Phthalates, chemicals often used as plasticizers, are present in a large variety of consumer products.
Various types of phthalates are associated with diabetes, excess weight, and insulin resistance in human studies. These conclusions are supported by animal studies. There is some evidence that exposure to phthalates-- at levels found in the general population-- may contribute to the development of type 2 diabetes.
In fact, an expert panel of scientists determined that in the European Union, phthalate exposure has a 40 - 69% probability of causing 53,900 cases of obesity in older women with €15.6 billion in associated costs. Phthalate exposure was also found to have a 40 - 69% probability of causing 20,500 new-onset cases of diabetes in older women with €607 million in associated costs (Legler et al. 2015).
The strongest evidence for the ability for environmental exposures to contribute to the development of diabetes comes from longitudinal studies. These are studies that take place over a period of time, where the exposure is measured before the disease develops.
The first longitudinal study of phthalates and type 2 diabetes has just been published using data from the U.S. Nurses Health Studies 1 and 2. In the Nurses Health Study 1, which includes older women (average age 66), total phthalate levels were not associated with type 2 diabetes. However, in the Nurses Health Study 2, which includes middle-aged women (average age 46), total phthalate levels were associated with type 2 diabetes. Thus, phthalate exposures may be associated with the risk of type 2 diabetes among middle-aged women, but not older women. These findings may be due to menopausal status. While the younger women had higher levels of phthalates than the older women, these differences did not explain the findings. Note that this paper also found similar results for BPA exposure levels (Sun et al. 2014).
A similar study by many of the same authors, also based on the Nurses Health Studies, found that women (without diabetes) with the highest levels of some phthalate (and BPA) exposures gained more weight during the 10 year follow-up period than those with lower levels of exposures (Song et al. 2014). For an article describing this study, see Household chemicals linked to slight weight gain, published by Environmental Health News
A study of elderly Korean adults found that urinary phthalate metabolite levels (from DEHP) were associated with increased insulin resistance, especially among women and those with diabetes. A marker of oxidative stress was also higher in those with higher insulin resistance and phthalate levels (Kim et al. 2013). In elderly Swedish women (not men), the phthalate MiBP was related to increased abdominal body fat two years later (Lind et al. 2012).
In New York City children, certain phthalate exposures measured at age 6-8 were associated with a higher body mass index and waist circumference one year later (Teitelbaum et al. 2012). In Italian adolescents, changes in DEHP metabolite levels were associated with obesity and insulin resistance. Also, the more MEHP was metabolized, the greater the insulin resistance (Smerieri et al. 2015). As another study below showed, the body's ability to metabolize phthalates may be important.
In 2011, it was discovered that in Taiwan, DEHP phthalate had been added to food illegally as an emulsifier. A study of some children exposed to high levels of DEHP showed that these children had lower body weight, height, and growth hormones (Tsai et al. 2016). Thus high levels of exposure may impede growth, but low levels (more normally encountered) may promote growth.
Evidence is growing that exposure to pollution during critical developmental periods, such as in utero or during childhood, may have effects later in life. Prenatal exposure to phthalates was associated with changes in BMI and head circumference during the first year of life in the Netherlands-- boys with lower phthalate exposures had a higher BMI than those more highly exposed, at 11 months of age (de Cock et al. 2014).
In Spain, prenatal phthalate exposure was associated with lower early weight gain in infancy and lower BMI at 4-7 years of age in boys, but with higher infant weight gain and childhood BMI in girls (Valvi et al. 2015). The same Spanish study, this time analyzing 27 different endocrine disrupting chemicals found that in utero levels of various persistent organic pollutants were associated with overweight/higher BMI at age 7, while other chemical levels (phthalates, flame retardants, arsenic, BPA, lead, and cadmium) were not associated (Agay-Shay et al. 2015).
A U.S. study found that levels of non-DEHP phthalates in the womb were associated with a lower BMI, smaller waist circumference, and lower fat mass in boys at age 5-7 (there was no association in girls, or with DEHP metabolite levels) (Maresca et al. 2015). A second U.S. study found that pre-natal phthalate levels were not associated with body fat in children at age 4-9, although high DEHP levels were associated with slightly lower fat mass at that age (Buckley et al. 2015). For an article on this study, see Phthalates and Childhood Body Fat: Study Finds No Evidence of Obesogenicity, published in Environmental Health Perspectives (Nicole 2016). A third U.S. study, of data from 3 different cohorts, found that maternal levels of the phthalate metabolite MCPP was associated with overweight/obesity in children at 4-7 years of age. DEPH levels were associated with lower BMI in girls as well (Buckley et al. 2016).
A Canadian study found that first-trimester maternal levels of phthalates were associated with higher leptin levels in male infants-- leptin is a hormone that controls the amount of fat stored in the body. These babies will be followed to see if there are any later-life health effects associated with early phthalate exposure (Ashley-Martin et al. 2014).
A study from Mexico City found that earlier exposure (from prenatal through puberty) to various phthalates were associated with aspects of metabolism in 8-14 year old children. The associations varied by sex, age, and stage of puberty. For example, exposure to MEP in the womb was associated with lower insulin secretion in boys at puberty and higher leptin levels in girls (Watkins et al. 2016).
A Korean study found that DEHP levels in newborns were associated with a higher body mass increase in the first three months after birth (Kim et al. 2016). A Japanese study found that maternal phthalate levels were associated with cord blood leptin and adiponectin (a hormone that helps regulate glucose levels) as well as birth size (Minatoya et al. 2016).
A study of three U.S. sites found that phthalate levels at age 6-8 were associated with gains in BMI and waist circumference at age 7-13. The associations were only found for low molecular weight phthalates (Deierlein et al. 2016).
Exposure to phthalates in pregnant women is associated with oxidative stress in the mothers (Holland et al. 2016), and with markers of oxidative stress and metabolic dysfunction in their children (Tran et al. 2016).
Cross-sectional studies are studies that measure exposure and disease at one point in time. These provide weaker evidence than longitudinal studies, since the disease may potentially affect the exposure, and not vice versa.
A study of U.S. adult women found that levels of several phthalates were associated with a higher risk of diabetes. Women with the highest levels of some phthalates had twice the risk of diabetes as those with the lowest levels (James-Todd et al. 2012). For an article about this study, see Plastics chemicals linked to diabetes in women; blacks and Hispanics most exposed, published by Environmental Health News. In an expansion of this study, some of the same researchers found that phthalate levels were associated with higher fasting blood glucose levels, fasting insulin levels, and increased insulin resistance. These associations were strongest in Mexican Americans and non-Hispanic blacks, suggesting that these groups may be more vulnerable to phthalate exposures relating to diabetes (Huang et al. 2014). They also found that phthalate levels were associated with metabolic syndrome (the specific phthalate that was associated with metabolic syndrome varied, depending on sex and menopausal status) (James-Todd et al. 2016).
In a study of Swedish elderly people, researchers found that 3 of 4 types of phthalate metabolites were associated with type 2 diabetes prevalence. The phthalate metabolites linked to diabetes included MMP, MiBP, and MEP, which are breakdown products of phthalates found in body care products. MiBP was related to poor insulin secretion, while MMP and MEP were related to insulin resistance. The phthalate metabolite MEHP, which is a breakdown product of the plasticizer DEHP, was not associated with diabetes in this study (Lind et al. 2012). Phthalates activate certain hormone receptors called PPARs. PPARs are known to influence blood glucose levels, via insulin resistance, insulin secretion, and fat formation. Interestingly, pharmaceutical drugs that have the opposite effect on PPARs are used to treat type 2 diabetes, by decreasing insulin resistance (Lind et al. 2012). Another study of the elderly, this time in men from Australia, also found phthalate levels to be associated with obesity (Bai et al. 2015).
Phthalates have also been associated with diabetes in a study of Mexican women. That study found that levels of three types of DEHP metabolites were higher in adult women with diabetes than those without diabetes. The results suggest that phthalate exposures may play a role in diabetes development (Svensson et al. 2011). In elderly Swedes, various phthalates were associated with fasting blood glucose levels, as well as cholesterol and blood pressure (Olsén et al. 2012). In obese Belgian adults, phthalate levels were linked to insulin resistance (Dirinck et al. 2015). While in Turkish adults, phthalate levels were strongly associated with BMI (Oktar et al. 2015). And in U.S. adults, certain phthalates were linked to high blood pressure, a component of metabolic syndrome (Shiue 2014a; Shiue 2014b).
In a U.S. study, levels of several phthalate metabolites were associated with increased insulin resistance and abdominal obesity in U.S. men (Stahlhut et al. 2007). In another U.S. study of people aged 6-80, various phthalate metabolites were associated with higher body mass index (BMI) and waist circumference in men aged 20-59. Effects in women were not as consistent. In some ages, exposures was associated with lower BMI (Hatch et al. 2008; Hatch et al. 2010). In a third U.S. study, a number of phthalates were associated with obesity in men and women, with differences depending on the type of phthalate, age, and sex (Buser et al. 2014). In a fourth U.S. study, certain phthalate metabolites were associated with an increased risk of overweight/obesity and BMI in black children, but not children of other ethnic groups (Trasande et al. 2013b). And a fifth study found that phthalate metabolite levels in U.S. women were associated with BMI, waist circumference, and cholesterol levels. The associations varied by metabolite. Women who had slower conversion of MEHP to its metabolite had both higher BMI and waist circumference (Yaghiyan et al. 2015). Thus the relationship between phthalates and obesity may depend on gender, age, race, type of phthalate, and metabolic rate of processing phthalates in the body.
A study of hairdressers in Slovakia exposed to high occupational levels of phthalates found that various phthalate levels were associated with BMI and fat mass (Kolena et al. 2016). In the Czech Republic, phthalate levels were higher in people with type 2 diabetes (but not associated with blood pressure or lipid/cholesterol levels) (Piecha et al. 2016).
In Taiwan, a study of both adults and children found phthalate levels were associated with various measures of growth hormones (Huang et al. 2016).
A study found that DEHP phthalate metabolite levels were associated with increased insulin resistance in U.S. adolescents (Trasande et al. 2013a). DEHP is being replaced with DINP and DIDP. It turns out that metabolites of those replacements are also associated with insulin resistance in U.S. adolescents (they also confirmed the previous association with DEHP metabolites) (Attina and Trasande 2015). Some of the same authors also report that higher molecular weight phthalates (a category that includes DEHP, DINP, and DIDP) are associated with insulin resistance in Mexican American and Hispanic 10-13 year olds (Kataria et al. 2017).
In Chinese schoolchildren, levels of certain phthalates were associated with increased BMI or waist circumference (Wang et al. 2013). Another Chinese study found that levels of certain phthalates were associated with higher BMI and fat distribution in boys over 10, but lower fat distribution in girls under 10 (Zhang et al. 2014). A third found that phthalates were associated with various growth hormone levels in young Chinese children (Wu et al. 2016). And in Korean children, certain phthalates were associated with obesity (Choi et al. 2014).
In Taiwanese adolescents, phthalate levels were associated with abdominal obesity (Hou et al. 2015).
Maternal exposure to phthalate metabolites has been associated with birth weight in infants. (Low/high birth weight is also associated with type 2 or 1 diabetes; see the Gestation and Birth page). Phthalate metabolite levels (DEHP and DBP) are associated with low birth weight in Chinese newborns (Zhang et al. 2009). A study of mothers from Greenland, Poland, and Ukraine found that the metabolite MEHHP was associated with lower birth weight, but that the metabolite MOiNP was associated with higher birth weight (Lenters et al. 2015). In a small study from the Netherlands, higher maternal levels of the metabolite MECPP were associated with lower birth weight in boys, but MEHHP was associated with higher birth weight in boys (de Cock et al. 2015).
In animals, rats given the phthalate DEHP developed symptoms of diabetes, including higher blood sugar and lower insulin levels. The changes reversed when the exposure was removed (Gayathri et al. 2004). A study at the cellular level shows the direct adverse effect of DEHP on the gene expression relating to insulin and glucose, suggesting that DEHP exposure may have a negative influence on insulin signaling (how the body responds to insulin) (Rajesh and Balasubramanian, 2013). Short term treatment of rats with a number of different phthalates found that some of the phthalates (DEHP, MEHP, and MBeP) caused high blood glucose levels (Kwack et al. 2010). Rats treated with DEP had higher blood glucose levels than controls as well (Pereria and Rao, 2006). Mice genetically prone to heart disease developed high blood sugar and glucose intolerance when exposed to phthalates, although the symptoms resolved 4-12 weeks after exposure ended (Zhou et al. 2015).
Female obesity-resistant mice exposed to DEHP for 10 weeks gained weight, had increased fat mass, and had impaired insulin tolerance. It appears that DEHP affects the function of fatty tissue, but perhaps not whole-body glucose metabolism, because things like glucose tolerance, glucose levels, and insulin levels were not affected (Klöting et al. 2015). Male mice given DEHP for 5 weeks gained weight and also developed hypothyroidism (Lv et al. 2015).
Adult rats given DEHP for a month developed high blood sugar, insulin resistance, and other changes associated with diabetes. Those given DEHP plus the antioxidant vitamins E and C, however, did not develop these symptoms of diabetes (Rajesh et al. 2013; Srinivasan et al. 2011). These vitamins essentially prevented diabetes in phthalate-exposed mice-- a sign of how nutrition and chemical exposures may interact to affect disease risk.
Rats exposed to DEHP had increased body weight, as well as higher lipid, insulin, and leptin levels (Jia et al. 2016). It appears that the insulin resistance caused by DEHP is due to mechanisms involving PPARγ (Zhang et al. 2016). MEHP also appears to act on fat cells via mechanisms related to PPARγ (Chiang et al. 2017).
The phthalate BBP also disrupts metabolism and increases fat cell development (Yin et al. 2016). BPP has been shown to increase adipogeneis via epigenetic mechanisms (Zhang and Choudhury, 2016).
In laboratory studies, the phthalate MEHP was found to promote the formation of fat cells (DEHP is converted to the metabolite MEHP when ingested) (Feige et al. 2007). The phthalate DCHP has also been shown to promote the formation of fat cells (Sargis et al. 2009). DCHP promotes fat formation through mechanisms involving the hormone glucocorticoid Sargis et al. 2010). Disturbed glucocorticoid action is associated with a number of conditions, including type 2 diabetes, obesity, and autoimmune disease (Odermatt et al. 2006).
Desvergne et al. (2009) discuss potential mechanisms of phthalate action on obesity, via what they call "metabolic disruptors," a subset of endocrine disrupting chemicals (such as phthalates) that can alter metabolism. MEHP promotes fat formation through metabolic disruption and by affecting gene expression (Feige et al. 2007 Ellero-Simatos et al. 2011). Metabolic disruptors also may affect things like fat storage in the liver; phthalates have been found to increase fat content of the liver and liver inflammation, for example (Chen et al. 2015; Zhang et al. 2016).
And, even fruit flies develop diabetes-like conditions when eating food contaminated with phthalates (DEHP), at levels comparable to human exposures (Cao et al. 2016); these fruit flies show that phthalates disrupt metabolism by controlling genes involved in glucose and lipid metabolism (Williams et al. 2016).
When pregnant and lactating rats were given DEHP, their offspring developed abnormal beta cells, and alternations of the genes controlling beta cell function at the time of weaning. In adulthood, the female offspring had high blood glucose, impaired glucose tolerance and impaired insulin secretion. The adult males had increased insulin secretion. These results suggest that developmental exposure to phthalates can lead to beta cell dysfunction and glucose abnormalities, and is a potential risk factor for diabetes development (Lin et al. 2011).
When pregnant rats were exposed to DEHP, their offspring developed higher blood glucose, impaired glucose tolerance, and impaired insulin secretion/beta cell dysfunction later in life. They also showed epigenetic effects that changed the expression of genes relating to beta cell development and function (Rajesh and Balasubramanian, 2014). Male rats exposed to DEHP in the womb were smaller at birth but then caught up to controls and grew fatter as adults, and ended up with glucose intolerance as well (Strakovsky et al. 2015).
Female mice that were exposed to phthalates had higher body weight, more fatty tissue, and higher food intake than unexposed mice. Their offspring, only exposed during fetal development and while nursing, also exhibited similar metabolic changes, including higher body weight and more fatty tissue (Schmidt et al. 2012). For an article describing this study, see Long-term outcomes after phthalate exposure: food intake, weight gain, fat storage, and fertility in mice, published in Environmental Heath Perspectives (Holtcamp 2012). Another study also found that mice exposed to DEHP in the womb had higher food intake (Hayashi et al.2012).
Mice exposed to the phthalate MEHP in the womb had higher blood glucose levels, gained more weight, and had higher cholesterol levels later in life than unexposed mice (Hao et al. 2012). A similar study by the same authors found that another phthalate, DEHP, had the same effects (Hao et al. 2013). A study of male rats exposed to DEHP in the womb found that the chemical exposure led to fatty tissue inflammation as well as an increased immune response. DEHP may affect the development of pre-fat cells into fat cells, without affecting overall body weight (Campioli et al. 2014). Rats exposed in the womb to the phthalate DiBP had lower leptin and insulin levels later in life than controls, suggesting metabolic dysfunction (Boberg et al. 2008).
Mice exposed to DEHP in the womb had more obesity, higher blood pressure, and increased cholesterol levels (Lee et al. 2015).
Rats exposed to low levels of DEHP only from nursing from their exposed mothers were found to have higher blood sugar and changes in insulin signaling later in life (Mangala Priya et al. 2014). Similarly, rats exposure to DEHP only in the womb were found to have higher blood sugar and insulin levels, and changes in insulin signalling later in life (Rajesh and Balasubramanian, 2014).
When pregnant mice were treated with the phthalate BBP, their offspring exercised less through early adulthood than untreated controls. Their body weight did not differ, however (Schmitt et al. 2016).
Laboratory studies have established that epigenetic modifications caused by developmental exposure to environmental chemicals can induce alterations in gene expression that may persist throughout life. In the case of phthalates, some of these effects can be transferred from one generation to following generations (Singh and Li, 2012).
Another study of developmental exposure to mixtures of chemicals is even more alarming. It tested a mixture of BPA and two types of phthalates (DEHP and DBP), both found in plastics. Pregnant rats were exposed to this mixture, and outcomes evaluated in their offspring, for 3 generations. The third generation offspring (the exposed mothers' great-grandchildren), had higher rates of obesity (in addition to many other health issues). The mechanism involved not changes to DNA, but epigenetic changes that were passed down from one generation to the next (Manikkam et al. 2013). You can listen to a recording of a call with one of the authors of this study, Transgenerational Effects of Prenatal Exposure to Environmental Obesogens in Rodents, sponsored by the Collaborative on Health and the Environment.
What are the effects of mixtures of chemicals? Very few studies have been done on chemicals in combination with one another, although that is how humans are exposed. One study exposed mice -- starting from before conception -- throughout life to very low doses (at levels thought to be "safe") of a combination of chemicals commonly found in food, including phthalates, BPA, dioxin, and PCBs, and fed them a high-fat diet. As adults, compared to unexposed controls, pollutant-exposed females developed impaired glucose tolerance, and males showed liver and cholesterol effects, as well as epigenetic changes (Naville et al. 2013). The same authors subsequently fed mice a high-fat, high-sugar diet, both with and without this same low-dose mixture of chemicals. This time, the chemical-exposed females showed improvement in glucose tolerance, inflammation, and insulin resistance at 7 weeks of age, but then worsening of these factors at 12 weeks of age. Thus the chemicals cause at first an apparent improvement, then a worsening as aging takes place (as compared to the mice fed the same diet but without chemicals) (Naville et al. 2015).
A cell culture study of mixtures of phthalates, BPA, and organotins increased the development of fat cells from stem cells-- the effects of phthalates and organotins were more significant than of BPA (Biemann et al. 2014). The phthalate MEHP disturbs the energy metabolism of fat cells as well (Chiang et al. 2014). A different lab showed that adult fat cells treated with MEHP led to inflammation and metabolic changes in the cells (Manteiga and Lee, 2016).
Phthalates alone can reduce insulin secretion from beta cells, and induce beta cell death. Phthalates can kill beta cells by increasing oxidative stress, and decreasing the ability of beta cells to protect themselves from this stress (Sun et al. 2014). It seems to me that this would be relevant for both type 1 and type 2 diabetes (as well as any other type, for that matter). At low doses, phthalate metabolites can also increase proliferation and insulin content of human beta cells (Güven et al. 2016). While this may sound positive, increasing insulin secretion can end up wearing out beta cells and leading to insulin resistance in the long run.
In 2002, an alternative chemical to phthalates was introduced to the market, known as DINCH (cyclohexane-1,2-dicarboxylic acid diisononyl ester). One of its metabolites, MINCH, has been found to facilitate the development of pre-fat cells into fat cells (Campioli et al. 2015). This seems to be typical-- replacement chemicals may not be an improvement over the old chemicals.
A review of phthalates in obesity concludes, "Many in vitro studies indicate that phthalates are likely obesogens, promoting obesity via several mechanisms, including activation of PPARs, antithyroid effects, and epigenetic modulation. The fetal period appears to be a critical window for exposure, and differential effects are observed depending on the dose of phthalates received and gender. Recent human studies have examined the possible effects of phthalate exposure on the development of obesity, although most of them are cross-sectional and short-term prospective studies. Although the random concentrations of phthalate metabolites have good reproducibility, large-scaled longitudinal study including measures at different life ages is needed to establish the impact of phthalate exposure on the obesity epidemic" (Kim and Park, 2014).
Another review finds that "Most data support the effects of ... some phthalates, such as di-2-ethyl-hexyl phthalate, diethyl phthalate, dibuthyl phthalate, dimethyl phthalate, dibenzyl phthalate, diisononyl phthalate and others on the development obesity and type 2 diabetes mellitus. These endocrine disrupting chemicals interfere with different cell signaling pathways involved in weight and glucose homeostasis." (Stojanoska et al. 2016).
There are no studies of type 1 diabetes in relation to phthalate exposure.
Laboratory studies do show that phthalates can affect the immune system, e.g., the secretion of inflammatory immune cells (Hansen et al. 2015). In a series of three studies, researchers examined the effects of phthalates on autoimmunity in mice. They found that after exposure to phthalates, different types of mice developed autoantibodies. But, only the autoimmune-prone mice went on to develop disease. They conclude that phthalates seem to be harmful only to susceptible strains of mice, while other strains are protected (Lim and Ghosh 2003; Lim and Ghosh 2004; Lim and Ghosh 2005). A study mentioned above found that male rats exposed to DEHP in the womb had an increased immune response, as well as chronic, low-grade systemic inflammation (Campioli et al. 2014). In fact, phtalate exposure in the womb caused epigenetic changes in adult male offspring in an area of genes that control the immune response (Martinez-Arguelles and Papadopoulos, 2014).
Phthalate levels are also linked to lower vitamin D levels (Johns et al. 2016), which may play a role in diabetes development (see the vitamin D page).
A study phthalates and gestational diabetes from Canada did not find an association between first trimester levels of phthalates and gestational diabetes (it did find an association with arsenic however) (Shapiro et al. 2015). Another study found that women with higher MBP and MIBP phthalate levels in their urine during early pregnancy actually had lower blood glucose levels when screened for gestational diabetes (Robledo et al. 2015).
However, a study of women in the Boston area found that exposure to MEP, a metabolite of the parent compound DEP, is associated with excessive gestational weight gain and impaired glucose tolerance during pregnancy. But higher DEHP was associated with a lower risk of impaired glucose tolerance (James-Todd et al. 2016). So, perhaps the associations depend on the type of phthalate measured?
A U.S. cross-sectional study found that phthalate levels were associated with retinopathy in people with type 2 diabetes (Mamtani et al. 2016).
Phthalate levels have also been associated with the risk of heart disease (Wiberg et al. 2014), as well as high cholesterol and blood pressure (Olsén et al. 2012), including higher blood pressure during pregnancy (Werner et al. 2015). Phthalates, as well as phthalate replacement chemicals, were associated with higher blood pressure in U.S. children as well (Trasande and Attina 2015; Trasande et al. 2013). (Those studies were not done in people with diabetes).
In animals, phthalate exposure accelerates atherosclerosis and interferes with cholesterol levels as well (Zhao et al. 2014).
To download or see a list of all the references cited on this page, see the collection Phthalates and diabetes/obesity in PubMed.