Healthy Eating Index-2020 and Trabecular Bone Score in US Adults: A Cross-Sectional Analysis of NHANES 2005-2008

Osteoporosis is a growing public health burden. Trabecular bone score (TBS) from dual-energy X-ray absorptiometry (DXA) reflects trabecular microarchitecture and predicts fractures beyond bone mineral density (BMD). The relationship between Healthy Eating Index 2020 (HEI-2020) and TBS is unknown.

We modeled the HEI-2020 in relation to TBS in a cross-sectional sample from the National Health and Nutrition Examination Survey (NHANES) 2005-2008 (n = 7,007), using multivariable linear regression, restricted cubic splines for nonlinearity, stratified and interaction analyses for effect modification, and mixture and clustering analyses.

Higher HEI-2020 scores were positively associated with TBS. Per 10-point increase: β = 0.0052 (95% CI 0.0026-0.0079). The highest versus lowest tertile had higher TBS (β = 0.0133, 95% CI 0.0063-0.0204; P for trend = 0.0242). The dose-response was linear. Associations were stronger in males and individuals with obesity, with significant interaction by sex (p = 0.0262) and body mass index (BMI; p < 0.0001). Mixture and clustering analyses supported positive dietary pattern effects, with the high-quality dietary cluster showing higher TBS (β = 0.0133, 95% CI 0.0053-0.0212). Sensitivity analyses confirmed robustness.

Higher HEI-2020 scores were linearly associated with higher TBS, with effect modification by sex and BMI. While these cross-sectional findings suggest better diet quality may benefit trabecular bone microarchitecture, longitudinal studies are needed to establish causality.