Association between anxiety disorder and osteoporosis risk: A population-based analysis using NHANES data

Osteoporosis is a common metabolic bone disease associated with increased fracture risk. Recently, its potential association with psychological conditions such as anxiety disorders has attracted growing attention. This study aimed to investigate the relationship between anxiety disorders and osteoporosis using National Health and Nutrition Examination Survey data and to develop a predictive model. A total of 2992 participants were included from 3 National Health and Nutrition Examination Survey cycles (1999-2004). Demographic and health-related information (such as age, sex, race, marital status, smoking, education, physical activity, and anxiety disorder symptoms) was collected. Osteoporosis status was assessed via self-reported questionnaires. Missing values were imputed using interpolation methods. Spearman correlation and multivariate logistic regression were applied to explore associated factors, and model performance was evaluated using receiver operating characteristic curves, calibration plots, and confusion matrices. Anxiety disorders were positively correlated with osteoporosis (R = 0.086, P < .001), while bone mineral density was negatively correlated (r = -0.474, P < .001). Individuals with mild anxiety disorder had a significantly higher risk of osteoporosis (odds ratios = 5.711, 95% confidence intervals: 3.827-8.520, P < .001). Other significant factors included age, sex, education level, marital status, race, and physical activity (all P < .001), whereas smoking status was not significantly associated. The predictive model demonstrated good performance, with an area under the curve of 0.87, accuracy of 82%, sensitivity of 83%, and F1 score of 82%. Anxiety disorder may be an important psychological risk factor for osteoporosis and should be considered in preventive strategies. The developed model shows good predictive capacity and may support early identification and personalized intervention for osteoporosis.