Bisohenol A (BPA) is one of the highest volume chemicals produced worldwide, with over six billion pounds produced each year [1]. It was mainly used for the production of epoxy resins and polycarbonate plastics. Epoxy resins are commonly used as food-contact surface lacquer coatings and polycarbonate plastics are used in compact disk manufacturing, household appliances, food packaging and plastic bottles among others [2]. Because unbound monomers remain after BPA polymerization, BPA molecules can be leached from those products into environment and food. The widespread occurrence of BPA in environment and food has been well documented [3]. The main route of human exposure to BPA is through food intake and BPA has been detected in human urine, blood, milk and tissues, indicating that human exposure to BPA is extensive [4]. Moreover, lab researches have found that BPA is a typical endocrine disrupting chemical (EDC) [5], and human exposure to BPA has been reported to be associated with various adverse effects, such as metabolic and reproductive diseases [6].

There is increasing evidence suggesting that some endocrine disrupting chemicals can act as obesogens and interfere with body’s natural weight control mechanisms by disrupting adipose tissue biology, endocrine hormone systems, or central hypothalamic-pituitary-adrenal axis [7, 8]. However, most of the studies about the association of BPA, one of focused EDCs, with obesity are lab researches [9, 10]. For example, Huc et al observed that lipid accumulation in HepG2 cells was induced by BPA at 10^-4-10^-12 M level [11]. Sargis et al. reported that BPA significantly stimulated glucocorticoid receptor (GR) to promote adipogenesis without significant activation of the peroxisome proliferator-activated receptor-γ in the 3 T3-L1 Cell Line at an incubation concentration of 100 nM [12]. Gestational or perinatal exposure of mice to 2.4-500 μg/kg body weight -day of BPA resulted in increased body weight of offspring [13–15].

To our knowledge, there have been only three published epidemiological studies primarily designed for the association between BPA exposure and obesity [16–18]. Two of them were conducted in adults, one in children and adolescents, and all of them used a cross-sectional design. Children and adolescents are in rapid growth and are more susceptible to external disturbance compared with adults. Additionally, it has been reported that children are extensively exposed to BPA and exposure levels are even higher compared with adults [19, 20]. In this study we examined the association between BPA exposure and body mass index (BMI) in Chinese school children.

Only few epidemiological studies have been conducted to determine the association between BPA exposure and obesity, and provided inconsistent results. Two cross-sectional studies found no significant associations: one used data from the InCHINTI Study, a prospective population-based study of Italian adults 20-74 years of age [33], and another used data from the National Health and Nutrition Examination Survey (NHANES) 2003-2004 of adults 18-74 years of age [34]. Other three cross-sectional studies found a significant positive association between BPA exposure and obesity based on combined data from the NHANES 2003-2004 and the NHANES 2005-2006 [16], data from children and adolescents who participated in the NHANES 2003-2008 [17], and data from Chinese adults 40 years of age or older [18]. The discrepancy between the studies conducted by Lang et al. [34] and Carwile et al. [16] might reflect a different statistical power to detect a moderate association. In contrast to the studies described above, our study’s participants were school children, and the analysis of BPA was performed in a short time span (one month), in the same laboratory, and by the same analytical team, which minimized potential measurement biases.

In the present study, multiple linear regression analysis showed that high urine BPA and daily intake estimate were significantly associated with an increase in BMI value in all subjects. Specific gravity correction weakened the association, especially after stratified by age or sex. It was reported that overweight and obese subjects might have less urine output [39], which might lead to a higher urine BPA concentration, and similarly a higher urine SG. In this respect, urine SG correction was appropriate. However, there is also a possibility that urine solute excretion increases urine SG in overweight or obese subjects [40], and urine SG correction might result in an underestimation of true urine BPA concentrations in overweight or obese subjects and therefore weaken the association with BMI. Small sample size could be another important reason for non-significant association when stratified by sex and age.

Animal and cell studies have demonstrated that BPA can promote adipogenesis by diverse mechanisms [7, 8]. Among them, BPA interactions with specialized nuclear receptors (such as steroid hormone receptors or thyroid hormone receptors) may serve as a primary mechanism for promoting adipogenesis [41].

BPA has been reported to result in a variety of dysfunctions by binding to estrogen receptors (ERs) [6]. Soriano et al. found that BPA behaved as a strong estrogen via nuclear ERβ by using pancreatic β-cell from ERβ-/- mice at 1 nM of BPA exposure level [42]. BPA also stimulated calcium influx and prolactin secretion in rat pituitary tumor cells by membrane estrogen receptor α at as low as pM level [43]. Three human cell lines (Ishikawa, HeLa and HepG2) were used to evaluate the estrogenic promoter activity of BPA on estrogen receptors α and β, and BPA were found to act as cell type specific agonists or antagonists at different concentration levels ranging from 1 nM to 1000 nM [44]. Moreover, a role for sex steroid hormones in regulating adipocyte hypertrophy and hyperplasia was confirmed by knockout models of sex steroid pathway components [7].

Thyroid function is critical to the maintenance of basal metabolism, and BPA may influences thyroid hormone. A large cross-sectional study from Denmark found that thyroid function,was associated with BMI [45]. Fox et al. found that thyroid function within the reference range, as assessed by serum thyroid stimulating hormone concentration, is associated with body weight in both sexes using data from Framingham Offspring Study [46]. Moreover, Moriyama et al. observed that BPA could inhibit the binding of T3 to the rat hepatic thyroid hormone receptors with an inhibition constant (Ki) of 200 μM and suppress the transcriptional activities mediated by endogenous thyroid hormone receptors at as low as 100 nM [47].

In our studies, we observed that there are some age- or sex-specific differences in the associations between urine BPA and BMI. Previous epidemiological studies also reported age- or sex-specific differences in the association between urine BPA and obesity or between urine phthalate metabolites and BMI [16, 48]. Different sex hormone profiles between sex and age subgroups might explain the differences observed. Puberty usually begins between 10 and 13 years of age, and serum levels of endogenous sex hormones in puberty significantly rise, especially estradiol in girls and testosterone in boys. There also exist distinct differences in sex hormones between prepubertal boys and girls. Klein et al. reported that prepubertal girls had a 8-fold higher estrogen level than prepubertal boys [49]. The differences may lead to different susceptibility of participants to sex hormone perturbation caused by BPA.

Although plausible physiological mechanisms for BPA as an obesogen are present, there are some important gaps between our study and lab researches for meaningful interpretations. In this study, the GM of daily intake estimates was 8.22 ng/kg-day, but it was approximately 290-60,000 times lower than the pre or perinatal exposure dose (2.4-500 μg/kg-day) tested in mice lab studies reported previously [13–15]. Moreover, based on a human test about BPA metabolism and kinetics [29], the average concentration level of free serum BPA in study participants was estimated at pM level using the average BPA exposure level (8.22 ng/kg-day) in this study. This estimated serum BPA level was comparable to the least effect concentration inducing lipid accumulation in the HepG2 cell [11], but about 50,000 times lower than that promoting adipogenesis in 3 T3-L1 cell [12]. The reasons for the discrepancy of detected effect level are not clear, and the impacting factors may include cross-species, different exposure window during life course, different exposure route and/or duration to BPA for animal studies and different cell types or effect endpoints tested for cell experiments.

There were some study limitations that should be considered when interpreting the results. First, the cross-sectional nature of the association of BPA and obesity could not rule out the possibility of reverse causation. BPA exposure could be a proxy for other variables related to obesity, such as caloric intake, diet composition, daily indoor time, parental education, and family income level [17]. Of them, caloric intake or diet composition is of concern. Because food is thought as the main exposure route for BPA in human population, it is possible that increased overall calaric intake or different diet composition among obese individuals might increase the risk of BPA exposure, compared to normal weight ones.

Second, due to the short half-life (less than 6 h) of BPA in human body [29], the one spot urine analysis is not an ideal measure for long-term exposure given that obesity was most likely associated with long-term low-dose exposure. Mahalingaiah et al. reported that spot urine samples showed a moderate sensitivity for predicting an individual’s tertile categorization. Misclassification due to this spot urine might result in an attenuated estimate of the strength of association between BPA exposure and BMI [30]. The first morning urine used in the current study improved this circumstance by adding more comparability between individuals than pure spot urine as most previous studies did. However, due to its rapid metabolism in human body, BPA exposure estimates from first morning urine may just represent the exposure at the prior meal (dinner), not daily or average exposure level. Given the food indigestion as the main exposure route to BPA, the use of first morning urine may result in an elevated BPA exposure estimate [50, 51].

Third, exposure to BPA might also be an indicator of exposure to multiple environmental chemicals such as phthalates and organotins. Some studies have reported that urine phthalate metabolites were significantly associated with BMI [52]. Urine concentrations of other environmental chemicals, especially phthalate metabolites and organotins, may be needed to be investigated to clarify their roles in the association between BPA exposure and BMI.

In this study, we found that urine BPA concentration and daily BPA intake estimate were positively associated with BMI in Chinese school children. Due to being much lower than the recommended tolerable daily intake of 50 μg/kg-day proposed by EFSA, the effective dose estimated from the current cross-sectional data required a further risk reassessment of BPA exposure. Given the cross-sectional nature of this study, longitudinal studies are warranted to confirm BPA exposure as a contributor to increased BMI.