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Millions of villagers in Bangladesh drink water which exceeds the Bangladesh arsenic (As) standard of 50 micrograms per liter. Exposure to elevated levels of inorganic As (As) is associated with cancers of the skin, bladder, and lung, developmental effects, cardiovascular disease, skin lesions, and decreased children's intellectual functioning. Arsenic mitigation typically involves an outsider coming into a village to test the well water for As. After the results of the As test are provided this person typically leaves the village without providing the resources to address health concerns or give advice on mitigation options. In this dissertation, in an effort to provide ongoing resources on the health implications of As and to reduce As exposure, we sought to evaluate community level intervention strategies that could be used for successful As mitigation in Bangladesh. In Singair, Bangladesh, we conducted a household drinking water survey of 6649 households. The results of our survey indicated that 80% of wells were untested for As. Furthermore, we demonstrated that testing all of these untested wells would increase the number of households that lived with fifty meters of an As safe drinking water source by nearly 2.5 fold. In a cluster based randomized control trial (RCT) of 1000 households, we evaluated the effectiveness of having community members, compared to outside representatives, disseminate As education and conduct water As (WAs) testing. In 10 villages, a community member disseminated As education and provided WAs testing. In a second set of 10 villages an outside representative performed these tasks. Overall, fifty three percent of respondents with unsafe wells at baseline switched after receiving the As education and WAs testing intervention. There was no significant association observed between the type of As tester and well switching (Odds ratio (OR) =0.77; 95% confidence interval (CI) (0.37-1.61)). At follow-up, the average UAs concentrations for those with unsafe wells at baseline who switched to safe wells significantly decreased. In both intervention groups a significant increase in knowledge of As was observed at follow-up compared to baseline. The unavailability of As-safe drinking water sources in some villages was the most substantial barrier to well switching identified. The Hach EZ As field test kit measurements conducted by the As testers were highly correlated with laboratory results. This finding indicates that the As testers were able to accurately measure the WAs concentration of wells. Furthermore in our pilot study, the performance of the Econo-Quick (EC) kit, a new field WAs testing kit, was comparable to that of the commonly used EZ kit and the Wagtech Arsenator kit. The EC kit has the advantage of a substantially shorter reaction time of only 12 minutes in comparison to the 40 minutes required by these other kits. Through this dissertation, we have demonstrated that As education and WAs testing programs can be used as an effective method to reduce As exposure and increase As awareness in many As affected areas of Bangladesh. Furthermore, our findings indicated that many households are using tubewells that are untested for As therefore demonstrating the urgent need for access to water As testing services.

The worldwide natural occurrence of high levels of arsenic (As) in groundwater and its deleterious effects on human health have inspired a great amount of related research in public health and geosciences internationally. With >100 million people in South and Southeast Asia exposed to >10 µg/L As in shallow groundwater that they use for drinking, the installation of deeper, low-As wells has emerged as a major strategy for lowering the exposure. As the magnitude of deep pumping continues to increase, this work focuses on the geochemical and hydrologic questions surrounding the vulnerability and sustainability of low-As aquifers in Bangladesh, the country most affected by As crisis. In an effort to better understand the residence time of groundwater in low-As aquifers at depth, radiocarbon (14C) and 13C in dissolved inorganic carbon, tritium (3H), stable isotopes of hydrogen (2H) and oxygen (18O), and noble gas concentrations were measured across a ~25 km2 area of Araihazar, ~30 km east of Dhaka. Groundwater from >120 m depth is shown to be ~10,000 years old and its isotopic signatures indicate that recharge occurred at the time of changing climate from the late Pleistocene to early Holocene, with little recharge occurring since. In contrast, the intermediate depth low-As aquifers (<120 m) have a heterogeneous distribution of groundwater chemistry and ages, and contain groundwater recharged <60 years ago in certain locations. In one such area surrounding a small village, the effects that subsurface clay layer distribution has on recharge patterns and redox status of the intermediate aquifer was investigated. The relevant hydrogeologic and geochemical processes that led to documented failures of a community well at the site were assessed using a combination of solid and water phase geochemistry with tritium-helium (3H/3He) dating, hydraulic head monitoring, and pumping tests. Organic matter seeping from a compressible clay layer, which is subject to a pumping-induced, downward hydraulic gradient, reduces iron oxides and helps release As in the grey, upper part of the intermediate aquifer. No recent recharge was detected by 3H measurements in the upper, grey sand layer, however a layer of orange sand beneath it contains groundwater that was recharged 10-60 years ago. This groundwater laterally bypasses the confining clay layer to recharge the middle of the aquifer and contains dissolved As levels of <10 µg/L. In this particular case, the pore water that leaches from clay layers contributes to As contamination, whereas the lateral recharge with shallow groundwater coincides with the low-As depth. Thus, clay layers may not always protect the low-As aquifers from As contamination, even if they can block direct vertical recharge with shallow groundwater enriched in As and organics. Finally, the adsorption of As to aquifer sediments, as a natural mechanism of the low-As aquifer defense against contamination, was assessed in the field via a column study. The column experiments were conducted by pumping shallow, high-As groundwater through freshly collected sediment cores to quantify the retardation of As transport through the aquifer. This study demonstrated an elegant method of assessing contaminant transport under nearly in situ conditions that resulted in sorption estimates similar to those made by field studies using more challenging methods or located at hard-to-find sites with convenient flow patterns. My work, therefore, contributed to a better understanding of low-As aquifers in Bangladesh from the perspectives of both the groundwater flow and water-sediment interactions on various scales, and it integrated methods that can be employed elsewhere to characterize aquifers and study contaminant transport.

This dissertation examines topics related to development, environment and health in developing countries using empirical methods. In the first chapter, I study how developing countries can increase enforcement to reduce subsidy leakage in public programs, by investing in the state capacity to target program beneficiaries. This chapter further attempts to understand how the formal sector and black market respond to a policy that reduces diversion of a subsidized commodity. I explore these questions using the case of a Unique ID-based direct fuel subsidy transfer policy in India. Second chapter focuses on the health and wealth trade off near mineral mining operations in developing countries. Using extensive data on mining, health outcomes and assets from 44 developing countries, this study quantifies the wealth gain and adverse health impact of mineral mining. With a number of empirical strategies, this study shows that, despite high wealth gains, how heavy metal mining significantly increases the level of anemia in women and stunting in children living near mines. In the third chapter, I estimate demand for a water quality diagnostic product -- arsenic testing, when it is offered at a price. I further look into various aspects related to selection, learning and households behavioral response to the information. This study is based on a field experiment in Bihar, India.

Background: In the country of Bangladesh, arsenic (As) exposure and high plasma homocysteine (hyperhomocysteinemia; HHcys) are widely prevalent. An estimated 35-77 million people in Bangladesh are exposed to As above the World Health Organization standard of 10 μg/L, while a cross-sectional study by our group estimated that 63% of men and 26% of women had HHcys. Both As exposure and HHcys are associated with adverse health outcomes. Arsenic exposure is an established cause of skin, lung, and bladder cancer, and cardiovascular disease, while HHcys is a strongly associated with increased risk for cardiovascular disease. Chronic kidney disease is emerging as an As-linked disease outcome. Potential mechanisms for adverse health effects induced by As (e.g. nephrotoxicity) include oxidative stress and inflammation. Inorganic As is metabolized through a series of methylation and reduction reactions which facilitate As excretion in urine; arsenite (AsIII), the primary form of As in Bangladesh drinking water, is converted to monomethylarsonic acid (MMAV), monomethylarsonous acid (MMAIII), and dimethylarsinic acid (DMAV). The methyl donor for these methylation reactions is S-adenosylmethionine (SAM). Because the availability of SAM is modulated by various nutritional parameters, nutritional interventions have the potential to enhance As methylation. Supplementation with folic acid (FA), which increases liver SAM, has been shown by our group to enhance As methylation and lower blood As in folate-deficient Bangladeshi adults. The endogenous synthesis of creatine from guanidinoacetate (GAA) consumes a large proportion of SAM, and creatine supplementation in the diet can downregulate endogenous creatine synthesis by inhibiting GAA production. In this way, creatine supplementation has the potential to spare SAM, enhance As methylation, and also lower homocysteine (Hcys), a by-product of SAM-dependent methylation. The potential for dietary creatine to enhance As methylation may explain the frequently observed associations of urinary creatinine with a decreased proportion of inorganic As in urine out of total urinary As (u%InAs), and an increased proportion of DMA in urine out of total urinary As (u%DMA) in epidemiological studies. Alternatively, it is possible that these associations are due to confounding by renal function, which could influence both As and creatinine excretion. Objectives: Our objectives were to determine (1) whether folic acid and creatine lower blood As in a mixed folate-deficient and replete population, (2) whether creatine lowers plasma total homocysteine (tHcys), (3) whether As exposure is associated with increased inflammation and decreased estimated glomerular filtration rate (eGFR), and whether these effects are greater in those with a more oxidized plasma glutathione redox potential (EhGSH), and (4) whether As metabolite proportions in urine and blood are associated with eGFR, and whether these associations may explain the relationship between As metabolite proportions and urinary creatinine. Methods: We addressed these objectives in five epidemiologic investigations of As-exposed Bangladeshi adults, employing data from a randomized placebo-controlled trial (the Folic Acid and Creatine Trial (FACT)) and two cross-sectional studies (the Nutritional Influences on Arsenic Toxicity (NIAT) study, and the Folate and Oxidative Stress (FOX) study). In the 24-week FACT study, participants were randomized to receive either placebo, 400 μg/day FA (FA400), 800 μg/day FA (FA800), 3 g/day creatine (Cr), or 3 g/day creatine + 400 μg/day FA (Cr+FA400). At week 12, half of the participants in the FA400 and FA800 groups were switched to placebo, while the other half continued their assigned supplements. Additionally, at week 12 participants in the Cr and Cr+FA400 groups were switched to placebo. In Chapter 4 (FACT), we examined whether FA400, FA800, Cr, or Cr+FA00 lowered blood As to a greater extent than placebo over the first 12 weeks of the trial, and whether a rebound in blood As occurred from week 12 to 24 related to cessation of FA supplementation. In Chapter 5 (FACT), we examined whether Cr or Cr+FA400 lowered plasma tHcys to a greater extent than placebo or FA400 alone, respectively, over the first 12 weeks of the trial. In Chapter 6 (NIAT), we examined the associations of water and urinary As with eGFR, and whether eGFR confounded the associations between urinary creatinine and the urinary %As metabolites; we also explored the associations of eGFR with the urinary %As metabolites. In Chapter 7 (FOX), we examined the associations of eGFR with the urinary and blood %As metabolites; we also examined whether the relationship between blood and urinary %As metabolites was decreased among those with reduced renal function. In Chapter 8 (FOX), we examined the associations of water, blood, and urinary As with markers of inflammation (C-reactive protein (CRP) and α-1 acid glycoprotein (AGP)), and eGFR, and investigated whether these associations were modified by the plasma EhGSH. Results: FA800 lowered blood As to a significantly greater extent than placebo over the 24 weeks of the FACT study, with no rebound in blood As related to cessation of FA supplementation. FA400, Cr, and Cr+FA400 did not lower blood As to a greater extent than placebo (Chapter 4). Cr and Cr+FA400 did not lower plasma tHcys to a greater extent than placebo or FA400 alone, respectively. However, in the Cr+FA400 group we observed a significant correlation between a decrease in plasma GAA over time and a decrease in plasma tHcys over time (Chapter 5). Total urinary As was marginally associated with a decrease in eGFR in the NIAT study, though water As was not. Additionally in the NIAT study, while eGFR did not confound the relationship between urinary creatinine and urinary %As metabolites, we observed a positive association between eGFR and u%InAs, and a negative association between eGFR and u%DMA (Chapter 6). Likewise in the FOX study, eGFR was positively associated with u%InAs and negatively associated with u%DMA; the associations of eGFR with the blood %As metabolites were in the same direction, although not statistically significant. We additionally observed that for a given increase in blood %InAs, the increase in urinary %InAs tended to be smaller in those with reduced renal function, compared to those with normal renal function (Chaper 7). In the FOX study we also observed the total blood As and urinary As were marginally associated with decreased eGFR, while water As was not. Water As, urinary As, and blood As were significantly positively associated with plasma CRP in those with low plasma GSH or a more oxidized plasma EhGSH (Chapter 8). Conclusions: Strategies to reduce risk for As-induced diseases are sorely needed, particularly due to barriers to As exposure removal and/or persistent elevated risk from past As exposure. Several susceptibility factors which can potentially be intervened upon have been discussed in this dissertation, namely folate nutritional status, redox status, and renal capacity to excrete As. Our finding that folic acid supplementation (800 μg/day) lowered blood As to a greater extent than placebo in a randomized trial indicates that improving the folate status of the general Bangladeshi population may reduce the body burden of As. Folate fortification of food in Bangladesh, in addition to potentially reducing risk for As-induced diseases, would have the additional benefit of substantially lowering the prevalence of HHcys. Our finding in a cross-sectional study that individuals with a more oxidized plasma glutathione redox potential were susceptible to As-induced inflammation may indicate that improving redox status can protect against As-induced inflammation. Randomized trials are needed to confirm a protective effect of antioxidants; upon confirmation, antioxidant dietary recommendations for As-exposed populations could potentially be implemented. Finally, our cross-sectional finding of a positive association between eGFR and urinary %InAs, and that eGFR modified the relationship between blood and urinary %InAs, suggests that InAs excretion may be impaired among individuals with reduced renal function. A decreased renal capacity to excrete InAs may lead to accumulation of InAs in tissues, and related health effects. Potential interventions related to renal function include treatment of risk factors for chronic kidney disease (e.g. blood pressure, blood glucose) in order to prevent onset of renal function deterioration, or to screen for chronic kidney disease in order to identify susceptible individuals and conduct directed interventions. Of these three susceptibility factors, the strongest evidence exists for the potential of folic acid to lower blood As. In Bangladesh, where As exposure and HHcys are widely prevalent, folate fortification should be considered a viable option for reducing risk for As- and Hcys-related diseases.

Background: Chronic arsenic (As) exposure in a global public health concern. Arsenic exposure through drinking water affects over 140 million people in at least 70 countries, including 40 million people in Bangladesh. In the United States (US), 2.4 million people rely on private wells or public water systems with As levels above the US maximum contaminant level. Ingested inorganic arsenic (InAs) is methylated to monomethyl (MMAs)- and dimethyl (DMAs)-arsenical species using the methyl donor S-adenosylmethionine (SAM). Full methylation of InAs to DMAs decreases As toxicity and facilitates urinary As excretion. Arsenic methylation capacity is influenced by nutrients involved in one-carbon metabolism (OCM), the biochemical pathway that synthesizes SAM. Folate recruits one-carbon units for the remethylation of homocysteine and the synthesis of SAM. The availability of one-carbon units is also impacted by nutrients including the alternative methyl donor betaine, its precursor choline, and possibly the cofactor vitamin B12. In addition, As methylation capacity may also be influenced by creatine; an estimated 50% of SAM is consumed by the final step of endogenous creatine synthesis. The adverse health outcomes associated with chronic As exposure include impaired intellectual function, cardiovascular disease, diabetes, inflammation, and cancers of the bladder, lung, kidney, liver, and skin. In utero As exposure is associated with adverse birth outcomes include decreased birth weight and gestational age. Elevated health risks persist after exposure has been reduced or ended, leading to the hypothesis that epigenetic dysregulation, including changes in DNA methylation, may be a biological mechanism linking As exposure to health outcomes. Objectives: This research has three main objectives: (1) to investigate the influence of OCM nutritional factors on As methylation by evaluating effects of folic acid (FA) and creatine supplementation on As methylation capacity, and effect modification by baseline status of OCM-related nutrients; (2) to examine associations between As exposure and loci-specific DNA methylation in an epigenome-wide association study (EWAS); and (3) to assess mediation of the association between in utero As exposure and birth outcomes (i.e., gestational age and birth weight) by DNA methylation of target genes identified in an EWAS, as well as the candidate gene DNA methyltransferase 3 alpha (DNMT3A), a protein-coding gene involved in de novo DNA methylation. Methods: This research used data from three studies of As-exposed individuals. To address the first objective, we used data from the Folic Acid and Creatine Trial (FACT), a 24-week randomized clinical trial of FA (400 or 800 μg/day) and/or creatine supplementation (3 g/day or 3 g creatine and 400 μg FA/day) among As-exposed adults in Bangladesh recruited independent of folate status (N = 622). We investigated overall FA and creatine treatment effects on mean within-person changes in As metabolite proportions in urine compared to the placebo group (weeks 0 to 12). Rebound of As methylation capacity following the cessation of FA supplementation was assessed from weeks 12 to 24. We also assessed effect modification by baseline choline, betaine, vitamin B12, and plasma folate of treatment effects on changes in homocysteine, guanidinoacetate (GAA) (biomarkers of OCM and endogenous creatine synthesis, respectively), total blood As, and urinary As metabolite proportions and indices. To address the second objective, we used data from the Strong Heart Study (SHS), a population-based prospective cohort of American Indians with low-moderate levels of As exposure. DNA methylation was measured in 2,325 participants using the Illumina MethylationEPIC array, which interrogates > 850,000 loci. We tested for differentially methylated positions (DMPs) and regions (DMRs), and conducted gene ontology (GO) enrichment analysis to understand functions of genes containing differential methylation. To address the third objective, we used data from a prospective birth cohort in Bangladesh. In a discovery phase, an EWAS was conducted to identify CpGs with methylation measured in cord blood that are associated with maternal water As levels and birth outcomes (N = 44). In a validation phase, DNA methylation in cord blood was measured using bisulfite pyrosequencing at three target CpGs annotated to miR124-3, MCC, and GNAL (N = 569). We applied structural equation models (SEMs) to assess mediation of the association between in utero As exposure and gestational age by DNA methylation. In addition, mediation of the association between in utero As exposure and birth outcomes by DNA methylation of the candidate gene DNA methyltransferase alpha (DNMT3A) was assessed. Results: In FACT, the mean within-person decreases %InAs and %MMAs and increase in %DMAs were greater among all groups receiving FA supplementation at weeks 6 and 12 compared to placebo (P < 0.05) (Chapter 3). Stratified by median choline and betaine concentrations at baseline, we observed a trend towards greater FA treatment effects among participants with levels below the median of both nutrients compared to participants above the median (Chapter 4). Among participants who discontinued FA supplementation, at week 24, %InAs and %DMAs were not significantly different than baseline levels, suggesting a rebound in As methylation capacity with cessation of FA supplementation. We observed a significantly greater mean within-person decreases in %MMAs with creatine supplementation compared to placebo at weeks 1, 6, and 12; mean within-person changes in %InAs and %DMAs did not differ significantly between the creatine and placebo groups (Chapter 3). The mean within-person decrease in urinary %MMAs at week 12 with creatine treatment was significantly greater than placebo among participants with baseline choline concentrations below the median, but did not differ from placebo among participants with choline concentrations above the median (Chapter 4). In an EWAS conducted in SHS, we identified 20 DMPs associated with urinary As levels at FDR < 0.05; five DMPs were significant at PBonferroni < 0.05 (Chapter 5). The top significant CpG, cg06690548, was located in solute carrier family 7 member 11 (SLC7A11 ), part of the amino-acid transporter cystine:glutamate antiporter system xc-, which is involved in biosynthesis of the endogenous antioxidant glutathione (GSH). Additional Bonferroni-significant CpGs were located in ANKS3, LINGO3, CSNK1D, and ADAMTSL4. We identified one FDR-significant DMR (chr11:2,322,050-2,323,247) including the open reading frame C11orf21 and tetraspanin 32 (TSPAN32 ). Mediation of the association between in utero As exposure and birth outcomes by cord blood DNA methylation was assessed in a Bangladeshi birth cohort. In the discovery phase (N = 44), the association between maternal water As levels and gestational age was fully mediated by DNA methylation of the top 10 CpGs associated with both variables. In a discovery phase (N = 569), there were significant indirect effects of maternal water As levels on gestational age through DNA methylation of miR124-3 and MCC ; the indirect effect through DNA methylation of GNAL was not significant (Chapter 6). In an adjusted SEM including miR124-3 and MCC, mediation of the association between in utero As exposure and gestational age by DNA methylation of miR124-3 was borderline significant (P = 0.06); DNA methylation of MCC did not act as a mediator. We also assessed mediation by DNA methylation of DNMT3A (Chapter 7). In an adjusted SEM including birth weight and gestational age, there was a significant indirect effect of maternal toenail As levels on gestational age through DNMT3A methylation, the indirect effect on birth weight was borderline significant (P = 0.082). However, the indirect effects of maternal toenail As levels on birth weight through all pathways including gestational age were statistically significant. A doubling in maternal toenail As concentrations had a total effect of a decrease in gestational age of 2.1 days and a decrease in birth weight of 28.9 g. Conclusions: Results from FACT (Chapters 3 and 4) provide evidence of the associations between OCM-related nutrients and As methylation capacity. Specifically, FA and creatine supplementation may increase As methylation capacity by increasing the availability of SAM, and treatment effects may be greater among individuals with low betaine and choline status, respectively. In addition, results reported in Chapters 5-7 support the hypotheses that chronic As exposure is associated with epigenetic dysregulation, and that changes in the epigenome may mediate the association between As exposure and adverse health effects. Findings from the research presented here may help inform public health interventions to reduce the adverse health effects of chronic As exposure. However, further research is needed to fully understand the biological mechanism that influence As methylation and that underlie the associations between chronic As exposure and adverse health outcomes.

Bibliography: leaves 106-114.

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Background: Environmental exposure to inorganic arsenic (InAs) is a considerable worldwide problem, and over 57 million people in Bangladesh have been chronically exposed to arsenic-contaminated drinking water. Ingested inorganic arsenic (InAs) undergoes hepatic methylation generating monomethyl- (MMAs) and dimethyl- (DMAs) arsenic species in a process that facilitates urinary As (uAs) elimination. Of these three metabolites (InAs, MMA and DMA), MMA the most toxic, InAs is the second most toxic, and DMA is the least toxic. Consequently, increased MMAs is associated with increased risk of As-related adverse health outcomes. One-carbon metabolism (OCM), the biochemical pathway that provides methyl groups for As methylation, is influenced by folate and B12. A growing body of research, including cell-culture, animal-model, and epidemiological studies, have demonstrated the role of OCM-related micronutrients in As methylation. While folate supplementation is known to increase As methylation and lowers blood As (bAs) in adults, little data is available for adolescents. OCM also supports nucleotide and amino acid synthesis, particularly during periods of rapid growth, such as adolescence. In Bangladesh, deficiencies in folate and vitamin B12 are widespread. These micronutrients are essential for OCM and As methylation, and they are also critical for neural development, since they are necessary for the synthesis of neurotransmitters and myelin, and critical for generation of S-adenosyl-methionine (SAM) via OCM. Deficiencies in folate and B12 have been shown to negatively influence cognitive function in adults and children, but this has not been adequately characterized in adolescents. Individuals living in Bangladesh, facing As exposure and nutritional deficiency, also experience environmental exposure to elevated levels of cadmium (Cd), manganese (Mn), and lead (Pb). These metals have been linked to adverse neurocognitive outcomes in adults and children, though their effects on adolescents are not yet fully characterized. Additionally, previous studies have linked selenium (Se) levels to protective effects against toxicity of these other metals, as Se is an essential nutrient. Metal mixtures are also understudied in adolescents, and more research is needed. Objectives: Firstly, the research presented in this dissertation will examine the previously published evidence that nutritional status and nutritional interventions can influence the metabolism and toxicity of As, with a primary focus on folate. Secondly, the associations between OCM-related micronutrients and As methylation in Bangladeshi adolescents chronically exposed to As-contaminated drinking water will be studied. Thirdly, this dissertation will investigate the associations between folate and B12 nutritional status, homocysteine, and cognitive function as measured by two different test instruments in Bangladeshi adolescents. Finally, the associations between mixed metals exposure and cognitive function in Bangladeshi adolescents will be examined. Methods: The Metals, Arsenic, & Nutrition in Adolescents study (MANAs) is a cross-sectional study of 738 Bangladeshi adolescents aged 14-16 years, whose parents were enrolled in our group’s previous Health Effects of Arsenic Longitudinal Study (HEALS). Venous blood samples were collected from adolescent participants for measurement of plasma folate, red blood cell (RBC) folate, plasma B12, plasma homocysteine (Hcys), blood As (bAs), blood cadmium (bCd), blood manganese (bMn), blood lead (bPb), and blood selenium (bSe). Urine samples were collected for measurement of urinary arsenic and urinary arsenic metabolites (InAs, MMA, and DMA) expressed as a percentage of total urinary As: %InAs, %MMAs, %DMAs. Additionally, participants completed a modified version of the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) and an abbreviated version of the Cambridge Neuropsychological Test Automated Battery (CANTAB). Associations between predictors and outcomes were assessed using linear regression analyses. Associations for the mixture of metals were also examined via Bayesian Kernel Machine Regression (BKMR), which assessed the effects of the metals mixture in addition to examining the effects each individual metal component. Results: In the linear regression analyses examining associations between nutritional status and arsenic methylation profiles controlling for water As and BMI, in girls we observed that RBC folate was inversely associated with bAs, plasma B12 was inversely associated with uAs, and, somewhat unexpectedly, plasma Hcys was inversely associated with %MMA. Among boys, we saw that plasma folate was inversely associated with %InAs and positively associated with %DMA, RBC folate was inversely associated with %InAs and positively associated with %MMA, while Hcys was positively associated with %InAs. In linear regression analyses examining the associations between nutritional status and cognitive function controlling for covariates, we found no significant associations between nutritional status and cognitive function as measured by WISC. For cognitive function as measured by CANTAB, we observed positive associations between plasma folate and spatial recognition memory, and between plasma B12 and spatial working memory. In our investigation of the associations between metal exposures and cognitive outcomes, linear regression analysis revealed negative associations between exposure to As and Mn and spatial working memory. Negative associations were also seen between bCd and Spatial Recognition Memory, and between bPb and Delayed Match to Sample. Finally, a positive association was seen between bSe and Spatial Span Length. Our BKMR results showed no overall effect of the mixture but further characterized the associations for individual metals within the mixture. BKMR analyses indicate that bPb has a negative association to Delayed Match to Sample, and that there are positive associations between bSe and Planning, Reaction Time, and Spatial Span. BKMR also showed higher concentrations of bCd to be negatively associated with Spatial Recognition Memory. Posterior inclusion probability consistently rated Se, which has a protective effect, as the most influential component of the mixture. Conclusions: These findings suggest that associations between OCM nutritional status, blood arsenic, and distribution of urinary As metabolites in adolescents are similar to previously reported observations in adults and in children. The inverse association between Hcys and %MMA in girls is unexpected since Hcys is known to be an indicator of impaired OCM and low folate/B12 in adults. These findings also suggest that associations between nutritional status and cognitive function in adolescents are consistent with previously reported associations in adults and children. The observation of positive associations between folate and spatial recognition memory and between B12 and spatial working memory are consistent with findings in animal models, children, and adults, all of which link deficiencies in these two micronutrients to memory deficits. The findings of the metals investigation are also consistent with previously reported observations in adults and children, and these results also suggest agreement between linear regression and BKMR analysis of the mixed metal exposure, with the BKMR further demonstrating associations seen in the linear regression analysis. Generally, Se had a protective effect for cognitive outcomes, whereas Mn and As were linked to poorer working memory, and Cd and Pb were linked to poorer visual recognition and memory. BKMR reinforced and further characterized results of the linear regression analyses. Overall, these results indicate that the associations between OCM-related micronutrients, arsenic methylation, metal exposure, and cognitive function in adolescents are generally similar to prior findings in adults and children. However, additional studies are needed to evaluate the impact of OCM and As methylation on As-related adverse health outcomes (such as cancer and cardiovascular disease) in people exposed to As during adolescence. These results also suggest that further investigation into the associations between nutritional status and measures of cognitive function in adolescents is merited, and that further exploration of homocysteine’s role in adolescent physiology is needed. Most importantly, these findings suggest that both nutritional interventions involving B12 and folate supplementation and metal exposure mitigation efforts may have a positive impact on overall health and well-being for individuals facing these environmental exposures. In the long term, interventions to reduce exposure to metals and nutritional deficiency, and interventions to attenuate the effects of these exposures have the potential to influence lifelong cognitive function, possibly influencing professional achievement and economic outcomes in regions having a high prevalence of nutritional deficiencies, arsenic exposure, and environmental exposure to metals mixtures.

Inorganic arsenic exposure is a well-known toxicant of which we are still discovering harmful effects. People are exposed to inorganic arsenic in the environment through either drinking arsenic-contaminated groundwater or consuming arsenic-contaminated food. Regarding global public health, drinking water is still the most important source of inorganic arsenic exposure and is the main focus of this work. The overall goal of this dissertation is to answer some pointing epidemiological questions about exposure to inorganic arsenic: How much do we know about inorganic arsenic and non-malignant lung disease in the general population? To what extent are adolescents with lifetime arsenic exposure susceptible to the respiratory consequences seen in adults? And what actions can be taken to effectively reduce exposure from arsenic-contaminated drinking water? First, we conducted a systematic review of 29 peer-reviewed articles from various populations around the world. The review focused on the different ways in which arsenic is associated with respiratory health to help inform policy makers and public health researchers on the existing evidence. In short, associations between arsenic and respiratory health were noted throughout the lifespan: in infancy, there was growing evidence that in utero arsenic exposure was associated with increased frequency and severity of respiratory tract infections; in childhood, evidence of respiratory symptoms also began to appear; and in adulthood, there was consistent evidence that arsenic exposure was associated with deficits in lung function and increased reports of coughing and breathing problems. The review also uncovered some research gaps, including few studies with strong exposure history from early life and few studies examining respiratory effects during adolescence. Next, we used a life course epidemiological approach to create a more precise understanding of arsenic exposure and respiratory health during the teenage years. This study examined the relationship between lifetime arsenic exposure and lung function in 14-17 year olds, thus studying the period of maximal lung function before natural decline. Overall, higher arsenic exposure was associated with lower lung function levels; however, these associations were only observed in males. This study used a sensitive marker of lung function to investigate early signs of small airway disease. Incorporating this common marker of small airway disease and airflow limitation in future studies on arsenic and respiratory health may help clarify how inorganic arsenic contributes to the development of chronic respiratory disease. Lastly, we evaluated the effectiveness of arsenic removal filters at the household-level in rural Bangladesh. Identifying sustainable ways of reducing exposure to arsenic from naturally contaminated groundwater has been a major environmental health challenge. Although lab-approved arsenic removal water filters exist, there was limited evidence of their prolonged efficacy in the field. To our knowledge, this was the largest and longest deployment of filters accompanied by monitoring of urinary arsenic. Our results demonstrated that filters can temporarily reduce arsenic exposure for weeks to a few months, but should not be considered as a long-term arsenic mitigation option. This failed attempt to reduce exposure confirmed that alternative mitigation strategies need to be employed in Bangladesh, particularly among more vulnerable populations, including pregnant women and young children. This dissertation has important policy implications for future arsenic research and mitigation efforts and should be effectively communicated to policy makers, public health officials, and the general population. Given the pervasive nature of arsenic exposure and the growing evidence of health consequences at different stages throughout the life course, the continued integration of information on inorganic arsenic and research collaborations across disciplines is critical for the prevention and mitigation of arsenic-induced health consequences.