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International Journal of Hygiene and Environmental Health 216 (2013) 50– 55

Contents lists available at SciVerse ScienceDirect

International Journal of Hygiene andEnvironmental Health

j o ur nal homep age: www.elsev ier .com/ locate / i jheh

ow levels of arsenic in drinking water and type 2 diabetes in Middle Banategion, Serbia

ragana Jovanovica,∗, Zorica Rasic-Milutinovicb, Katarina Paunovicc, Branko Jakovljevicc,nezana Plavsica, Jelena Milosevicd

Institute of Public Health of Serbia “Dr Milan Jovanovic Batut”, Dr Subotica 5, Belgrade, SerbiaDepartment of Endocrinology, University Hospital Zemun, Vukova 9, Belgrade, SerbiaInstitute of Hygiene and Medical Ecology, Faculty of Medicine, Dr Subotica 8, Belgrade, SerbiaPrimary Care Center ‘Dijagnostika’, Vitanovacka 13, Belgrade, Serbia

r t i c l e i n f o

rticle history:eceived 30 August 2011eceived in revised form9 December 2011ccepted 15 January 2012

eywords:iabetes mellitusype 2rsenicater pollution

rinking water

a b s t r a c t

Arsenic in drinking water presents a serious public health problem in Serbia, but its relationship withdiabetes has not been studied previously. The aim of this study was to explore the association betweenexposure to arsenic in drinking water and the occurrence of type 2 diabetes in Middle Banat region,Serbia.

This cross-sectional study comprised two populations. Exposed population in Middle Banat region con-sumes drinking water with arsenic (mean = 56 �g/L); unexposed population from six regions in CentralSerbia consumes arsenic below detection limit (2 �g/L). Newly diagnosed cases of type 2 diabetes wereobtained from the National Registry of Diabetes in 2008. The Registry included age, gender, family historyof diabetes, presence of overweight, central obesity, cholesterol and triglyceride levels. In addition, thenumber of cases of diabetes reported in years 2006, 2007 and 2009 was used to calculate standardizedincidence rates for both populations.

Two populations were comparable by age, family history of diabetes and prevalence of overweightpersons. Unexposed population was more likely to have central obesity, and high total cholesterol and

triglycerides. Standardized incidence rates of type 2 diabetes were higher in exposed population. Oddsratios for type 2 diabetes were significantly higher for the exposed population, both men and women, inthe period from 2006 to 2009, when compared with the unexposed population.

The population from Middle Banat region, consuming drinking water with low levels of arsenic, was athigher risk for the occurrence of type 2 diabetes in comparison to the unexposed population in Central

Serbia.

ntroduction

Type 2 diabetes accounts for 90–95% of all cases of diabetes mel-itus and presents a major public health problem worldwide (Wildt al., 2004). The World Health Organization and the Internationaliabetes Federation estimated that 285 million people worldwideill suffer from type 2 diabetes in 2010 (Sicree et al., 2009), and

hat the number of diabetics would increase up to 439 millioneople by 2030 (Shaw et al., 2010). Prevalence of type 2 diabetes

n Serbia (Kosovo and Metohia excluded) is approximately 600

Abbreviations: As, arsenic; HDL, high-density lipoprotein; LDL, low-densityipoprotein; SIR, standardized incidence rate.∗ Corresponding author at: Institute of Public Health of Serbia “Dr Milan Jovanovicatut”, Dr Subotica no. 5, 11000 Belgrade, Serbia. Tel.: +381 641511120;

ax: +381 112685140.E-mail address: dragana jovanovic@batut.org.rs (D. Jovanovic).

438-4639/$ – see front matter © 2012 Elsevier GmbH. All rights reserved.oi:10.1016/j.ijheh.2012.01.001

© 2012 Elsevier GmbH. All rights reserved.

thousand persons, or 8.2% of the total population, similarly to Euro-pean prevalence (Sicree et al., 2009). Apart from traditional riskfactors for type 2 diabetes (obesity, physical inactivity, age andgenetic polymorphism), some environmental toxicants, such asarsenic, may play a role in its development (Chen et al., 2007;Longnecker and Daniels, 2001; Navas-Acien et al., 2006; Sharp,2009).

Arsenic is not uniquely present in waters in Serbia. Geograph-ically, Serbia consists of two regions separated by the rivers Savaand Danube. The northern region is Vojvodina, which belongs tothe southern part of the Pannonian Basin, together with Hungary,Romania, Slovakia and Slavonia (Croatia). Quaternary sedimentaryaquifers within the Pannonian Basin contain high concentrationsof naturally occurring arsenic (Varsanyi and Kovacs, 2006). In the

water-sediment system, arsenic is specially enriched in clay frac-tion of the soil; tertiary magmatic rocks contain 3.1 mg As/kg,whereas soils contain 10 mg As/kg (Dangic, 2007). On the other side,the central and southern regions of Serbia belong to the Danube

giene and Environmental Health 216 (2013) 50– 55 51

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iver basin, which contains much lower levels of arsenic (Dangic,007). The highest arsenic concentrations in Serbia are measured

n drinking water in the Middle Banat region within VojvodinaJovanovic et al., 2011). Although arsenic is a known water pol-utant this region for many decades, public water supply systemsack technical and financial resources for its removal (Jovanovict al., 2011; Kristoforovic-Ilic et al., 2009). These geographical andeological characteristics create a specific phenomenon for thessessment of toxic effects of arsenic in drinking water.

Given the lack of epidemiological studies on the effects of arsenicn health of Serbian population, we have decided to undertake atudy using a national registry data on the occurrence of type 2iabetes in two populations consuming drinking water with dif-erent levels of arsenic. The aim of this study was to explore thessociation between exposure to arsenic in drinking water and theccurrence of type 2 diabetes in Middle Banat region, Serbia.

aterial and methods

tudy sample

The research was designed as a registry-based cross-sectionaltudy comprising two separate populations in Serbia. The popula-ions were selected based on arsenic levels in drinking water. Thexposed population consuming higher arsenic levels in drinkingater was chosen from the Middle Banat region (total popula-

ion 195,190) within Vojvodina, the northern province of Serbia.he unexposed population was selected from six regions in Cen-ral Serbia (an administrative name for all southern, eastern andestern provinces of Serbia; Kosovo excluded) where arsenic isot present in drinking water. The population of these regionsKolubarski, Podunavski, Branicevski, Pomoravski, Zlatiborski andcinjski region) in 2008 was 1.324489. According to national cen-us data, people living in Vojvodina and Central Serbia share similarducation level and family income, indicators of socioeconomictatus (Statistical Office of the Republic of Serbia, 2003). The geo-raphical distribution of the selected regions is presented in Fig. 1.

All newly diagnosed cases of type 2 diabetes were obtained fromhe National Registry of Diabetes in Serbia and from the Institute ofublic Health of Zrenjanin in 2008. Type 2 diabetes was defineds a fasting glucose concentration ≥7.0 mmol/L in two samplesnalyzed in two consecutive days, or as a glucose concentration11.1 mmol/L obtained on an oral glucose tolerance test (Nationalxpert Commission for the Development and Implementation ofuidelines in Clinical Practice, 2005).

The National Registry of Diabetes in Serbia contains person’s age,ender, family history of diabetes, smoking habits (current smoker,on-smoker), presence of overweight (defined as body mass index25 kg/m2), central obesity (defined as waist circumference greater

han 94 cm for men, and greater than 80 cm for women), andrevious diagnosis of arterial hypertension (defined as medicallyonfirmed diagnosis or use of any antihypertensive drug). Further-ore, the registry includes elevated total cholesterol level (defined

s total cholesterol exceeding 4.5 mmol/L), decreased high-densityipoprotein (HDL; defined as high-density lipoprotein lower than.03 for men, and lower than 1.29 mmol/L for women), elevated

ow-density lipoprotein (LDL; defined as low-density lipoproteinxceeding 2.5 mmol/L), and elevated triglyceride level (defined asriglyceride exceeding 1.7 mmol/L).

The National Registry is updated annually with new cases of dia-etes diagnosed in primary care units and hospitals all around the

ountry. For the purpose of this investigation, we obtained indi-idual data on newly diagnosed cases of diabetes including theiriabetes risk factors, registered in the exposed and the unexposedrea in 2008. In addition, we were able to obtain the number of cases

Fig. 1. Geographical distribution of the investigated regions in Serbia according toexposure to arsenic in drinking water (dark grey area – the exposed region; lightgrey areas – the unexposed regions; white areas – unanalyzed regions).

of diabetes reported in both areas in 2006, 2007, and 2009, but notthe individual data from the registry. The number of reported caseswas used to calculate standardized incidence rates of diabetes inboth areas, and odds ratios for the occurrence of diabetes for theexposed population in comparison to the unexposed population forthe period 2006–2009.

Water sampling and analysis

Arsenic levels in drinking water from public water supply sys-tems in all investigated regions were obtained from the NationalWater Quality Monitoring Programs. Public water supply systemswere constructed in the 1960s all around Serbia, and they distributedrinking water to more than 95% of the population. We assumedthat the exposure to arsenic lasted for more than 40 years, becausewe could not obtain the length of residence in the exposed and theunexposed area from the registry.

Arsenic concentrations were measured in all investigated watersystems in 2006 and 2009. No statistical difference was observedbetween the samples regarding the year of measurement; the mostrecent data were, therefore, included into the analysis. Bottledwater and water from individual wells were not analyzed.

Water sampling and analyses were performed at the labora-tories of the Institute of Public Health in Zrenjanin, and at theInstitute of Public Health of Serbia in Belgrade. Both laboratorieswere accredited and authorized according to ISO/IEC 17025 andISO 9001 standards (ISO/IEC 17025:2005; ISO 9001:2000). Labora-tory procedures for sample management, analytical methods, andquality control measures (accuracy, precision, and detection lim-its) were standardized by the Serbian law (Book of Regulations onthe Hygienic Correctness of Drinking Water, 1998). Current Serbianregulations limit arsenic levels at 10 �g/L (Book of Regulations on

the Hygienic Correctness of Drinking Water, 1998).

Total arsenic water was determined using the HG-AAStechnique (Perkin-Elmer 1100 atomic absorption spectrometerequipped with a MHS-20 hydride generation system, Perkin-Elmer

5 giene and Environmental Health 216 (2013) 50– 55

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2 D. Jovanovic et al. / International Journal of Hy

orp., Norwalk, CT, USA). Reagents of analytical grade or higheruality were used. Hydride generation was performed using a% (w/v) NaBH4 in 1% NaOH (both Merck suprapur; E. Merck,armstadt, Germany) solution. The radiation source was a hollowathode lamp of arsenic (Perkin-Elmer) used at a wavelength of93.7 nm and a spectral slit width of 0.7 nm. Hydride generationHG) was performed with 0.6% NaBH4 dissolved in 0.5% NaOH and

mol/dm3 HCl. The hydrides were then transported to a heateduartz cell and the atomic absorption of the analyte was measured.y analyzing 4 series of 10 repeated analyses of blank samples, andalculating three standard deviations of these responses, the limitf detection of this method was 0.5 �g/L, and the limit of quantifi-ation equalled 2.0 �g/L. Recovery of standards was 80–120%.

tatistical analysis

The data are presented as mean values (and standard deviationor parameteric data) or as relative numbers for non-parametricata. Differences between variables were analyzed using Student’s-test for parametric data and Pearson’s chi-square test for non-arametric data. Standardized incidence rates (SIR) were calculatedy direct standardization, using the World (ASR-W) standard popu-

ation. STATISTICA software was used for all data analyses (Version, StatSoft Inc., Tulsa, OK, USA).

esults

Mean arsenic concentrations in drinking water from publicater supply systems in Middle Banat region are presented in

ig. 2. Mean concentration of arsenic in 383 samples in Mid-le Banat region was 56.1 �g/L, median value 38.0 �g/L, range.0–349.0 �g/L. Mean arsenic concentration in 525 samples in Cen-ral Serbia was 2.0 �g/L, Median value 2.0 �g/L, range 0.5–4.0 �g/Ldata not shown).

General characteristics of the investigated populations withype 2 diabetes are shown in Tables 1 and 2. In total, 541 newlyiagnosed cases of type 2 diabetes were recorded in the exposediddle Banat region in 2008, as well as 2746 cases in the unexposed

ix Central Serbian regions.Men with type 2 diabetes from the exposed area were more

ikely to be overweight, have a positive family history of diabetes,ow HDL cholesterol, and high LDL cholesterol. Men with type 2iabetes from Middle Banat were significantly less likely to beurrent smokers, have central obesity, and have high cholesterol

nd triglyceride levels than were men from the unexposed areaTable 1).

Women with type 2 diabetes living in the exposed area wereore likely to have a positive family history of diabetes, low HDL

able 1eneral characteristics of men with type 2 diabetes in two investigated populations (new

Characteristics Exposed population Unexppopul

Population size 95,325 650,8No. of cases 242 1315Age (years) 60.1 ± 10.9 60.8 ±Family history of diabetes (%) 88 (36.4) 438 (3Overweight (%) 163 (67.4) 795 (6Central obesity (%) 65 (26.9) 468 (3Current smoker (%) 47 (19.4) 360 (2Elevated total cholesterol level (%) 151 (62.4) 1000

Decreased HDL cholesterol (%) 29 (12.0) 87 (6.Elevated LDL cholesterol (%) 66 (27.3) 216 (1Elevated triglyceride level (%) 119 (49.2) 772 (5Arterial hypertension (%) 139 (57.4) 780 (5

a Student’s t-test.b Pearson’s chi-square test.

Middle Banat region.

cholesterol, and high LDL cholesterol level. They were also lesslikely to be overweight, with central obesity, and have high choles-terol and triglyceride levels than were women from the unexposedarea (Table 2).

The standardized incidence rates of type 2 diabetes were sig-nificantly higher for the exposed population, men and women, incomparison to the unexposed population from Central Serbia at anytime point from 2006 to 2009 (Table 3).

Odds ratios for the occurrence of type 2 diabetes were signifi-cantly higher for the exposed population in Middle Banat region, incomparison with the unexposed population from Central Serbia, inthe period from 2006 to 2009 (Table 4).

Population from Middle Banat area was further divided intopopulation exposed to arsenic over 100 �g/L, and those exposedto arsenic below 100 �g/L. Odds ratios for the development of dia-

betes were somewhat higher for people consuming arsenic over100 �g/L, compared to people from the same area consumingarsenic in drinking water below 100 �g/L (Table 5).

ly diagnosed in 2008).

osedation

p-Value Relativerisk (RR)

95% confidenceinterval for RR

77

11.2 0.875a

3.3) 0.375b 1.09 0.91–1.310.5) 0.044b 1.11 1.01–1.235.6) 0.010b 0.75 0.61–0.947.4) 0.011b 0.71 0.54–0.93

(76.1) <0.001b 0.82 0.74–0.916) 0.007b 1.81 1.23–2.696.4) <0.001b 1.66 1.31–2.118.7) 0.007b 0.84 0.73–0.969.3) 0.619b 0.97 0.86–1.09

D. Jovanovic et al. / International Journal of Hygiene and Environmental Health 216 (2013) 50– 55 53

Table 2General characteristics of women with type 2 diabetes in two investigated populations (newly diagnosed in 2008).

Characteristics Exposed population Unexposedpopulation

p-Value Relativerisk (RR)

95% confidenceinterval for RR

Population size 99,865 673,612No. of cases 299 1431Age (years) 61.7 ± 9.8 63.5 ± 10.7 0.786a

Family history of diabetes (%) 103 (34.4) 475 (33.2) 0.637b 1.04 0.87–1.23Overweight (%) 104 (34.8) 625 (43.7) 0.005b 0.80 0.67–0.94Central obesity (%) 52 (17.4) 412 (28.8) <0.001b 0.60 0.47–0.78Current smoker (%) 34 (11.4) 188 (13.1) 0.448b 0.86 0.61–1.22Elevated total cholesterol level (%) 196 (65.6) 1106 (77.3) <0.001b 0.85 0.78–0.92Decreased HDL cholesterol (%) 44 (14.7) 139 (9.7) 0.013b 1.51 1.10–2.08Elevated LDL cholesterol (%) 106 (35.5) 209 (14.6) <0.001b 2.43 1.99–2.96Elevated triglyceride level (%) 130 (43.5) 825 (57.6) <0.001b 0.75 0.66–0.86Arterial hypertension (%) 211 (70.6) 1042 (72.8) 0.434b 0.97 0.89–1.05

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a Student’s t-test.b Pearson’s chi-square test.

iscussion

The study has shown a significantly higher odds ratio and highertandardized incidence rates for the occurrence of type 2 diabetesn the population exposed to arsenic, compared to the unexposedopulation in Central Serbia. It supports the hypothesis that arsenicxposure may play a role in the occurrence of diabetes type 2 in theiddle Banat region.

Another important result of this study is the decrease of stan-

ardized incidence rates and odds ratios for type 2 diabetes from006 to 2009. Considering the fact that SIRs decreased among thexposed and the unexposed populations, we hypothesize that this

able 3tandardized incidence rates (SIR) of type 2 diabetes per 100,000 in the exposed andhe unexposed populations from 2006 to 2009.

Population Year Exposed population Unexposed population

SIR 95% confidenceinterval for SIR

SIR 95% confidenceinterval for SIR

Total population 2006 202.7 187.6–218.6 136.4 134.0–138.82007 162.5 149.1–176.8 114.1 111.9–116.32008 159.3 146.4–173.0 107.9 105.8–110.02009 145.8 133.1–159.3 119.2 117.0–121.4

Men 2006 216.7 193.8–241.6 147.0 143.4–150.72007 154.2 135.1–175.2 120.2 116.9–123.62008 160.4 140.9–181.9 111.2 108.0–114.42009 160.7 141.3–181.9 126.0 122.6–129.4

Women 2006 187.7 168.4–208.6 126.3 123.2–129.42007 169.6 151.1–189.7 108.1 105.2–111.02008 158.2 140.8–177.2 104.3 101.5–107.12009 132.0 115.7–149.9 112.7 109.8–115.6

able 4dds ratio for the occurrence of type 2 diabetes in the exposed population from006 to 2009.

Population Year Odds ratio(OR)

95% confidenceinterval for OR

Total population 2006 1.56 1.42–1.702007 1.31 1.17–1.462008 1.62 1.46–1.802009 1.22 1.09–1.36

Men 2006 1.56 1.37–1.782007 1.19 1.01–1.412008 1.52 1.30–1.772009 1.36 1.16–1.58

Women 2006 1.55 1.36–1.772007 1.43 1.23–1.652008 1.71 1.49–1.972009 1.09 0.93–1.28

trend was related to the registry procedure. The registry was re-established in 2006 and there is a possibility that some newlydiagnosed cases of diabetes were reported with delay. This mighthave resulted in the underestimation of the presented data. Thethird important finding was that people who consumed arsenicexceeding 100 �g/L in drinking water were at slightly increasedrisk for the occurrence of type 2 diabetes, in comparison to peoplefrom the same geographic area consuming arsenic below 100 �g/L.We assume that this risk may be higher once the registry databaseis well established and consistent.

The presented results are similar to studies conducted in othergeographically diverse parts of the world. A positive associationbetween ingested inorganic arsenic and the prevalence of diabeteswas found among people from southern Taiwan, residing in vil-lages where arsenic is endemically present in drinking water. Thisstudy showed a dose–response relationship between cumulativearsenic exposure and prevalence of diabetes (Lai et al., 1994). Ina recent study in Taiwan, the prevalence of type 2 diabetes wasassessed in two areas, the one with arsenic concentrations in drink-ing water exceeding 0.35 mg/L (the arseniasis-endemic area), andthe non-endemic area, comprising the rest of the country. The studyreported higher prevalence of diabetes in the arsenic-exposed area(7.5% vs. 3.5% in the non-exposed area) across all age groups, andfor both men and women. The prevalence odds ratio for diabeteswas 2.69 (95% CI = 2.65–2.73) in the endemic area, in comparison tothe non-endemic area, after adjustment for age and gender (Wanget al., 2003).

A similar concept was applied in a study in Bangladesh. Theexposed population resided in areas with high arsenic concentra-tions, ranging from 0.01 to over 2.1 mg/L; the unexposed population

Table 5Odds ratios for type 2 diabetes for population from Middle Banat consuming arsenic≥100 �g/L, compared to population consuming arsenic below 100 �g/L.

Population Year Odds ratio(OR)

95% confidenceinterval for OR

Total population 2006 1.25 1.01–1.562007 0.88 0.69–1.142008 0.89 0.71–1.132009 1.32 1.01–1.73

Men 2006 1.52 1.11–2.132007 0.91 0.63–1.312008 0.82 0.58–1.172009 1.22 0.85–1.75

Women 2006 1.04 0.77–1.352007 0.86 0.61–1.212008 0.97 0.71–1.332009 1.47 1.00–2.23

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4 D. Jovanovic et al. / International Journal of Hy

esided in the Dhaka area, with mean arsenic level below 0.01 mg/L.he crude prevalence ratio for diabetes among subjects exposed torsenic was 4.4 (95% CI = 2.5–7.7); the prevalence ratio adjustedor age, sex, and body mass index was 5.2 (95% CI = 2.5–10.5). Inddition, the approximate time-weighted exposure levels werestimated for all subjects. The prevalence of diabetes was related toumulative arsenic exposure in a dose–response pattern (Rahmant al., 1998).

A positive association between prevalence of diabetes and totalrinary arsenic concentrations was reported in the USA (Navas-cien et al., 2008), Mexico (Coronado-González et al., 2007),nd Korea (Kim and Lee, 2011). Similarly, a positive relationshipetween hair arsenic and the prevalence of metabolic syndromeincreased fasting glucose levels being one of the five componentsf this syndrome) was found among people living in an industrialrea in Taiwan (Wang et al., 2007).

On the contrary to these studies, the Health Effects of Arsenicongitudinal Study in Bangladesh found no association betweenrsenic levels in water and urine samples and type 2 diabetes (Chent al., 2010). Similarly, a reanalysis of the data from the 2003–2004ational Health and Nutrition Examination Survey in the USA didot indicate that arsenic exposure would increase the risk of dia-etes (Steinmaus et al., 2009).

The presented results are not easily comparable to other sur-eys due to several methodological differences. First, we selectedatients from a national registry database, which is more accuratehan a cross-sectional study. A similar approach, i.e. based on aational insurance database, was applied in Taiwan (Wang et al.,003). Other studies were conducted on representative nationalamples (Chen et al., 2010; Kim and Lee, 2011; Navas-Acien et al.,008; Steinmaus et al., 2009), and on small samples (Coronado-onzález et al., 2007; Lai et al., 1994; Rahman et al., 1998; Wangt al., 2007). Second, the diagnostic criteria for diabetes were basedn fasting glucose and oral glucose tolerance test. These criteriaere applied in Taiwan (Lai et al., 1994), Bangladesh (Rahman et al.,

998), Mexico (Coronado-González et al., 2007), and Korea (Kimnd Lee, 2011). Other studies used self-reported physician diag-osis of diabetes or reported use of insulin or diabetic medicationChen et al., 2010; Navas-Acien et al., 2008; Steinmaus et al., 2009).oth diagnostic criteria were applied by Rahman et al. (1998),oronado-González et al. (2007), Kim and Lee (2011), and Wangt al. (2003).

Another possible explanation may be related to general char-cteristics of investigated populations. People with diabetes hadigher body mass index in our study, in Mexico (Coronado-onzález et al., 2007), and in the USA (Navas-Acien et al., 2008;teinmaus et al., 2009), than did people in Bangladesh (Chent al., 2010; Rahman et al., 1998). Fourth, more than a half ofhe reported cases with diabetes had arterial hypertension. Therevalence of concurrent hypertension was similar among dia-etics in Mexico (Coronado-González et al., 2007), and TaiwanWang et al., 2007). Nevertheless, the reported prevalence of hyper-ension among persons with diabetes (14% of men and 26% ofomen) in Korea was lower than in our study (Kim and Lee,

011). This implies that arsenic-related studies must take otherffects of arsenic into consideration, especially cardiovascular dis-ases, which could directly and indirectly be influenced by arsenicMedrano et al., 2010).

Our study provides little evidence of the pathological mech-nisms underlying the association between arsenic and theevelopment of type 2 diabetes. Some studies propose that arsenicffects glucose metabolism, increases oxidative stress, affects

nsulin secretion, increases insulin resistance, and causes endothe-ial dysfunction (Longnecker and Daniels, 2001; Navas-Acien et al.,006; Tseng, 2004). However, several biological mechanismsnderlying the relationship between chronic arsenic exposure and

and Environmental Health 216 (2013) 50– 55

diabetes mellitus remain unknown (National Research Council,2001).

Risk factors for diabetes were not uniformly distributedbetween investigated populations in this study. Exposed popula-tion was at higher risk of being overweight, and more often hadlow HDL cholesterol and high LDL cholesterol. The unexposed pop-ulation, on the other hand, was more likely to have central obesityand high total cholesterol and triglyceride levels. Having in mindthat waist circumference (a measure of central obesity) stronglycorrelates with the development of diabetes (Wei et al., 1997), wehypothesize that the unexposed population was at higher overallrisk for the development of diabetes. These findings suggest thathigher prevalence of diabetes in the exposed population may berelated to arsenic exposure, despite the absence of other major riskfactors.

The limitations of this study include the lack of data from alonger period of time, primarily because the National Registry ofDiabetes in Serbia was re-established in 2006. Second, we were notable to obtain data on each case with diabetes from the NationalRegistry reported in 2006, 2007 and 2009. In addition, the registrydid not contain the length of residence for persons with diabetes,which would be valid to calculate cumulative arsenic exposure.This estimate helps researchers establish a dose–response pat-tern between arsenic exposure and diabetes prevalence (Lai et al.,1994; Rahman et al., 1998). Third, we could not obtain any bio-logical markers of arsenic exposure. Apart from urinary arsenic, anindicator of recent or short-term exposure, Mosaferi et al. (2005)proposed hair arsenic to be an indicator of chronic exposure.Arsenic levels in the hair were proportionate to plasma glucose,plasma lipids, and the prevalence of metabolic syndrome in Taiwan(Wang et al., 2007). Fourth, we did not control for other confound-ing factors, such as body mass index, nutrition, physical activity,occupation, stress, socioeconomic status, or life-style habits thatmay increase a risk of diabetes, or modify arsenic exposure. Anincreased risk for the development of diabetes was shown in coppersmelters with high arsenic exposure (Rahman and Axelson, 1995).Malnutrition was significantly related to arsenicosis in Bangladesh(Milton et al., 2004); but it may not be relevant for the populationin Serbia. Finally, we did not take into account the average dailyuse of water for drinking and cooking. It is possible that peopleexposed to arsenic sometimes drink bottled water instead of tapwater, but use tap water for food preparation. Drinking bottledwater may decrease arsenic exposure, but some cooking proce-dures may increase the amount of ingested arsenic (Rahman et al.,2006).

To authors’ knowledge, this is the first study reporting the asso-ciation between arsenic exposure to any health problem in Serbianpopulation. The strengths of this study were a large size of the inves-tigated population with diabetes, and analysis of drinking waterfrom both exposed and unexposed areas. Nevertheless, future stud-ies should determine time-weighted arsenic exposure of peoplewith diabetes in Middle Banat region, and assess the trend for dia-betes in relation to cumulative arsenic exposure. This approachwould help researchers verify the possibility that the associationbetween arsenic and type 2 diabetes is causal.

Conclusion

This cross-sectional study showed that population from MiddleBanat region in Serbia, exposed to low levels of arsenic in drinkingwater, was at higher risk for the occurrence of type 2 diabetes, in

comparison to the unexposed population from six regions in Cen-tral Serbia. These results support the hypothesis that exposure toarsenic in drinking water may play a role in the occurrence of type2 diabetes.

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