By Robert W. Boxer, MD, Fellow of the American Academy of Environmental Medicine, the American Academy of Allergy and Immunology, and the American College of Allergy and Immunology. (Editor's note: we are very grateful to Dr. Boxer for revising and updating this 1994 article to currently available resources in June, 2002).
Environmental management is essential for achieving good health. This is particularly true for allergic patients but to a large extent applies to all people interested in optimal health.
For the purposes of this discussion, we will divide environmental control into two sections, namely: water and air; and we will include in air contacts such as detergents and fabric softeners. An additional aspect could, of course, be food. However, NOHA speakers have dealt with this on many separate occasions and in much more detail than I could, other than from an allergic point of view, and therefore I will restrict my comments to water and air in a general sense.
Water quality can vary from area to area and it is probably important to have local tap or well water analyzed in order to determine bacterial or parasitic contamination, and also the presence of potentially toxic heavy metals and pesticides. Many will be interested in the levels of chlorine and possibly the levels of fluoride as well.
It is important not to drink salt-softened water since with salt softeners, the important elements, calcium and magnesium, are lost and are replaced with less desirable sodium. Any type of water filtration that removes calcium and magnesium is automatically potentially harmful since these minerals are so important in normal functioning of the central nervous system and the cardiovascular system, as well as the musclo-skeletal system. A number of studies from around the world have indicated a much higher incidence of a fatal outcome to any myrocardial infarction among patients who have drunk salt-softened water for a substantial period of time. The assumption is that these patients are much more prone to cardiac arrhythmias because of the relative deficiency of calcium and magnesium.
Carbon block or other types of charcoal filters are recommended and these are especially effective in removing chlorine and some other particulate substances. For removal of fluoride or other potential toxics, a combination of reverse osmosis and carbon block filters is recommended. Many of the companies that sell water filters are capable of also installing reverse osmosis filters.
We recommend having the filtered water checked by a water testing facility independent from the installers, and perhaps recommended by the local board of health, after installation.
Of course, lead in water is an important consideration. It is a good idea to let water run for several minutes, especially in the morning, before drinking it. The lead from the solder flux in pipe joints leaches into the water, particularly when the water is left sitting overnight or for an extended period of time.
If bottled water is used, we prefer it to be in glass containers, like Mountain Valley, although there are a number of other brands, even in plastic, that do produce relatively good bottled mineral water. It is not good to drink distilled water for any length of time, again because of the lack of minerals.
In regard to air pollution, obviously there are concerns regarding chemical air pollutants. However, probably as important as removing them, is awareness that they may be present to begin with. In general, this article deals with environmental control within the house rather than without. Obviously, living on an approach to an airport, or near a factory, or near a highway can be a source of pollutants external to the house. One of the advantages of air conditioning is that during hot weather, it allows windows to be kept closed so that air pollutants of any nature can be kept outside. Obviously, besides chemical air pollutants, there are natural air pollutants such as pollens and molds, which affects patients who are allergic to them.
Within the house, it is important that sources of chemicals be avoided to begin with. You actually can start with the way the house is constructed but, since that is a topic unto itself and not a very practical discussion for people who already have houses, we will confine our thoughts in general to homes already built. It is important to also avoid scented candles since these cause trouble even when never lit, simply by outgassing. Also avoid new furniture, particularly new carpeting and padding, pot pourri, strong cleaning agents, oil-based paints, lacquers and varnishes, polyurethane or other strong floor finishes, etc. Some patients have had good success tolerating a water-base polyurethane floor finish.
Naturally there is concern regarding carbon monoxide and natural gas in homes heated by gas. There are inexpensive devices to detect the presence of carbon monoxide.
Electromagnetic fields (EMFs) can arise from outside from proximity to power lines or step-down transformers or, more often than not, can arise from within the house from a variety of sources including electric blankets, water mattresses, irons, electric hair dryers, typewriters and adding machines, computers and television screens, and just about any item that uses electricity. In an office, and sometimes in the home as well, copiers and fax machines can also be a source of problems in this area. Microwave ovens are, of course, a potent source of EMFs in the kitchen and one should try to position microwave ovens so that it is rarely necessary to be within four or five feet of them while they are in use. A usually unsuspected source of electromagnetic fields in the kitchen is the dishwasher. Naturally an electric range or oven also can be a source of problems as can be electric timers that are set toward the front of a range or cook top. Clock radios and other electrically operated alarms should be several feet from a personís head if they are at bedside.
In terms of biologic pollutants, house dust and house dust mites are major air-borne interior problems. Dust and dust mites originate from organic material and appear on the skin and in upholstered items. Dust mites produce fecal material which is also allergenic.
Besides washing and cleaning clothes periodically, avoiding over-stuffed furniture, thick plush carpeting, and heavy lined drapes; the use of air conditioning during spring, summer, and fall will help to dehumidify the air and somewhat decrease the concentration of mites.
It is important to cover the mattress and box-springs with plastic or another type of total enclosure zippered covers. The mattress pad and top and bottom sheet should be removed and laundered in hot water weekly. Any other temperature will not destroy mites or their allergic fecal products. While the bedding is off, the exposed surface of the mattress and box-springs should be either wiped with a damp cloth if there are plastic covers, or vacuumed with special hypoallergenic vacuums if these are available and the cover is other than a wipeable plastic. Ideally the blankets should be washed weekly as well, but every two weeks is acceptable, and the bedspread should be washed frequently as well.
The average vacuum cleaner will pull dirt and dust out but will simply disseminate smaller particles of dust, which are not trapped by most vacuum cleaner filters. There are special filters that are now available to retrofit many vacuum cleaners, which do enhance their efficiency from an allergy point of view. These can be obtained through Allergy Asthma Technology Ltd. 1-800-621-5545. They are reasonably priced.
There are now a number of special vacuum cleaners that are designed specifically for allergy and perhaps of these, the Nilfisk is probably the best and this can be purchased through a number of sources. We suggest avoiding bagless vacuum cleaners.
There are other vacuum cleaners such as Miele, which have greater than average filtration capacity. For those who might be building a house, it is wise to remember that central vacuum systems are probably ideal. Retrofitting an existing home with a central vacuum system is fairly expensive. There are many reasonably priced HEPA filtered vacuum cleaners available through many sources.
Central Air Cleaning
For those who have central forced air heating and air-conditioning systems, duct cleaning every 5 to 10 years is a good idea, especially if it is done professionally by those who have had considerable experience. We recommend against spraying the antibacterial antifungal spray after cleaning.
We no longer recommend electronic air cleaners, and have not recommended these for the last 25 years, because of the possibility that they may produce ozone, which can have toxic effects. We do recommend HEPA-like media-type air cleaners, which are slightly less efficient in terms of cleaning but are in our experience and opinion considerably safer. The SpaceGard is the original but Honeywell, Carrier, and Trane also make these air cleaners, which fit into the plenum of the furnace in central systems. It is important to specify non-electronic, in our opinion, when choosing a centrally installed air cleaner for forced air systems.
There are a number of less expensive filters such as the Permatron and the Newtron, which are electrostatic but not electronic and which fit into the regular slot where the furnace filter would ordinarily be and do not require any installation. These are reasonably effective, washable, and do not produce ozone ordinarily. They simply are not as effective as the HEPA-like media-type air cleaner such as SpaceGuard.
Portable Air Cleaners
There are a number of portable HEPA air cleaners that are quite effective for areas such as the bedroom or an office. The Foust 400 is probably one of the better ones for taking both particulate matter such as dust, dust mites, pollen, and mold, and chemicals as well. It is available through Foust in Elmhurst and costs approximately $600.00. It has the added advantage of being attractive enough to be considered a piece of furniture. (Available through Foust in Elmhurst, IL.)
The Austin Healthmate is a good one, which a number of our patients have purchased. It is priced around $400.00. Foust also makes other filters that are less expensive and also effective. Allermed makes a line of various size air cleaners that range from large room size to table top. One of theirs that is particularly good for chemicals and particulate matter is the Air Star 5. This can be purchased directly from Allermed, or through N.E.E.D.S at 1-800-634-1380. Sometimes local pharmacies or surgical supply houses may carry portable HEPA filters. They can also be purchased through N.E.E.D.S. The Aireox is a nicely sized attractive white enameled portable room size air cleaner from N.E.E.D.S., which we have recommended for a number of patients.
People interested in obtaining catalogs that may list a number of these items should call N.E.E.D.S. at 1-800-643-1380, or Allergy Control Products, Inc. at 1-800-422-DUST, or Allergy Asthma Technology at 1-800-621-5545.
Obviously animal danders can be a source of air pollutants for allergic patients within the house and cats in particular are potential trouble makers. Litter boxes should be kept as far away from the patient as possible and they should be changed by someone other that the patient. If cats can be washed weekly, this cuts down the number of cat allergens. Obviously for those allergic to cats or dogs, pets should be restricted from the bedroom, and the patient should wash their hands after touching the pet. Wiping cats weekly with a wash cloth also helps. Wearing dust and pollen masks when handling litter is helpful.
Needless to say, in our opinion, everyone should totally prohibit smoking within the house and avoid all volatile insecticides, fungicides, and other pesticides. Safe alternatives are available.
Clothes that are dry cleaned should be aired out away from any living area before being worn or stored in a clothes closet. The perchloroethylene used in dry cleaning is highly toxic. Choose dry cleaners that leave less or no odor.
For those who might buy a portable air cleaner other than the ones we have mentioned, be sure that there is no particle board in the motor housing or some other item that will emit formaldehyde, and defeat the purpose of the air cleaner, and actually make all the inhabitants of the house sick.
Additional points that we usually make are reminders to use humidifiers, for central application in furnaces, that are flow-through type, and avoid humidifiers with stagnant water. If console humidifiers are used, be sure to clean them thoroughly at least every two weeks. We advise that chemicals not be added to humidifiers.
Chemically sensitive patients may have trouble when parking their cars inside attached garages. Tight fitting doors and panels to the attic may help; and sometimes it is useful to park the car outside the garage and let it cool down. Most of the vapors are emitted in the first 30 minutes after driving the car and thereafter it would be much safer to pull it into the garage. Some exhaust system for the garage would be useful. If there is not a security problem, the garage door can be left open for a while after the car is pulled into the garage.
The less time allergic patients spend in basements or any subgrade area, the better. Allergic patients should choose homes with full dry basements and should try to avoid crawl spaces, particularly damp, uncemented crawl spaces.
Although many claim, and perhaps correctly so, that plants detoxify air pollutants, for allergic patients, the smuts and molds that can be created offset any benefit in our opinion.
We think it is much more hygienic not to have carpeting in the bedroom. Wood or tile floors can get cleaned up with damp mops or specially treated mops or can be vacuumed. If you must install carpeting try to find a company that may be able to hang and air the carpet pad for six to eight weeks prior to installation.
Cedar closets and other sources of cedar can be a real problem for some allergic patients.
We generally ask allergic patients who are allergic to avoid feathers and even foam rubber in pillows. Foam rubber is made from a chemical that can be allergenic and the foam rubber itself can become moldy once it is older and crumbles.
Stuffed toys, animals, bookcase headboards, shelves, desks, dolls, canopy and bunk beds are all potential sources of dust and dust mites for allergic patients.
Simple washable curtains or shutters are better than heavy-lined draperies and blinds are difficult to keep clean.
Fireplaces are a source of chemicals and mold and there should be an excellent draft. Logs are best stored out of the house.
Naturally, school and occupational exposures have to be considered for most patients also.
Detergents that have a fragrance are best avoided. Some of the newer ones, such as Arm & Hammer, scent and dye free and Cheer Free, seem to be better tolerated. Fabric softeners, which are scented, or for that matter any kind of fabric softener that goes in the dryer can cause a problem. Usually there are residues left on sheets and pillowcases as well as towels and undergarments and pajamas that are the source of problems. Bleach also causes symptoms in some patients.
Colognes, hair sprays, perfumes, after-shave lotions are all capable of bothering susceptible patients.
Although requiring some investment of research, time, and money, environmental control has rewards in good health and in the end certainly is more economical. We hope that medicine takes the preventive approach since this may be one of the few realistic ways of ultimately cutting costs of health care.
Article from NOHA NEWS, Vol. XIX, No. 2, Spring 1994, pages 2-4.