| Summary: | Background: The non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is an emerging composite lipid marker of atherosclerosis. However, its relationship with bone mineral density (BMD) remains unclear. This study aimed to investigate the association between NHHR and BMD at different skeletal sites. Methods: Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES, 1999–2018) were analyzed. Weighted multivariable linear regression models were used to assess the relationship between NHHR and BMD at various sites. Restricted cubic spline (RCS) analysis was applied to explore potential nonlinear associations. Threshold effect analysis, subgroup analyses, and interaction tests were also performed. Results: Weighted regression analyses revealed a consistent and significant positive association between NHHR and both femoral neck and total femur BMD in fully adjusted models. RCS analysis demonstrated a nonlinear, inverted U-shaped relationship between NHHR and BMD at these sites. Threshold effect analysis identified an inflection point at NHHR = 3.275 for femoral neck BMD and NHHR = 3.441 for total femur BMD. Subgroup analyses indicated that the relationship between NHHR and femur BMD was significantly modified by hyperlipidemia. Conclusions: NHHR may serve as a comprehensive biomarker for simultaneously assessing the impact of lipid levels on bone mass and the risk of cardiovascular disease.
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