Lifestyle and Bone Health: Analyzing the Association Between LE8 Scores and BMD

doi:10.21203/rs.3.rs-4704887/v1

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Lifestyle and Bone Health: Analyzing the Association Between LE8 Scores and BMD

https://doi.org/10.21203/rs.3.rs-4704887/v1

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Purpose

This study aims to investigate the association between Life's Essential 8 scores(LE8) and bone mineral density(BMD) in adults aged 20–59 years.

Methods

This cross-sectional study utilized nationally representative data from NHANES 2011–2018. Weighted multiple linear regression models were used to explore the relationship between LE8 scores and different levels of cardiovascular health(CVH) with BMD. Additionally, subgroup analyses were conducted to examine the differences in the impact of LE8 scores on BMD across different age groups, genders, races, socioeconomic statuses, and BMI.

Results

A total of 2,159 participants were included in the study. After adjusting for all covariates, LE8 scores were significantly and positively linearly associated with lumbar spine BMD, thoracic spine BMD, trunk BMD, and total BMD (P < 0.05). Compared to the low CVH group, individuals in the medium and high CVH groups had higher BMD (P < 0.05). Subgroup analyses revealed that this relationship was more pronounced in the 20–35 age group and within the normal BMI range (P < 0.05). In females, thoracic spine BMD was more sensitive to changes in LE8 scores (P < 0.05).

Conclusion

This study reveals a positive linear relationship between LE8 and BMD. Higher LE8 scores are associated with greater BMD in adults aged 20–59 years, suggesting that lifestyle interventions can effectively prevent and treat OP.

cardiovascular health

Life's Essential 8

bone mineral density

NHANES

Osteoporosis

This study investigates the relationship between Life's Essential 8 (LE8) scores and bone mineral density (BMD) in adults aged 20-59 using NHANES 2011-2018 data. Weighted linear regression models reveal a significant positive correlation between LE8 scores and BMD in the lumbar spine, thoracic spine, trunk, and total body (P<0.05). Higher BMD is observed in individuals with medium and high cardiovascular health (CVH) compared to those with low CVH (P<0.05). The association is stronger in the 20-35 age group and normal BMI range, particularly affecting thoracic spine BMD in females. The findings suggest that lifestyle improvements reflected in higher LE8 scores may help prevent and treat OP.

Osteoporosis (OP) is a global health issue characterized by reduced bone mineral density (BMD), affecting a significant portion of the middle-aged and elderly population^[1]. According to the International OP Foundation, over 30% of women and 20% of men above the age of 50 worldwide are at risk of fractures due to decreased bone mass^[2]. The pathogenesis and etiology of OP are complex and associated with multiple risk factors^[3-5]. Recent studies have increasingly indicated that individuals with a history of cardiovascular disease (CVD) have an elevated risk of developing OP^[6]. Common risk factors such as obesity, hypertension, and metabolic syndrome are associated with both CVD and OP^[7-9], suggesting a potential physiological link between the two conditions.

In 2022, the American Heart Association (AHA) updated its quantitative assessment tool for cardiovascular health (CVH), known as Life's Essential 8 (LE8)^[10]. Multiple studies have confirmed that individuals with higher LE8 scores typically lead healthier lifestyles and have a significantly lower risk of CVD^[11]. Recent research has demonstrated the advantages of LE8 scores in reducing the risk of kidney stones, predicting stroke risk, and assessing arterial stiffness^[12-14]. However, the correlation between LE8 and BMD has not been thoroughly investigated. Some studies suggest that a healthy lifestyle can reduce inflammation and oxidative stress, potentially benefiting BMD^[15].Therefore, exploring the relationship between LE8 and BMD is of significant theoretical and practical importance. First, it can contribute to a more comprehensive understanding of the pathogenesis of OP. Second, for adults aged 20-59, improving LE8-related lifestyle and behavioral factors may offer new intervention strategies for the prevention and treatment of OP. This study aims to reveal the potential relationship between LE8 and BMD, thereby providing new perspectives and methods for the comprehensive treatment of OP.

1.1 Study population

The National Health and Nutrition Examination Survey (NHANES), supported by the National Center for Health Statistics (NCHS), is a cross-sectional study to evaluate the health and nutritional status of the civilian population in the United States^[16].All participants provided informed consent. This study utilized data from 39,156 participants collected between 2011 and 2018 to assess the correlation between LE8 scores and BMD.This study excluded 24,222 individuals aged below 20 or above 59 years;992 postmenopausal women;1,753 individuals with chronic diseases affecting bone metabolism, including 9 with cirrhosis, 1,003 with thyroid disorders, 165 with rheumatoid arthritis, and 576 with malignancies;270 individuals with a history of fractures, OP, or familial OP;9,201 individuals with missing data on LE8 scores or BMD.The final analytical sample comprised 2,159 participants aged between 20 and 59 years^[17] (Supplementary File: Figure S1).

1.2 Measurement of the LE8

The LE8 encompasses four health behaviors (diet, physical activity, nicotine exposure, and sleep duration) and four health factors (body mass index (BMI), non-high-density lipoprotein cholesterol, blood glucose, and blood pressure)^[18]. Dietary assessment was conducted using the Healthy Eating Index (HEI) 2015, based on 24-hour dietary recalls from participants. Data on physical activity, nicotine exposure, sleep duration, diabetes status, and medication history were collected via standardized questionnaires. Height and weight were measured during physical examinations and used to calculate BMI, defined as weight in kilograms divided by the square of height in meters. Laboratory data provided measurements for blood lipids and blood glucose. Blood pressure was measured in the Mobile Examination Center (MEC) after participants had been seated quietly for 5 minutes, with an average of three consecutive readings used for analysis. The detailed algorithms for calculating each LE8 component score have been previously published (Supplementary File: Table S1).

Each LE8 component is scored on a scale from 0 to 100, with the total LE8 score being the unweighted average of the eight component scores^[19]. According to the guidelines of the AHA, a high CVH score (80–100) indicates optimal CVH status with a significantly reduced risk of CVD. A moderate CVH score (50–79) suggests a moderate risk of CVD, highlighting the need for attention and improvement in health behaviors to prevent cardiovascular events. A low CVH score (0–49) reflects poor CVH status, associated with a high risk of CVD^[20].

1.3 Measurement of the BMD

In this study, all eligible individuals underwent dual-energy X-ray absorptiometry (DXA) measurements using the Hologic QDR 4500A fan-beam densitometer^[21]. DXA is internationally recognized as a crucial screening tool for assessing the risk of osteoporotic fractures. The measurements were performed by trained and certified radiologic technologists. Whole-body DXA scans provided BMD data for the head, lumbar spine, thoracic spine, trunk (including thoracic and lumbar vertebrae, bilateral ribs, and pelvis), and the entire body. These data were collected for the specified anatomical sites between 2011 and 2018.

1.4 Definition of covariates

In this study, covariates included multiple factors previously shown or hypothesized to be associated with CVH or BMD. Demographic data comprised age, gender, race, education level, and the poverty income ratio (PIR). Information on alcohol consumption was obtained from the dietary interview individual food file^[22].Alcohol consumption was categorized based on questionnaire responses into the following groups: 1–5 times per month, 5–10 times per month, more than 10 times per month, and never (defined as having never consumed 12 alcoholic drinks in a lifetime). Smoking history was obtained through questionnaires and categorized as never smokers (having smoked fewer than 100 cigarettes in their lifetime), former smokers (having smoked more than 100 cigarettes in their lifetime but not currently smoking), and current smokers (having smoked more than 100 cigarettes and currently smoking).Hypertension and diabetes histories were diagnosed based on clinical measurements, medication use, and self-reports. Hypertension was defined as an average systolic blood pressure ≥ 140 mm Hg, diastolic blood pressure ≥ 90 mm Hg, physician diagnosis, or the use of antihypertensive medication. Diabetes was defined as an HbA1c level ≥ 6.5%, fasting glucose level ≥ 7 mmol/L, physician diagnosis, or the use of diabetes medication or insulin.Laboratory data included measurements of vitamin D intake, total cholesterol, high-density lipoprotein cholesterol, fasting glucose, HbA1c, serum creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and serum calcium. All serological measurements were conducted in certified laboratories using standardized and validated analytical methods.

1.5 Statistical analysis

Due to the complex sampling design of NHANES, sample analyses were conducted using appropriate weights (WTMEC 2YR). The normality of the data distribution was assessed using the Shapiro-Wilk test. Continuous variables following a normal distribution were presented as mean ± standard deviation (x̄± s), and group comparisons were performed using analysis of variance (ANOVA ). For continuous variables not following a normal distribution, data were presented as medians and interquartile ranges (Q1-Q3), and group comparisons were conducted using the Kruskal-Wallis test. Categorical variables were expressed as the sample size (weighted percentages), with group comparisons analyzed using the Rao-Scott χ² test.The association between LE8 scores, different CVH groups, and BMD was examined using multivariable weighted linear regression analyses. Model 1 was unadjusted; Model 2 adjusted for age, gender, and race; Model 3 further adjusted for all covariates listed in Table 1. Additionally, subgroup analyses were performed to investigate the association between LE8 scores and BMD.All statistical analyses were conducted using R software (version 4.3.2) and EmpowerStats (version 4.1). All tests were two-sided, with P < 0.05 considered statistically significant.

2.1 Baseline characteristics

Table 1 presents the weighted baseline demographic characteristics of participants distributed across low, moderate, and high CVH (CVH) levels. The study included a total of 2,159 participants, with 52.15% being male, and the average age was 36.61 ± 10.95 years. The mean LE8 score was 68.98, with a standard deviation of 14.76. Among the participants, 212 (9.82%) were classified in the low CVH group, 1,385 (64.15%) in the moderate CVH group, and 562 (26.03%) in the high CVH group.Compared to the low CVH group, participants in the high CVH group were younger, predominantly female, non-Hispanic white, and had higher educational levels and socioeconomic status, with the majority never having smoked. Additionally, participants in the high CVH group exhibited significantly higher levels of ALT, AST, and high-density lipoprotein cholesterol within the normal range, while their BMI, total cholesterol, fasting glucose, and hemoglobin levels were significantly lower within the normal range. As CVH scores increased, both lumbar spine BMD and trunk BMD showed an upward trend. Furthermore, the proportion of individuals without hypertension and diabetes was significantly higher in the high CVH group (both P < 0.05).

Table 1 Baseline Characteristics of the study population

Variable	Total N=2159	LowCVH N=212	ModerateCVH N=1385	HighCVH N=562	pvalue
Age(years)	36.61(10.95)	42.57(10.25)	37.21(10.96)	32.88(9.83)	<0.001
Gender(%)					<0.001
male	1126(52.15)	128(60.37)	783(56.53)	215(38.26)
female	1033(47.85)	84(39.62)	602(43.46)	347(61.74)
Race/ethnicity(%)					<0.001
MexicanAmerican	324(15.00)	31(14.62)	223(16.10)	70(12.46)
Non-HispanicBlack	231(10.70)	20(9.43)	157(11.34)	54(9.61)
Non-HispanicWhite	751(34.79)	84(39.62)	467(33.72)	200(35.59)
OtherHispanic	433(20.06)	54(25.47)	310(22.38)	69(12.46)

Continued1

Variable	Total N=2159	LowCVH N=212	ModerateCVH N=1385	HighCVH N=562	pvalue
Other/multiracial	420(19.45)	23(10.85)	228(16.46)	169(30.07)
Educationlevel (%)					<0.001
Lessthanhighschool	347(16.07)	53(25.00)	257(18.56)	37(6.58)
Highschoolorequivalent	456(21.12)	69(32.55)	327(23.61)	60(10.68)
Abovehighschool	1356(62.81)	90(42.45)	801(57.83)	465(82.74)
PIR(%)	2.20(1.07,4.17)	1.44(0.90,3.02)	2.03(1.03,3.93)	3.00(1.31,4.96)	<0.001
BMI(kg/m2)	28.38(6.56)	33.87(7.71)	29.15(6.34)	24.41(3.92)	<0.001
Alcoholintake/day(g)	0.00(0.00,7.00)	0.00(0.0,11.33)	0.00(0.0,7.45)	0.00(0.0,6.19)	<0.001
Drinkingstatus(%)					<0.001
1-5drinks/month	1292(59.84)	150(70.75)	816(58.92)	326(58.01)
5-10drinks/month	145(6.72)	11(5.19)	89(6.43)	45(8.01)
10+drinks/month	291(9.31)	17(8.02)	139(10.04)	45(8.01)
Nondrinker	521(24.13)	34(16.04)	341(24.62)	146(25.98)
Smokingstatus(%)					<0.001
Currentsmoker	417(19.31)	124(58.49)	287(20.72)	6(1.07)
Formersmoker	347(16.07)	32(15.09)	250(18.05)	65(11.57)
Neversmoker	1395(64.61)	56(26.42)	848(61.23)	491(87.37)
Historyofhypertension(%)					<0.001
No	1575(72.95)	79(37.26)	968(69.89)	528(93.95)
Yes	584(27.05)	133(62.74)	417(30.11)	34(6.05)
Historyofdiabetes(%)					<0.001
No	1984(91.89)	155(73.11)	1269(91.63)	560(99.64)
Yes	175(8.11)	57(26.89)	116(8.38)	2(0.365)
VitaminDintake(mcg)	58.74(23.25)	54.11(22.96)	57.50(22.74)	63.52(23.87)	<0.001
TC(mmol/L)	4.83(0.99)	5.44(1.09)	4.89(0.99)	4.44(0.79)	<0.001
HDL-C(mmol/L)	1.36(0.37)	1.21(0.35)	1.33(0.35)	1.51(0.38)	<0.001

Continued1

PIR:Poverty Income Ratio ,TC:Total Cholesterol,HDL-C:High-Density Lipoprotein Cholesterol,ALT:Alanine Aminotransferase,,AST:Aspartate Aminotransferase,LE8:Life's Essential 8.

2.1 LE8 score and BMD

This study utilized weighted multivariate linear regression models to investigate the relationship between LE8 scores, various CVH groups, and BMD. In the fully adjusted model, LE8 scores were positively associated with lumbar spine BMD (β = 0.016, 95% CI: 0.009, 0.022, P < 0.001), thoracic spine BMD (β = 0.009, 95% CI: 0.004, 0.014, P < 0.001), trunk BMD (β = 0.013, 95% CI: 0.009, 0.018, P < 0.001), and total BMD (β = 0.010, 95% CI: 0.006, 0.015, P < 0.001). These significant associations remained evident across different CVH groups.

Specifically, compared to the low CVH group, the high CVH group showed increases of 0.042 g/cm² in lumbar spine BMD, 0.033 g/cm² in thoracic spine BMD, 0.046 g/cm² in trunk BMD, and 0.049 g/cm² in total BMD. The results from the smooth curve fitting further illustrated a linear positive correlation between LE8 scores and BMD at the lumbar spine, thoracic spine, trunk, and total body levels. Detailed findings are presented in Table 2 and Figure 1.

Table 2Weighted linear regression showing the relationship between LE8/CVH and BMD

	Model 1 β (95%CI) P 值	Model 2 β (95%CI) P 值	Model 3 β (95%CI) P 值
Head BMD
LE8 per 10 points increase	0.003(-0.008,0.013) 0.599	0.006(-0.004,0.016) 0.264	0.016(-0.001,0.032) 0.055
Low CVH	Reference	Reference	Reference
Moderate CVH	0.032(-0.023,0.084) 0.299	0.042(-0.003,0.091) 0.072	0.061(0.002,0.113) 0.050
High CVH	0.033(-0.031,0.093) 0.324	0.042(-0.014,0.101) 0.116	0.072(-0.004,0.141) 0.053
P for trend	0.451	0.247	0.127
Lumbar spine BMD
LE8 per 10 points increase	0.012(0.008,0.016) <0.001	0.015(0.010,0.019） <0.001	0.016(0.009，0.022） <0.001
Low CVH	Reference	Reference	Reference
Moderate CVH	0.032(0.015,0.053) 0.003	0.037(0.013,0.058) 0.002	0.037(0.006,0.052) 0.020
High CVH	0.053(0.036,0.088) <0.001	0.063(0.045,0.088) <0.001	0.042(0.022,0.074) 0.0032
P for trend	<0.001	<0.001	0.007
Thoracic spine BMD
LE8 per 10 points increase	0.008(-0.002,0.036) 0.289	-0.002(-0.005,0.001) 0.230	0.009(0.004,0.014) <0.001
Low CVH	Reference	Reference	Reference
Moderate CVH	0.013(-0.038,0030) 0.131	-0.006(-0.028,0.018) 0.654	0.029(0.004,0.035) 0.041
High CVH	0.035(-0.005,0.075) 0.262	-0.017(-0.028,0.012) 0.4462	0.033(0.014,0.056) 0.0049
P for trend	0.095	0.423	<0.001
Trunk BMD
LE8 per 10 points increase	0.003(0.001,0.006) 0.045	0.008(0.005,0.011) <0.001	0.013(0.009,0.018) <0.001

Continued2

	Model 1 β (95%CI) P 值	Model 2 β (95%CI) P 值	Model 3 β (95%CI) P 值
Low CVH	Reference	Reference	Reference
Moderate CVH	0.020(0.039,0.036) 0.0153	0.03(0.009,0.036) 0.0014	0.028(0.013,0.044) 0.004
High CVH	0.021(0.007,0.036) 0.0046	0.037(0.021,0.052) <0.001	0.046(0.026,0.067) <0.001
P for trend	<0.001	<0.001	<0.001
Total BMD
LE8 per 10 points increase	-0.001(-0.004,0.002) 0.704	0.006(0.003,0.009) <0.001	0.010(0.006,0.015) <0.001
Low CVH	Reference	Reference	Reference
Moderate CVH	0.023(0.004，0.032) 0.027	0.022(0.011,0.036) 0.003	0.032(0.013,0.042) 0.001
High CVH	0.012(-0.018,0.023) 0.354	0.033(0.016,0.042) <0.001	0.049(0.022,0.061) <0.001
P for trend	0.958	<0.001	<0.001

Model 1: Unadjusted.

Model 2: Adjusted for age, gender, and race/ethnicity.

Model 3: Adjusted for age, gender, race/ethnicity, education level, PIR, BMI, alcohol consumption (amount and frequency), smoking history, history of hypertension, history of diabetes, vitamin D intake, total cholesterol, HDL-C, fasting glucose, hemoglobin, ALT, AST, serum creatinine, and serum calcium.

2.3 Results of subgroup analysis

This study conducted subgroup analyses to evaluate the stability of the relationship between LE8 scores and BMD across different demographic backgrounds. After adjusting for all covariates, significant differences in the association between LE8 scores and BMD at four anatomical sites were observed across age and BMI groups (P < 0.05). Notably, individuals aged 20–34 years showed a significant increase in BMD compared to other age groups. For every 10 point increase in LE8 scores, lumbar spine BMD increased by 0.022 g/cm², thoracic spine BMD by 0.012 g/cm², trunk BMD by 0.017 g/cm², and total BMD by 0.013 g/cm² in the 20–34 year age group (P < 0.05).In the BMI subgroup analysis, individuals within the normal BMI range (18.5–24.9) exhibited a more pronounced increase in BMD compared to the other two BMI groups. For every 10 point increase in LE8 scores, lumbar spine BMD increased by 0.020 g/cm², thoracic spine BMD by 0.014 g/cm², trunk BMD by 0.021 g/cm², and total BMD by 0.018 g/cm² within the normal BMI range group (P < 0.05). Conversely, individuals in the underweight and overweight groups showed smaller increases in BMD (P < 0.05).Furthermore, the study found a significant increase in thoracic spine BMD among females (β = 0.011, 95% CI: 0.002, 0.019, P < 0.001), which was not observed in males (P > 0.05). This indicates that thoracic spine BMD in females is more sensitive to changes in LE8 scores compared to males. Table 3

Table 3

Subgroup analysis of the relationship between LE8 and BMD.
Subgroup	Lumbar spine BMD	P for interaction	Thoracic spine BMD	P for interaction	Trunk BMD	P for interaction	Total BMD	P for interaction
Age		0.0195		0.0252		0.0423		0.0478
20–34 years	0.022(0.012,0.032)		0.012(0.005,0.019)		0.017(0.010,0.024)		0.013(0.006,0.020)
35–49 years	0.014(0.004,0.025)		0.009(0.001,0.016)		0.014(0.007,0.021)		0.011(0.004,0.018)
50–59 years	0.002(0.001,0.007)		0.001(0.001,0.004)		0.001(0.002,0.004)		0.003(0.002,0.004)
Gender		0.1794		0.0108		0.8410		0.8688
Male	0.007(0.005,0.015)		0.001(0.001,0.007)		0.008(0.001,0.017)		0.006(0.001,0.014)
Female	0.011(0.001,0.019)		0.011(0.002,0.019)		0.009(0.001,0.017)		0.007(0.001,0.015)
Race/Ethnicity		0.5842		0.9186		0.9447		0.9152
Mexican American	0.013(-0.001,0.026)		0.008(-0.001,0.16)		0.009(0.001,0.018)		0.007(-0.001,0.015)
Other Hispanic	0.018(0.005,0.031)		0.004(-0.004,0.013)		0.011(0.002,0.021)		0.005(-0.004,0.015)
Non-Hispanic White	0.011(-0.004,0.018)		0.006(-0.003,0.014)		0.010(0.001,0.018)		0.008(-0.001,0.015)
Non-Hispanic Black	0.015(0.002,0.028)		0.008(-0.002,0.017)		0.012(0.004,0.021)		0.010(0.001,0.019)
Other Race	0.017(0.005,0.028)		0.009(-0.001,0.017)		0.009(0.001,0.017)		0.008(0.001,0.017)
Education Level		0.3430		0.2815		0.1663		0.1521
Less than High School	0.002(-0.010,0.034)		0.003(-0.005,0.012)		0.010(0.002,0.019)		0.001(-0.002,0.005)
High School	0.006(-0.011,0.022)		0.006(-0.001,0.003)		0.005(-0.007,0.011)		0.002(-0.010,0.005)
More than High School	0.004(-0.005,0.012)		0.006(-0.003,0.009)		0.006(-0.013,0.001)		0.004(-0.007,0.006)
BMI		0.0147		0.0003		0.0029		0.0017
Underweight (< 18.5)	0.013(-0.006,0.015)		0.013(-0.004,0.016)		0.005(-0.002,0.007)		0.003(-0.001,0.006)
Normal Range (18.5–24.9)	0.020(0.008,0.032)		0.014(0.006,0.023)		0.021(0.013,0.029)		0.018(0.010,0.026)
Overweight (≥ 25)	0.007(-0.001,0.014)		0.006(0.001,0.008)		0.005(-0.001,0.010)		0.001(-0.001,0.014)
PIR		0.1002		0.6755		0.2837		0.3776
< 1.3	0.020(0.008,0.032)		0.010(0.002,0.018)		0.013(0.009,0.021)		0.014(0.006,0.022)
1.3–3.5	0.019(0.008,0.030)		0.008(0.001,0.016)		0.007(0.001,0.013)		0.008(0.001,0.016)
> 3.5	0.004(-0.008,0.016)		0.005(-0.004,0.013)		0.005(-0.004,0.013)		0.006(-0.002,0.014)

This study identified a positive correlation between LE8 scores and BMD at the lumbar spine, thoracic spine, trunk, and total body sites. This is the first study to reveal the potential of LE8 scores in preventing BMD loss and OP^[23–28]. Previous research has shown that factors such as dietary structure, physical activity, smoking, and sleep quality are related to OP risk. For instance, a balanced diet^[29], adequate physical activity^[25], smoking cessation^[30], maintaining normal sleep^[31], and a normal BMI^[28] are considered protective against OP and effective in reducing its risk.Our study adds to the existing literature by integrating these risk factors and exploring the relationship between LE8 and BMD. The results demonstrate a significant positive correlation between LE8 scores and BMD, especially notable in the high CVH group, emphasizing the importance of LE8 scores in monitoring BMD and highlighting the potential positive impact of modifiable factors on BMD.

Additionally, the study underscores the need to consider demographic characteristics such as age, BMI, and gender when formulating public health strategies targeting bone health. It was found that the relationship between LE8 scores and BMD varies significantly across different age groups, BMI ranges, and genders. Young adults (aged 20–34) exhibited a more pronounced increase in BMD compared to other age groups, possibly due to more active bone metabolism, robust bone growth and repair capabilities, and stable hormone levels in this age group^[32–33]. Individuals within the normal BMI range (18.5–24.9) typically have better nutritional status and physical activity levels, which are beneficial for bone health. Studies indicate that these individuals are more likely to maintain adequate calcium and vitamin D intake, and moderate body weight exerts optimal pressure on bones, aiding in BMD maintenance^[34].Furthermore, the study observed a significant increase in thoracic spine BMD among females, potentially due to higher baseline thoracic BMD in males or differences in hormone levels, such as estrogen, which is known to significantly affect BMD in females^[35]. Estrogen levels can influence bone density, and healthy behaviors included in the LE8 score, such as physical activity and nutritional intake, may help maintain or increase estrogen levels, thereby enhancing BMD.The study did not find a significant relationship between LE8 scores and head BMD^[36]. This could be due to the unique nature of cranial bones in the skeletal system, where measurement methods and clinical significance differ from other sites. For example, cranial bone measurements can be influenced by hair and skin thickness, cranial shape, and density distribution, affecting measurement accuracy and statistical significance^[37]. Differences in BMD measurement techniques, such as DXA and ultrasound, also play a role. DXA advancements have improved spatial resolution for assessing bone microstructure and strength, but these improvements are mainly applied to the spine and hip, not the cranium^[38]. These factors might explain the lack of a significant relationship between LE8 scores and head BMD.

In conclusion, this study, using nationally representative data, provides comprehensive insights into the association between LE8 scores and BMD among U.S. adults, offering new perspectives on the use of LE8 scores in preventing OP. The findings also highlight the potential value of interdisciplinary collaboration, especially between endocrinologists and cardiologists, in identifying lifestyle and health behavior factors associated with increased CVD risk, allowing for comprehensive patient health assessments and interventions.However, the study has limitations. The cross-sectional design prevents establishing causality. Self-reported data may introduce bias. Although the study controlled for many potential confounders, it could not eliminate all possible confounding factors. Due to database limitations, hip BMD and femoral neck BMD data, collected only in 2017–2018, were not included due to the small sample size. Future research should explore the association between LE8 and BMD in these populations. Additionally, the exclusion of postmenopausal women means the findings may not apply to this important group. Future studies should expand sample sizes and include postmenopausal women to reveal differences across physiological stages.

This study found a linear positive correlation between LE8 and BMD in individuals aged 20 to 59 years, with higher BMD observed in the high CVH group. LE8 scores have the potential to serve as predictive indicators for the early diagnosis and prevention of OP. However, further longitudinal and cohort studies are needed to confirm these findings.

ALT: Alanine aminotransferase

AST: Aspartate aminotransferase

BMD: BMD

BMI: Body mass index

CI: Confidence interval

CVD: CVD

CVH: CVH

FBG: Fasting blood glucose

HB: Health behavior

HbA1c: Hemoglobin A1c

HDL-C: High-density lipoprotein cholesterol

HEI: Healthy Eating Index

HF: Health factor

LE8: Life’s Essential 8

NCHS: National Center for Health Statistics

NHANES: National Health and Nutrition Examination Survey

β: Beta

SD: Standard deviation

TC: Total cholesterol

Data availability statement

The analysis in this study utilized publicly available datasets, which are accessible at www.cdc.gov/nchs/nhanes/.

Ethics statement

The NCHS Ethics Review Board reviewed and approved this study. All patients/participants provided written informed consent to participate.

Author contributions

Y.Cui conceptualized the study. Z.Xu, Z.Cui, Y.Guo and W.Pei conducted data collection and analysis. Y.Cui, Z.Xu, and Z.Cui drafted the manuscript. X.Zhou, Y.Guo, and P.Wei provided critical revisions to the manuscript. All authors contributed to and approved the final version of the article.

Conflict of interest

The authors, Y. Cui, Z. Xu, Z. Cui, Y. Guo, P. Wu, S. Liu, S. Cao, and X. Zhou, confirm that the research was conducted without any commercial or financial relationships that could be perceived as potential conflicts of interest.

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No competing interests reported.

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Lifestyle and Bone Health: Analyzing the Association Between LE8 Scores and BMD

Status:

Version 1

Abstract

Figures

Mini Abstract

Introduction

1.1 Study population

1.2 Measurement of the LE8

1.3 Measurement of the BMD

1.4 Definition of covariates

1.5 Statistical analysis

Results

2.1 Baseline characteristics

2.1 LE8 score and BMD

2.3 Results of subgroup analysis

Discussion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1