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Metals in urine in relation to the prevalence of pre-diabetes, diabetes and atherosclerosis in rural India
  1. Ganesan Velmurugan1,
  2. Krishnan Swaminathan1,2,
  3. Ganesh Veerasekar2,
  4. Jonathan Q Purnell3,
  5. Sundaresan Mohanraj2,
  6. Mani Dhivakar1,
  7. Anil Kumar Avula1,
  8. Mathew Cherian2,
  9. Nalla G Palaniswami2,
  10. Thomas Alexander3,
  11. Thalappil Pradeep1
  1. 1 Department of Chemistry, DST Unit of Nanoscience and Thematic Unit of Excellence in Water Research, Indian Institute of Technology Madras, Chennai, Tamil Nadu, India
  2. 2 KMCH Research Foundation, Kovai Medical Centre and Hospital, Coimbatore, Tamil Nadu, India
  3. 3 Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
  1. Correspondence to Dr Krishnan Swaminathan, KMCH Research Foundation, Kovai Medical Centre and Hospital, Coimbatore, TN 641 014, India; snehasswaminathan{at} and Thalappil Pradeep, Indian Institute of Technology Madras; pradeep{at}


Objective Diabetes and cardiovascular diseases are growing burdens in rural communities worldwide. We have observed a high prevalence of diabetes among rural farming communities in India and sought to evaluate the association of non-traditional risk factors, such as metals, with diabetes and other cardiometabolic risk factors in this community.

Methods Anthropometric measurements, chemistries and carotid intima-media thickness were determined in 865 participants of the Kovai Medical Center and Hospital-Nallampatti Non-Communicable Disease Study-I (KMCH-NNCD-I, 2015), a cross-sectional study conducted in a farming village in South India. Urinary metal levels were determined by inductively couped plasma-mass spectrometry analysis and corrected to urinary creatinine level. Statistical analyses were performed to study the association between urinary metal levels and clinical parameters.

Results 82.5% of the study population were involved in farming and high levels of toxic metals were detected in the synthetic fertilisers used in the study village. The prevalence of pre-diabetes, diabetes and atherosclerosis was 43.4%, 16.2% and 10.3%, respectively. On logistic regression analysis, no association of traditional risk factors such as body mass index, blood pressure and total cholesterol with disease conditions was observed, but urinary levels of metals such as arsenic, chromium, aluminium and zinc showed an association with diabetes, while arsenic and zinc showed an association with pre-diabetes and atherosclerosis.

Conclusions Our data suggest a probable role of metals in the aetiology of diabetes and cardiovascular diseases in rural communities. Identifying and eliminating the causes of increased levels of these environmental chemicals could have a beneficial impact on the burden of non-communicable diseases in rural population.

  • arsenic
  • atherosclerosis
  • cardiometabolic risk factors
  • diabetes
  • metals
  • pre-diabetes
  • rural health

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  • GV and KS contributed equally.

  • Contributors Conceived and designed the experiments: GVel, KS, GVee, MC, NGP, TA and TP. Involved in sample collection: GVel, KS, GVee and NGP. Performed the experiments: GVel, KS, SM, MD and AKA. Analysed the data: GVel, KS, GVee, JQP and TP. Contributed reagents/materials/analysis tools: KS, JQP, MC, NGP, TA and TP. Wrote the manuscript: GVel and KS. Revised the manuscript: JQP, SM, MD, AKA, GVee, MC, NGP, TA and TP.

  • Funding The work is funded by DST-Nano Mission, Government of India and KMCH Research Foundation, India.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The study design and protocol were approved by KMCH Ethics Committee, Kovai Medical Center and Hospital Limited, Coimbatore (approval no EC/AP/02/2015 dated 16 February 2015).

  • Provenance and peer review Not commissioned; externally peer reviewed.