Associations of lifestyle, nutrition, and mixed environmental exposures with bone mineral density in U.S. children and adolescents : A dual-cohort analysis from NHANES 2017–2018
- 1Department of Orthopedics and Joint Surgery, The First Affiliated Hospital of Jinan University, First Clinical Medical College of Jinan University, Guangzhou, Guangdong, China
- 2Department of Traumatic Orthopedics, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
- 3Department of Orthopedics, Chaoshan Hospital of The First Affiliated Hospital of Jinan University, Chaozhou, Guangdong, China.
Abstract
Peak bone mass accrual during childhood and adolescence is pivotal for lifelong skeletal health. While lifestyle and nutrition are well-established determinants, the combined osteotoxic impact of pervasive environmental heavy metal mixtures remains poorly understood, largely due to the limitations of traditional linear regressions in handling collinear co-exposures. Utilizing a dual-cohort design from National Health and Nutrition Examination Survey 2017 to 2018, a primary sample (N = 1973) was evaluated for broad lifestyle/nutritional factors. A stringent environmental sub-cohort (N = 1265) was established to assess the joint effects of heavy metals (Lead [Pb], cadmium, mercury). Traditional ordinary least squares regression, Weighted Quantile Sum regression, Bayesian Kernel Machine Regression and Random Forest modeling were deployed. In the primary cohort, physical activity and calcium intake were positively associated with total bone mineral density (BMD), whereas screen time and sugar-sweetened beverages showed inverse associations. In the environmental sub-cohort, traditional fully-adjusted ordinary least squares models exhibited “statistical masking,” artificially attenuating independent metal toxicities. However, stratified analyses revealed extreme skeletal vulnerability in adolescent females (13–19 years) to blood Pb (β = −0.020, P = .001). Crucially, weighted quantile sum regression and Bayesian kernel machine regression bypassed collinearity to unmask profound synergistic osteotoxicity, with Pb, cadmium, and mercury contributing equally (~33%) to bone mineral density decline. random forest models identified critical nonlinear toxicological thresholds at exceptionally low exposure levels. Traditional linear models tend to underestimate mixed environmental threats. Heavy metal mixtures exhibit synergistic cross-sectional associations with reduced bone mineral density, particularly in pubertal females. Comprehensive mitigation strategies targeting lifestyle, nutrition, and multi-metal exposures are imperative for pediatric health.
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BibTeX
@article{wang2026associations,
title = {{Associations of lifestyle, nutrition, and mixed environmental exposures with bone mineral density in U.S. children and adolescents : A dual-cohort analysis from NHANES 2017–2018}},
author = {Yifei Wang and Yali Xu and Jiaqing He and Tengfeng Zhuang and Zhengang Zha and Wenrui Wu},
journal = {Medicine},
year = {2026},
month = oct,
doi = {10.1097/md.0000000000051332},
url = {https://europepmc.org/article/PMC/PMC13727189},
note = {CC BY},
}
RIS
TY - JOUR
TI - Associations of lifestyle, nutrition, and mixed environmental exposures with bone mineral density in U.S. children and adolescents : A dual-cohort analysis from NHANES 2017–2018
AU - Yifei Wang
AU - Yali Xu
AU - Jiaqing He
AU - Tengfeng Zhuang
AU - Zhengang Zha
AU - Wenrui Wu
PY - 2026
DA - 2026/10/30
JO - Medicine
DO - 10.1097/md.0000000000051332
UR - https://europepmc.org/article/PMC/PMC13727189
AB - Peak bone mass accrual during childhood and adolescence is pivotal for lifelong skeletal health. While lifestyle and nutrition are well-established determinants, the combined osteotoxic impact of pervasive environmental heavy metal mixtures remains poorly understood, largely due to the limitations of traditional linear regressions in handling collinear co-exposures. Utilizing a dual-cohort design from National Health and Nutrition Examination Survey 2017 to 2018, a primary sample (N = 1973) was evaluated for broad lifestyle/nutritional factors. A stringent environmental sub-cohort (N = 1265) was established to assess the joint effects of heavy metals (Lead [Pb], cadmium, mercury). Traditional ordinary least squares regression, Weighted Quantile Sum regression, Bayesian Kernel Machine Regression and Random Forest modeling were deployed. In the primary cohort, physical activity and calcium intake were positively associated with total bone mineral density (BMD), whereas screen time and sugar-sweetened beverages showed inverse associations. In the environmental sub-cohort, traditional fully-adjusted ordinary least squares models exhibited “statistical masking,” artificially attenuating independent metal toxicities. However, stratified analyses revealed extreme skeletal vulnerability in adolescent females (13–19 years) to blood Pb (β = −0.020, P = .001). Crucially, weighted quantile sum regression and Bayesian kernel machine regression bypassed collinearity to unmask profound synergistic osteotoxicity, with Pb, cadmium, and mercury contributing equally (~33%) to bone mineral density decline. random forest models identified critical nonlinear toxicological thresholds at exceptionally low exposure levels. Traditional linear models tend to underestimate mixed environmental threats. Heavy metal mixtures exhibit synergistic cross-sectional associations with reduced bone mineral density, particularly in pubertal females. Comprehensive mitigation strategies targeting lifestyle, nutrition, and multi-metal exposures are imperative for pediatric health.
SN - 0304-5412
SN - 1536-5964
SN - 0025-7974
ER -