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Bis(2-ethylhexyl) phthalate (di-2-ethylhexyl phthalate, diethylhexyl phthalate, DEHP; dioctyl phthalate, DOP), is an organic compound with the formula C8H4(C8H17COO)2. DEHP is the most common member of the class of phthalates which are used as plasticizers. It is the diester of phthalic acid and the branched-chain 2-ethylhexanol. This colorless viscous liquid is soluble in oil, but not in water. Accounting for an almost 54% market share in 2010, DEHP is a High Production Volume Chemical.

Production and use
Due to its suitable properties and the low cost, DEHP is widely used as a plasticizer in manufacturing of articles made of PVC. Plastics may contain 1% to 40% of DEHP. It is also used as a hydraulic fluid and as a dielectric fluid in capacitors. DEHP also finds use as a solvent in glowsticks.

Approximately three billion kilograms are produced annually worldwide. It is estimated that at least 241 million pounds of dioctyl phthalates were produced in the US in 1999, so DEHP is a High Production Volume Chemical. Four companies operating five facilities are the primary U.S. producers of DEHP: Aristech Chemical Company in Neville Island, Pennsylvania; Hatco Chemical Company in Fords, New Jersey; Teknor Apex Company in Brownsville, Tennessee and Hebronville, Massachusetts; and Tennessee Eastman Company in Kingsport, Tennessee.

Industrial production entails the reaction of phthalic anhydride with 2-ethylhexanol:


 * C6H4(CO)2O +  2 C8H17OH  →  C6H4(CO2 C8H17)2  +  H2O

2-Ethylhexanol is chiral, and the resultant DEHP consists of a mixture of (R,R)-, (S,S)-, and (R,S)-isomers (left).

Environmental exposure
More than 2 million tons of DEHP are produced worldwide each year. Products that contain DEHP include tablecloths, floor tiles, shower curtains, garden hoses, rainwear, dolls, toys, shoes, medical tubing, furniture upholstery, and swimming pool liners. DEHP is an indoor air pollutant in homes and schools. Common exposures come from the use of DEHP as a fragrance carrier in cosmetics, personal care products, laundry detergents, colognes, scented candles, and air fresheners. The most common exposure to DEHP comes through food with an average consumption of 0.25 milligrams per day. It can also leach into a liquid that comes in contact with the plastic; it extracts faster into nonpolar solvents (e.g. oils and fats in foods packed in PVC). Fatty foods that are packaged in plastics that contain DEHP are more likely to have higher concentrations such as milk products, fish or seafood, and oils. Food and Drug Administration (FDA) therefore permits use of DEHP-containing packaging only for foods that primarily contain water.

DEHP can leach into drinking water from discharges from rubber and chemical factories; The US EPA limits for DEHP in drinking water is 6 ppb. It is also commonly found in bottled water, but unlike tap water, the EPA does not regulate levels in bottled water. DEHP levels in some European samples of milk, were found at 2000 times higher than the EPA Safe Drinking Water limits (12,000 ppb). Levels of DEHP in some European cheeses and creams were even higher, up to 200,000 ppb, in 1994. Additionally, workers in factories that utilize DEHP in production experience greater exposure. The U.S. agency OSHA's limit for occupational exposure is 5 mg/m3 of air.

Use in medical devices
DEHP is the most common phthalate that has been used as a plasticizer in medical devices such as intravenous tubing and bags, IV catheters, nasogastric tubes, dialysis bags and tubing, blood bags and transfusion tubing, and air tubes. DEHP makes these plastics softer and more flexible and was first introduced in the 1940’s in blood bags. For this reason, concern has been expressed about leachates of DEHP transported into the patient, especially for those requiring extensive infusions, e.g. newborns in intensive care nursery settings, premature babies, lactating and pregnant women, hemophiliacs, and kidney dialysis patients. According to the European Commission Scientific Committee on Health and Environmental Risks (SCHER), exposure to DEHP may exceed the tolerable daily intake in some specific population groups, namely people exposed through medical procedures such as kidney dialysis. The American Academy of Pediatrics has advocated not to use medical devices that can leach DEHP into patients and, instead, to resort to DEHP-free alternatives. In July 2002, the U.S. FDA issued a Public Health Notification on DEHP, stating in part, "We recommend considering such alternatives when these high-risk procedures are to be performed on male neonates, pregnant women who are carrying male fetuses, and peripubertal males" noting that the alternatives were to look for non-DEHP exposure solutions; they mention a database of alternatives. The CBC documentary The Disappearing Male raised concerns about sexual development in male fetal development, miscarriage (as DEHP is an androgen antagonist (not a pseudo-estrogen) found in polyvinyl chloride (PVC) plastic products, many cosmetics and fragrances, and numerous other consumer products), and as a cause of dramatically lower sperm counts in men. A review article in 2010 in the Journal of Transfusion Medicine showed a consensus that the benefits of a lifesaving treatments with these devices far outweigh the risks of DEHP leaching out of these devices. Although more research is need to develop alternatives to DEHP that gives the same benefits of being soft and flexible which are required for most medical procedures. If a procedure requires one of these devices and if patient is at high risk to suffer from DEHP then a DEHP alternative should be considered if medically safe.

Metabolism
DEHP hydrolyzes to mono-ethylhexyl phthalate (MEHP) and subsequently to phthalate salts. The released alcohol is susceptible to oxidation to the aldehyde and carboxylic acid.

Toxicity
The acute toxicity of DEHP is low in animal models: 30 g/kg in rats (oral) and 24 g/kg in rabbits (dermal). Concerns instead focus on its potential as an endocrine disruptor.

Endocrine Disruption
DEHP, along with other Phthalates, is believed to cause endocrine disruption in males through its action as an androgen antagonist, and may have lasting effects on reproductive function both for childhood and adult exposures. Prenatal phthalate exposure has been shown to be associated with lower levels of reproductive function in adolescent men. In another study, airborne concentrations of DEHP at a PVC pellet plant were significantly associated with a reduction in sperm motility and chromatin DNA integrity. Additionally, the authors noted that the daily intake estimates for DEHP were comparable to the general population, indicating that a “high percentage of men are exposed to levels of DEHP that may affect sperm motility and chromatin DNA integrity”.

Development
In one study, the level of phthalates and DEHP metabolites in the blood of pregnant women was significantly correlated with decreased penis width, shorter anogenital distance, and incomplete descent of testes of their newborn sons, replicating effects identified in animals. Approximately 25% of US women have phthalate levels similar to those in the study. However, the study author cautioned that replication of these results are needed to strengthen any links between phthalates and adverse health outcomes in humans.

Numerous studies of DEHP have shown changes in sexual function and development in mice and rats. DEHP exposure during pregnancy has been shown to disrupt placental growth and development in mice, resulting in higher rates of low birthweight, premature birth, and fetal loss. In a separate study, exposure of neonatal mice to DEHP through lactation caused hypertrophy of the adrenal glands and higher levels of anxiety during puberty. In another study, pubertal administration of higher-dose DEHP delayed puberty in rats, reduced testosterone production, and inhibited androgen-dependent development; low doses showed no effect.

Obesity
A study on CDC data, published in Environmental Health Perspectives (EHP), "revealed that American men with abdominal obesity or insulin resistance (a precursor to diabetes) were more likely to have high levels of [DEHP and DBP] metabolites in their urine than men without those problems." Epidemiological studies have also found an association between increased DEHP levels in female urine and female obesity.

When DEHP is ingested intestinal lipases convert it to MEHP, which then is preferentially absorbed. MEHP is suspected to have an obesogenic effect, in vitro studies done with human cells indicate that MEHP-dependent PPAR-gamma activation promotes adipogenesis, promotes tryglyceride synthesis and storage in mature adipocytes. All of which, have the potential to contribute to the possible obesogenic effect of MEHP. DEHP’s activation of PPAR-gamma also causes increased insulin sensitivity, an effect that is similar to that of thiazolidines, which have increased weight gain as a side-effect.

Rodent studies and human studies have shown DEHP to be a possible disruptor of thyroid function, which plays a key role in energy balance and metabolism. Exposure to DEHP has been associated with lower plasma thyroxine levels and decreased uptake of iodine in thyroid follicular cells. Previous studies have shown that slight changes in thyroxine levels can have dramatic effects on resting energy expenditure, similar to that of patients with hypothyroidism, which has been shown to cause increased weight gain in those study populations.

Cardiotoxicity
A clinically relevant dose and duration of exposure to DEHP has been shown to have a significant impact on the behavior of cardiac cells in culture. This includes an uncoupling effect that leads to irregular rhythms in vitro. Untreated cells had fast conduction velocity, along with homogenous activation wave fronts and synchronized beating. Cells treated with DEHP exhibited fractured wave fronts with slow propagation speeds. This is observed in conjunction with a significant decrease in the amount of expression and instability of gap junctional connexin proteins, specifically connexin-43, in cardiomyocytes treated with DEHP.

The decrease in expression and instability of connexin-43 may be due to the down regulation of tubulin and kinesin genes, and the alteration of microtubule structure, caused by DEHP; all of which are responsible for the transport of protein products. Also, DEHP caused down regulation of several growth factors, such as angiotensinogen, transforming growth factor-beta, vascular endothelial growth factor C and A, and endothelial-1. The DEHP-induced down regulation of these growth factors may also contribute to the reduced expression and instability of connexin-43.

DEHP has also been shown, in vitro using cardiac muscle cells, to cause activation of PPAR-alpha gene, which is a key regulator in lipid metabolism and peroxisome proliferation; both of which can be involved in atherosclerosis and hyperlipidemia, which are precursors of cardio vascular disease.

Other health effects
Studies in mice have shown other adverse health effects due to DEHP exposure. Ingestion of 0.01% DEHP caused damage to the blood-testis barrier as well as induction of experimental autoimmune orchitis. There is also a correlation between DEHP plasma levels in women and endometriosis.

DEHP is also a possible cancer causing agent in humans, though human studies remain inconclusive, due to the exposure of multiple elements and limited research. In vitro and rodent studies indicate that DEHP is involved in many molecular events, including increased cell proliferation, decreased apoptosis, oxidative damage, and selective clonal expansion of the initiated cells; all of which take place in multiple sites of the human body.

Alternative plasticizers
Manufacturers of flexible PVC articles can choose among several alternative plasticizers offering similar technical properties as DEHP. These alternatives include other phthalates such as diisononyl phthalate (DINP), di-2-propyl heptyl phthalate (DPHP), diisodecyl phthalate (DIDP), and non-phthalates such as 1,2-cyclohexane dicarboxylic acid diisononyl ester (DINCH), dioctyl terephthalate (DOTP), and citrate esters.

Taiwan
In October 2009, Consumers' Foundation, Chinese Taipei (CFCT) published test results that found 5 out of the sampled 12 shoes contained over 0.1% of phthalate plasticizer content, including DEHP, which exceeds the government's Toy Safety Standard (CNS 4797). CFCT recommend that users should first wear socks to avoid direct skin contact.

In May 2011, the illegal use of the plasticizer DEHP in clouding agents for use in food and beverages has been reported in Taiwan. An inspection of products initially discovered the presence of plasticizers. As more products were tested, inspectors found more manufacturers using DEHP and DINP. The Department of Health confirmed that contaminated food and beverages had been exported to other countries and regions, which reveals the widespread prevalence of toxic plasticizers.

European Union
Fears that toxic chemicals were ingested by children when chewing plastic toys prompted the European Commission to order a temporary ban on phthalates in 1999, the decision of which is based on an opinion by the Commission’s Scientific Committee on Toxicity, Ecotoxicity and the Environment (CSTEE). A proposal to make the ban permanent was tabled shortly after but stuck in Council because EU ministers disagreed over how far it should go. Until 2004, EU banned the use of DEHP along with several other phthalates (DBP, BBP, DINP, DIDP and DNOP) in toys for young children. In 2005, the Council and the Parliament compromised to propose a ban on three types of phthalates (DINP, DIDP, and DNOP) “in toys and childcare articles which can be placed in the mouth by children”. Therefore, more products than initially planned will thus be affected by the directive. In 2008, six substances were considered to be of very high concern (SVHCs) and added to the Candidate List including Musk Xylene, MDA, HBCDD, DEHP, BBP, and DBP. In 2011, those six substances have been listed for Authorization in Annex XIV of REACH by Regulation (EU) No 143/2011. According to the regulation, phthalates including DEHP, BBP and DBP will be banned from February 2015.

In 2012, Danish Environment Minister Ida Auken decided to ban four industrial chemicals including DEHP, DBP, DIBP and BBP, pushing Denmark ahead of the European Union which had already started a process of phasing out phthalates. However, it was postponed by two years and would take effect in 2015 and not in December 2013, which was the initial plan. The reason is that the four phthalates are far more common than expected and that producers cannot phase out phthalates as fast as the Ministry of Environment requested.

In 2012, France became the first country in EU to ban the use of DEHP in paediatrics, neonatal and maternity wards in hospitals. The ban came into effect in July 2015. This is an important first step towards the phase out of phthalates in all medical devices in Europe. The current EC proposal for a Regulation on Medical Devices only requires that phthalates are labelled, either on the sales package or on the device itself, meaning that health professionals and patients might not be aware that devices used for treating diseases contain phthalates.