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Kathleen M. McCarty,¹ E. Andres Houseman,² Quazi Quamruzzaman,³ Mahmuder Rahman,³ Golam Mahiuddin,³ Thomas Smith,¹ Louise Ryan,² and David C. Christiani¹

¹Department of Environmental Health, and ²Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA; ³Dhaka Community Hospital, Dhaka, Bangladesh

Abstract
An established exposure-response relationship exists between water arsenic levels and skin lesions. Results of previous studies with limited historical exposure data, and laboratory animal studies suggest that diet may modify arsenic metabolism and toxicity. In this study, we evaluated the effect of diet on the risk of arsenic-related skin lesions in Pabna, Bangladesh. Six hundred cases and 600 controls loosely matched on age and sex were enrolled at Dhaka Community Hospital, Bangladesh, in 2001-2002. Diet, demographic data, and water samples were collected. Water samples were analyzed for arsenic using inductively coupled plasma mass spectroscopy. Betel nut use was associated with a greater risk of skin lesions in a multivariate model [odds ratio (OR) = 1.67 ; 95% confidence interval (CI) , 1.18-2.36]. Modest decreases in risk of skin lesions were associated with fruit intake 1-3 times/month (OR = 0.68 ; 95%CI, 0.51-0.89) and canned goods at least 1 time/month (OR = 0.41 ; 95% CI, 0.20-0.86) . Bean intake at least 1 time/day (OR = 1.89 ; 95% CI, 1.11-3.22) was associated with increased odds of skin lesions. Betel nut use appears to be associated with increased risk of developing skin lesions in Bangladesh. Increased intake of fruit and canned goods may be associated with reduced risk of lesions. Increased intake of beans may be associated with an increased risk of skin lesions. The results of this study do not provide clear support for a protective effect of vegetable and overall protein consumption against the development of skin lesions, but a modest benefit cannot be excluded. Key words: arsenic, Bangladesh, betel nut, case-control, diet. Environ Health Perspect 114:334-340 (2006) . doi:10.1289/ehp.7916 available via http://dx.doi.org/ [Online 29 September 2005]

Address correspondence to D.C. Christiani, Department of Environmental Health, Harvard School of Public Health, Building I 1408, 665 Huntington Ave., Boston, MA 02115 USA. Telephone: (617) 432-1260. Fax: (617) 432-3323. E-mail: dchristi@hsph.harvard.edu

We thank A. Ascherio, A. Smith, R. Wilson, and H. Ahsan for their expertise ; the Dhaka Community Hospital field team for subject recruitment, sample collection, and data entry ; J. Frelich for data management ; and L. Portier for programming assistance. We also thank L. Su and T. Van Geel (Harvard Molecular Epidemiology Laboratory) , L. Shimada, and U. Kirtani.

This work was supported by grants ES 05947, ES 00002, and ES 11622 from the National Institutes of Health. K.M.M. is supported by training grant T32ES 06790 from the National Institute of Environmental Health Sciences.

The authors declare they have no competing financial interests.

Received 10 January 2005 ; accepted 29 September 2005.

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The authors found several errors in the original manuscript published online:

• Figure 1A was incorrect ; it has been corrected here.
• Instead of being "loosely matched," cases and controls were frequency matched on age and sex.
• The authors would like to clarify that this study was designed not to investigate the main effects of arsenic exposure on skin lesion but to investigate modifiers of this relationship.
• In the "Results" and the "Discussion," respectively, the authors state that "There was a strong exposure-response relationship between arsenic level of tube-well water and skin lesions" and "the increased risk of skin lesions with increasing arsenic exposure remained statistically significant." However, they actually could not interpret the main effects of arsenic on skin lesions because of control selection, as shown by the sensitivity analysis (Figure 1) .