily free of lung-damaging compounds).
A 10-year study of 3,000 children found that those with vinyl flooring in their bedrooms were one and a half times more likely to have asthma than children with wood, linoleum or other flooring materials. (The vinyl is polyvinyl chloride or PVC, a type of plastic widely used in construction). If mothers had vinyl flooring in their bedrooms while pregnant, the children were twice as likely to have asthma. "Our results suggest that PVC flooring exposure during pregnancy could be a critical period in the development of asthma in children at a later time," concluded the Swedish researchers in the International Journal of Environment and Health.
The researchers speculate that it's the phthalates—chemicals used to soften plastic—that are doing the dirty work. Phthalates leach into household dust, creating constant exposure.
The Preservative in Pre-Moistened Wipes
You've probably never heard of it, but in 2013 the dermatologists of the American Contact Dermatitis Society dubbed it the "Allergen of the Year." The compound? (Take a deep breath). Methylisothiazolinone (MI)—the preservative in most premoistened toilet, feminine and baby wipes (and in various liquid soaps, hair products, sunscreens, cosmetics, laundry products and cleaners). MI replaced other toxic, irritating preservatives, such as formaldehyde and parabens. The only problem: MI is irritating, too!
"In the last 2 or 3 years, we've seen a big increase in people with allergy to MI," said Matthew Zirwas, MD, director of the Contact Dermatitis Center at the Wexner Medical Center of the Ohio State University. The allergy produces red, raised, itchy bumps similar to poison ivy. The three areas most affected by the rash include the fingers and hands (from handling wipes), the buttocks and genitals (from applying the wipes) and the face (from soaps and shampoos). Needless to say, most people (and their primary care doctors) never figure out the cause of the rash.
Adapted from Health-Defense.
This article was reposted with permission from our media associate Rodale Wellness.
Two days ago, I put my son Conor on an airplane to Europe. Conor has anaphylactic peanut allergies so, before he left, we purchased a new EpiPen for the trip. We both got sticker shock.
Ten years ago, I was paying a $12 co-pay for each EpiPen I purchased. In 2007, the wholesale price for an EpiPen in the U.S. was around $57 and our insurance company paid everything but the co-pay. This week, I learned that the wholesale price was now $600 for a two pack, which is the smallest quantity available for purchase. We paid the $600. EpiPens have saved Conor's life more than once.
A Senate committee has asked the pharmaceutical company Mylan to appear before Congress to explain the company's 400 percent price hike for this life-saving device. The company's CEO, Heather Bresch, the daughter of West Virginia Sen. Joe Manchin, will be on the hot seat. She is a greedy, malicious scoundrel and it's my hope that the senators who question her will not give her kid glove comity just because she is kin to a colleague.
Mylan raised its prices because it could get away with the scam. Its only U.S. competitor, Sanofi, abandoned the American market in 2015. In Canada, EpiPen's still cost around US$100. In Europe there are four manufacturers and the prices are still lower.
Children in anaphylactic shock often need two doses of epinephrine. Following the U.S. Food and Drug Administration's recommendations, my doctor suggested that we always keep two EpiPen's at home, two at school and two in our automobile. Each EpiPen expires after one year, so Mylan's price hike represents an $1,800 annual recurring cost for the families of the 15 million Americans with allergies.
According to the U.S. Centers for Disease Control, food allergies are responsible for more than 300,000 ambulatory-care visits a year in children under 18. About 200 children die. Bresch's greed is likely to cost the lives of many more.
"I regularly write notes to the families of children who have died from anaphylaxis after inadvertently eating peanuts," said Dr. James R. Baker, CEO of FARE: Food Allergy Research & Education. "One death is too many."
Reposted with permission from Rodale News.
They may be little, but those tiny, blood-sucking ticks can cause big problems with your health, including Lyme disease, babesiosis, bartonella, anaplasmosis, Rocky Mountain spotted fever and ehrlichiosis. And the list of tick-related ills just keeps growing. Doctors are now confirming a link between lone star tick bites and cases of severe red meat allergies plaguing patients in Southeastern states. Victims of the odd tick bite side effect have been reported in places like Tennessee, North Carolina and Virginia, but doctors say the problem is spreading up the Eastern Seaboard fast.
Doctors are now confirming a link between lone star tick bites and cases of severe red meat allergies. Photo courtesy of Shutterstock
According to Robert Valet, MD, assistant professor of medicine at Vanderbilt's Asthma, Sinus and Allergy Program (A.S.A.P.), some patients are developing post-tick-bite allergies to the alpha-gal sugar present in red meat, causing symptoms ranging from diarrhea, difficulty breathing and a drop in blood pressure, to hives and swelling. Some patients are reacting to milk.
"It is not completely understood exactly how the allergy starts," explains Dr. Valet. "The thought is that the tick has the alpha-gal sugar in its gut and introduces it as part of the allergic bite, and that causes the production of the allergy antibody that then cross-reacts to the meat."
Since the alpha-gal is stored in the animal fat, which takes several hours to digest, people with the allergy can go into delayed anaphylactic shock anywhere from four to six hours after eating red meat, making it difficult to diagnose. "It certainly is a big disruption for a lot of people's lives," explains Dr. Valet. "Things like your classic barbecue really become off limits."
Repeated tick bites can raise the level of allergy antibody, so Valet warns people with this allergy to avoid even small quantities of red meat and milk. He also suggests carrying an EpiPen in case a person suffers from an exposure and needs to self-treat.
Whether you're affected by the allergy or not, it's important to practice good tick-avoidance procedures:
Strip down as soon as you step inside.
Remove your clothing, toss it in the washing machine and jump in the shower as soon as you walk inside the house after spending time outdoors. Be sure to then throw your freshly washed clothing into the dryer to kill any lurking ticks.
Get to know your private parts well.
Your groin maintains the perfect humidity for ticks looking to hide in moist, dark areas. The bugs also attach to the back of men's scrotums or women's bikini lines, so be sure to perform a thorough check of your groin and buttocks area at least once a day using a magnifying glass and/or mirror to see more hidden areas.
Treat your shoes.
Although we don't normally recommend chemical treatment, we understand how debilitating tick-borne diseases can be. So rather than applying toxic DEET directly on your skin, try getting a pair of outdoor gardening or workout shoes treated with Insect Shield instead.
Plant some beautyberry bushes.
The leaves of the American beautyberry bush possess tick-repelling qualities, so try working a few into your landscape.
Clean up your woodpile.
Moist, wooded areas are most inviting for ticks. Sunny, dry conditions are not. So keep any woodpiles outside in a spot that gets lots of sun to dry them out faster.
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By Minda Berbeco
Have your eyes been running more in the spring? Are you sneezing more in the fall?
After this frigid and snowy winter, it may be hard to remember what the allergy season feels like. But if you‘re one of the more than 80 million Americans who suffer from seasonal allergies, you might recall that last year’s allergy season was a doozy in many parts of the U.S.
Photo courtesy of Shutterstock
And it turns out that people might at least be partially responsible for a more allergenic environment. As we change the climate, many of the plants that terrorize us through the allergy season are becoming more pernicious. While a warming climate lengthens the pollen season, increased carbon dioxide is making some allergens more noxious.
This change is most obvious with the troublesome ragweed plants, which are the curse of many allergy sufferers. A group of flowering plants found all over the U.S., the hardy ragweed loves a disturbed environment. It pops up along roadways and at the edges of agricultural fields, colonizing abandoned lots. Ragweed is common enough that you most certainly have seen it before, and it is highly likely that a ragweed plant’s pollen has made you or a loved one sneeze at least once.
Ragweed pollen is one of the largest causes of allergic rhinitis—also known as hay fever—the sneezy, runny nose reaction many people are familiar with.
Unlike many other plants, ragweed doesn’t ring in the spring with large flowering blooms. Rather, it flowers in the late summer, releasing pollen just in time for a congested fall. Normally this plant is trouble enough, having a pollen season that can last between two and three months. Now, with a longer-frost free season (the amount of time between the spring thaw and fall freeze) due to a warming climate, the ragweed plant has a longer time period to get larger and hardier to produce more pollen.
A longer growing season is only one part of the problem. Ragweed also responds positively to increases in carbon dioxide in the atmosphere. Carbon dioxide levels before the Industrial Revolution were about 280 parts per million. With the increase in emissions through the burning or fossil fuels and other human activities, those levels have recently reached 400 parts per million.
Research has demonstrated that plants grown in pre-industrial CO2 concentrations produced less pollen than those grown in current levels. Worse yet, when these plants were grown in concentrations predicted for the future, pollen levels continued to go up. For those of us with ragweed allergies, this is not good news.
Those who are familiar with allergens, though, know that it’s not just how large the plant is, or even how much pollen it’s producing that can increase the risk of an allergic reaction. There’s also the potency of the pollen itself—the amount of allergen in the pollen. It turns out that ragweed plants grown in higher CO2 environments carry more allergens in the pollen.
Larger plants, creating more pollen, means more allergies. Sounds like a terrific future. But of course, it’s not the future, it’s occurring right now. How do your sinuses feel at the thought of that?
These findings are not unique to ragweed plants. Poison ivy, the bane of hikers everywhere, is looking like it might also prosper in a higher CO2 environment. Researchers have found that when grown under high CO2 conditions, poison ivy became larger and produced a more allergenic form of urushiol, the active compound that leads to the red itchy rash everyone is familiar with.
Given how important environmental factors like temperature, rainfall and CO2 levels are to all ecosystems, the question remains how other allergenic plants will be impacted by a changing climate. As flowers bloom earlier, with a longer growing season, should we start expecting spring allergies to arrive weeks sooner? Could a longer frost-free season lead to extended allergy seasons for people throughout the year? How will these types of climatic changes affect other allergenic organisms such as molds?
To those who suffer from seasonal allergies, these questions only bring more concerns. Rather than worry, though, perhaps we could start to plan ahead. We could work to reduce our carbon emissions to help future generations suffer less. We could create management plans to reduce the spread of allergenic plants.
Or, we could take a financial approach and start investing in Benadryl futures. Unfortunately, with the way carbon pollution regulations are going so far, the latter might be the most prudent approach.
Ever wonder about chemicals in your day-to-day life?
Ed Brown wondered these same things after his wife suffered two miscarriages (they now have two beautiful children). But instead of just wondering, he traveled around the country with his video camera to interview top minds in the fields of science, advocacy and law and learned there are unacceptable levels of chemicals in so many things. Including our bodies.
Brown’s documentary, Unacceptable Levels, dissects the ways chemicals saturate our homes and environment amid the backdrop of a glaring lack of regulation. It chronicles the results of the post-World War II chemical boom and details common avenues of exposure, from food to fluoride to toxic sludge.
Some "unacceptable facts" from the film:
- Autism now affects one in 50 children.
- Cancer is the leading cause of death (after accidents) in children younger than 15 years in the U.S.
- In the last 20 years, the rates of asthma, allergies and Attention Deficit Hyperactivity Disorder (ADHD) are on the rise: 400 percent increase in allergies, 300 percent increase in asthma, 400 percent increase in ADHD.
- $2.6 trillion of the Gross Domestic Product is spent on treating disease every year.
- Approximately 200 synthetic industrial chemicals interact with our cells every single day.
Brown is touring the country this summer, which started with a premiere June 12 in Hollywood, CA, where he was joined by Mariel Hemingway, Gary Hirschberg, Christopher Gavigan and other passionate environmentalists to inspire others to take action.
This film is a huge eye-opener! Once a parent sees this, they thankfully won’t ever approach their child’s health and future the same way ever again!
Visit the Unacceptable Levels website for a growing list of screenings.