Introduction: Whether environmental exposure to heavy metals is associated with long-term mortality in adults with diabetes remains controversial. We evaluated the associations of urinary metal levels (antimony [Sb], arsenic, barium, cadmium [Cd], cesium, cobalt [Co], lead [Pb], platinum [Pt], mercury, molybdenum, and uranium) with risk of all-cause, cardiovascular disease (CVD) , cancer, and diabetes related mortality in U.S. adults with diabetes in the U.S. National Health and Nutrition Examination Survey (NHANES) 1999-2014.

Methods: We conducted a prospective cohort analysis of 14,975 adults in NHANES 1999-2014 surveys followed up until end of 2014. We used Cox regression model to examine the hazard ratio (HR) of outcomes adjusted for potential risk factors at baseline. Urinary metal levels were creatinine-adjusted, and log 10-transformed to reduce skewness.

Results: Of 14,975 adults, 2,167 (14.5%) had diabetes at baseline. During a mean follow-up of 7 years, 475 (21.9%) died (113 CVD, 92 cancer, and 138 diabetes related mortality) . The age of the participants ranged from 20 to 85 years. Urinary Cd (HR=1.87, 95% CI: 1.29-2.71) , Pb (HR=1.55, 95% CI: 1.12-2.15) , Co (HR=1.65, 95% CI: 1.23-2.20) , Sb (HR=1.59, 95% CI: 1.18-2.14) , Pt (HR=1.40, 95% CI: 1.15-1.70) was associated with higher all-cause mortality. In cause-specific analysis, urinary Cd, Pb, and Pt level was associated with high cancer mortality. Urinary Cd, Co, Sb, and Pt was associated with diabetes related mortality, while Sb and Pt was associated with increased CVD related mortality.

Conclusion: Urinary Cd, Pb, Co, Sb, Pt levels was associated with all-cause mortality and cause-specific mortality in adults with diabetes. More studies on the association of toxic metals with death risk in people with diabetes are warranted.


J.Yang: None. K.Lo: None. J.Li: None. Y.Zhou: None. Q.Yang: None. A.Yang: None.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at