Publications and Research

Document Type


Publication Date

Spring 2-16-2023


Background: Turkish immigrants form the largest ethnic minority group in the

Netherlands and show a higher prevalence of (i) cardiovascular disease (CVD),

(ii) cigarette smoking, and (iii) type 2 diabetes (T2D) as compared to the native

Dutch. This study examines the association of CVD risk factors: serum cotinine, as

an indicator of cigarette smoke, and lipid-related indices among first-generation

(foreign-born) Turkish immigrants with T2D living in deprived neighbourhoods in the


Methods: A total of 110 participants, physician-diagnosed with T2D, aged 30 years

and older, were recruited by convenience sampling from the Schilderswijk

neighbourhood of The Hague in a clinic-based cross-sectional design. Serum

cotinine (independent variable) was measured with a solid-phase competitive

chemiluminescent immunoassay. Serum lipids/lipoproteins (dependent variables)

were determined by enzymatic assays and included: total cholesterol (CHOL), highdensity

lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c),

and triglycerides (TG). The Castelli Risk Index-I (CRI-I), and Atherogenic Coefficient

(AC) were calculated using standardised formulas and assessed as dependent

variables in multiple linear regression (MLR) models. Log-transformation of HDL-c,

TG, CRI-I, and AC values were performed to account for the extreme right skewness

of the data. Statistical analyses included descriptive characteristics and MLR models

were adjusted for all major confounders of cotinine and lipids.

Results: The sample size had a mean age of 52.5 years [standard deviation

(SD) = 9.21]. The geometric mean of serum cotinine level was 236.63 ng/mL

[confidence interval (CI) = 175.89 ± 318.36]. The MLR models indicated that high

serum cotinine levels (!10 ng/mL) was positively associated with HDL-c (P = 0.04),

CRI-I (P = 0.03), and AC (P = 0.03) in the age, gender, WC, diabetes medications, and

statins-adjusted models (n = 32).

Conclusion: This study indicated that lipid ratios of HDL-c, CRI-I and AC

are dependent determinants of serum cotinine and higher serum cotinine

levels (!10 ng/mL) are associated with worse HDL-c, CRI-I and AC values in

participants with T2D. Clinical comprehension of these biochemical indicators

(lipids/lipoproteins) and symptomatic results (CVD risk) in individuals with T2D

will aid in the intervention (smoking) approach for this vulnerable cohort (Turkish

immigrants). Therapy that is targetted to modify this behavioural risk factor may

improve cardiovascular health outcomes and prevent comorbidities in Turkish

immigrants with T2D living in deprived neighbourhoods in the Netherlands. In the

meantime, this report contributes to a growing body of information and provides

essential guidance to researchers and clinicians.



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