Lower Calcium/Phosphorus Ratio is Associated with the Severity of Deformity in Patients with Scoliosis

Lower Calcium/Phosphorus Ratio is Associated with the Severity of Deformity in Patients with Scoliosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Lower Calcium/Phosphorus Ratio is Associated with the Severity of Deformity in Patients with Scoliosis Ruicong Li, Min Wang, Huiying Wang, Shifeng Wen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8748126/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Apr, 2026 Read the published version in European Spine Journal → Version 1 posted 7 You are reading this latest preprint version Abstract Objective To explore the association between the serum calcium/phosphorus Ratio and the severity of spinal deformity in scoliosis patients and its clinical significance. Methods Based on retrospective cohort data from 141 non-surgically treated scoliosis patients at Department of Spine Surgery at Guangzhou First People’s Hospital between 2019 and 2025, the Ca/P Ratio and spinal deformity severity were analyzed. Multivariable logistic regression, restricted cubic spline (RCS) analysis, and subgroup analyses were conducted to assess the independent association between the Ca/P Ratio and deformity severity. Adjustments were performed for confounders to improve the validity of the findings. Results Patients in the highest Ca/P Ratio quartile (Q4) exhibited significantly milder spinal deformity (P<0.001). Multivariable analysis demonstrated that each unit increase in the Ca/P Ratio was associated with a reduced risk of severe deformity (OR=0.24, 95% CI: 0.07-0.87, P=0.030). RCS analysis revealed a nonlinear association between the Ca/P Ratio and deformity severity (nonlinear P=0.0495). Subgroup analyses indicated that the protective effect was more pronounced in patients without hypertension/diabetes, males, those with lower BMI, or lower bone mineral density. Conclusion The serum Ca/P Ratio is an independent predictor of spinal deformity severity in scoliosis patients. Its imbalance may exacerbate spinal structural abnormalities by affecting bone metabolism, providing a novel target for metabolic interventions. Figures Figure 1 Figure 2 Figure 3 Figure 4 1 Introduction Scoliosis is defined as a lateral spinal curvature exceeding 10°[ 1 ]. It comprises a heterogeneous group of spinal deformities with diverse etiologies, including congenital anomalies, neuromuscular disorders, degenerative processes, and idiopathic forms[ 2 ]. Although adolescent idiopathic scoliosis (AIS) represents the largest subgroup, scoliosis also affects adults due to residual deformity from childhood or age-related degenerative changes. Across all forms, increasing curvature magnitude is measured by the Cobb angle. This magnitude correlates with mechanical instability, functional limitations, pain, and, in severe cases, cardiopulmonary compromise[ 3 ]. Identifying modifiable systemic factors that influence the progression of spinal deformity is critical for improving patient outcomes. Among systemic regulators of bone health, calcium (Ca) and phosphorus (P) are fundamental to bone matrix mineralization and vertebral strength[ 4 ]. In the bloodstream, the serum Ca/P ratio reflects the dynamic balance between intestinal absorption, renal excretion, and hormonal regulation mediated by parathyroid hormone (PTH), active vitamin D, and fibroblast growth factor-23 (FGF-23)[ 5 , 6 ]. Unlike static dietary intake, serum concentrations integrate both external supply and internal homeostatic adjustments. They provide a real-time physiological indicator of mineral status[ 7 ]. A low serum Ca/P ratio may arise from excessive renal phosphate retention, impaired calcium mobilization from bone, or dysregulated hormonal signaling[ 8 ]. It has been associated with reduced bone mineral density (BMD) and increased fracture risk in various populations[ 9 ]. Animal studies demonstrate that experimentally induced reductions in serum Ca/P ratio lead to decreased trabecular bone volume and compromised mechanical properties[ 10 ]. Human observational studies have linked low serum Ca/P ratios with diminished BMD in postmenopausal women and older men, as well as with elevated bone turnover markers[ 11 , 12 ]. However, whether alterations in serum Ca/P ratio influence spinal deformity severity in scoliosis patients remains unexplored. Unlike generalized osteopenia, scoliosis progression depends not only on overall BMD but also on localized vertebral competence under asymmetric loading[ 1 ]. If a persistently low serum Ca/P ratio weakens vertebral bone quality or reduces resistance to mechanical stress, it could facilitate curve progression. Previous investigations into scoliosis have frequently measured BMD in the lumbar spine and hip, with inconsistent findings. Some studies report reduced BMD in scoliosis patients compared with controls, particularly on the concave side of curves[ 13 ]. This finding suggests asymmetric bone remodeling driven by altered loading patterns. Others find no significant differences, attributing variations to confounding factors such as physical activity, muscle mass, or nutritional status. Importantly, few studies have evaluated serum Ca/P ratio as a potential biomarker of deformity severity. Given its ability to reflect integrated mineral metabolism and endocrine regulation, the serum Ca/P ratio may offer unique insight into the biological pathways linking systemic mineral status to spinal structural integrity. Large scale epidemiological data show that serum phosphate levels are influenced by dietary habits, renal function, and hormonal factors, while serum calcium is tightly regulated within a narrow range[ 14 , 15 ]. Nevertheless, interindividual variability in serum Ca/P ratio is substantial. Certain subgroups, including those with chronic kidney disease, vitamin D deficiency, or endocrine disorders, may exhibit ratios skewed toward lower values. In scoliosis patients, such imbalance could theoretically impair vertebral bone remodeling, especially during periods of rapid growth or hormonal fluctuation. If a low serum Ca/P ratio is indeed associated with weaker vertebral bone, then monitoring and correcting this parameter might represent a novel strategy to mitigate deformity progression. To examine this question, we conducted a retrospective analysis of scoliosis patients to investigate the association between serum Ca/P ratio and the severity of spinal deformity, quantified by Cobb angle. Unlike studies focused solely on dietary intake, our analysis utilized directly measured laboratory values obtained from clinical records. This approach captured the biologically active fraction of calcium and phosphorus available for bone metabolism. We hypothesized that a lower serum Ca/P ratio would be independently associated with greater Cobb angles, after adjusting for potential confounders such as age, sex, BMI, and renal function. This study investigates how systemic calcium and phosphorus balance, as reflected in serum measurements, relates to clinical measures of deformity severity in scoliosis patients. The findings may inform future risk stratification approaches and support the development of targeted metabolic interventions to preserve spinal bone quality alongside conventional treatments such as bracing, physiotherapy, and surgery. 2 Materials and methods 2.1 Study design and population This investigation employed a retrospective cohort design, utilizing the medical records of scoliosis patients treated at the Department of Spine Surgery, Guangzhou First People’s Hospital, from January 1, 2019, to December 31, 2025, all of whom did not receive surgical intervention. Ethical approval was granted by the Institutional Review Board (Ethics Committee) of the participating hospital, and the study was carried out and documented in full compliance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines[ 16 ]. Because the study relied solely on anonymized clinical data collected retrospectively, the ethics committee waived the requirement for written informed consent. The flowchart illustrates the application of rigorous inclusion and exclusion criteria. Inclusion criteria were as follows(Fig. 1 ). Patients were diagnosed with scoliosis, defined by a Cobb angle of ten degrees or greater on radiographic imaging. They also visited the Department of Spine Surgery at Guangzhou First People’s Hospital between January first, twenty nineteen, and December thirty first, twenty twenty five, and did not undergo surgical treatment. Exclusion criteria included the following. There was a history of spinal surgery, including instrumentation or fusion. Data for calcium and phosphorus were missing. Medical records contained obvious errors or inconsistent information that could not be resolved upon verification. Full length anteroposterior and lateral spine radiographs were not available, or the image quality was insufficient for reliable Cobb angle measurement. 2.2 Measurement of Cobb angle Cobb angle was measured on full‑length anteroposterior and lateral spine radiographs using a standardized protocol(Fig. 2 ). The selection of the upper and lower end vertebrae was performed by identifying the vertebrae most tilted at the superior and inferior ends of the primary curve. Lines were drawn along the superior endplate of the upper end vertebra and the inferior endplate of the lower end vertebra. Perpendicular lines were then constructed from each of these lines, and the angle formed at their intersection was recorded as the Cobb angle[ 17 ]. All measurements were performed by two independent observers experienced in spinal deformity assessment. And discrepancies were resolved by consensus review. 2.3 Data collection For the present study, the data were collected retrospectively. The dataset encompassed demographic and clinical characteristics, including sex, age, height, weight, body mass index (BMI), marital status, history of hypertension, history of diabetes, and educational level. In addition to the Cobb angle, calcium (Ca), and phosphorus (P), laboratory measurements were obtained, including urea (UREA), creatinine (CREA), glucose (GLU), uric acid (UA), cystatin C (CYC‑C), magnesium (Mg), alkaline phosphatase (ALP), total cholesterol (TC), triglycerides (TG), high‑density lipoprotein cholesterol (HDL‑C), low‑density lipoprotein cholesterol (LDL‑C), fasting blood glucose (FBG), and estimated glomerular filtration rate (eGFR). 2.4 Statistical analysis For continuous variables following a normal distribution, data are presented as mean ± standard deviation (SD), and intergroup comparisons were performed using the independent samples t-test. For non-normally distributed continuous variables, data are expressed as median and interquartile range, with group differences assessed using the Mann–Whitney U test. Categorical variables are reported as frequencies (percentages), and differences between groups were evaluated using the chi-square test or Fisher’s exact test, depending on data distribution and sample size. Patients were categorized into quartiles based on the Ca:P Ratio. To enhance the robustness of the findings, the Ca:P Ratio was analyzed both as a categorical and a continuous variable. Multivariable logistic regression models were constructed to evaluate the association between the Ca:P Ratio and the severity of spinal deformity, estimating odds ratios (OR) and corresponding 95% confidence intervals (95%CI). From a clinical specialty perspective, three logistic regression models were developed. Model 1 was unadjusted. Model 2 was adjusted for sex, age, marital status, history of diabetes, history of hypertension, education level, lumbar BMD, and BMI. Model 3 further adjusted for UREA, FBG, UA, CYC-C, Mg, ALP, TC, TG, HDL-C, LDL-C, and eGFR. Multicollinearity diagnostics revealed that the variance inflation factor (VIF) for all variables were below 5, except for CREA(Supplementary Table 1). Restricted cubic spline (RCS) logistic regression was additionally employed to explore potential nonlinear associations between the Ca:P Ratio and spinal deformity severity. Receiver operating characteristic (ROC) curves were plotted to assess the predictive value of the Ca:P Ratio for spinal deformity severity, with the area under the curve (AUC) used as a quantitative metric. Finally, subgroup analyses were conducted to examine result heterogeneity across strata defined by sex, age, marital status, education level, history of diabetes, history of hypertension, lumbar BMD (≤ 0.92 g/cm² vs. >0.92 g/cm²), and BMI. Interaction terms were also incorporated to evaluate the potential influence of effect modification among different factors on the study outcomes. Statistical analyses were performed using R software (version 4.5.0). Statistical significance was defined as a two‑sided P value of less than 0.05. 3 Results 3.1 Baseline characteristics of the patients Table 1 displays the characteristics of the study patients stratified by quartiles of the Ca:P Ratio. The final analysis included 141 patients with scoliosis. Significant differences were observed between the highest and lowest Ca:P Ratio quartiles across multiple indicators. Participants in the higher Ca:P Ratio group were older. In addition, the prevalence of hypertension and the proportion of married individuals were significantly higher in the high Ca:P Ratio group, whereas levels of CREA, eGFR, and Cobb angle were relatively lower in this group. Table 1 Baseline characteristics of the study patients Variables Total (n = 141) Q1 ≤ 2.22 (n = 35) 2.22<Q2 ≤ 2.48 (n = 35) 2.482.72 (n = 35) P Age, years, Mean ± SD 64.53 ± 20.52 49.64 ± 27.55 64.89 ± 16.60 71.97 ± 13.79 71.41 ± 12.96 <0.001 Height, cm, Mean ± SD 154.35 ± 14.60 150.34 ± 17.93 154.60 ± 7.15 158.14 ± 9.06 154.20 ± 19.71 0.166 Weight, kg, Mean ± SD 55.42 ± 15.23 53.85 ± 20.51 53.70 ± 8.97 57.64 ± 9.65 56.41 ± 18.60 0.635 Marital status, n(%) 0.007 Married 108 (76.60) 20 (57.14) 31 (88.57) 31 (86.11) 26 (74.29) Other 33 (23.40) 15 (42.86) 4 (11.43) 5 (13.89) 9 (25.71) Hypertension, n(%) 0.009 Yes 52 (36.88) 6 (17.14) 12 (34.29) 20 (55.56) 14 (40.00) No 89 (63.12) 29 (82.86) 23 (65.71) 16 (44.44) 21 (60.00) Diabetes, n(%) 0.695 Yes 19 (13.48) 3 (8.57) 4 (11.43) 6 (16.67) 6 (17.14) No 122 (86.52) 32 (91.43) 31 (88.57) 30 (83.33) 29 (82.86) Gender, n(%) 0.134 Male 34 (24.11) 6 (17.14) 5 (14.29) 11 (30.56) 12 (34.29) Female 107 (75.89) 29 (82.86) 30 (85.71) 25 (69.44) 23 (65.71) Education level, n(%) 0.987 Primary school or below 61 (43.26) 15 (42.86) 14 (40.00) 16 (44.44) 16 (45.71) Middle school 45 (31.91) 10 (28.57) 12 (34.29) 11 (30.56) 12 (34.29) High school or above 35 (24.82) 10 (28.57) 9 (25.71) 9 (25.00) 7 (20.00) Lumbar BMD, g/cm 2 , Mean ± SD 0.95 ± 0.25 0.92 ± 0.22 0.97 ± 0.24 1.01 ± 0.25 0.91 ± 0.27 0.255 BMI, kg/m 2 , Mean ± SD 29.01 ± 57.58 32.46 ± 63.33 22.43 ± 3.14 23.16 ± 3.98 38.15 ± 97.13 0.612 UREA, mg/dL, Mean ± SD 34.56 ± 11.82 33.81 ± 13.10 31.61 ± 8.65 35.57 ± 12.01 37.24 ± 12.76 0.223 CREA, mg/dL, Mean ± SD 0.76 ± 0.23 0.69 ± 0.20 0.72 ± 0.15 0.82 ± 0.28 0.83 ± 0.25 0.016 FBG, mg/dL, Mean ± SD 100.58 ± 27.66 94.80 ± 21.46 100.15 ± 27.26 100.28 ± 21.14 107.08 ± 37.53 0.326 UA mgdL, Mean ± SD 5.83 ± 1.78 5.92 ± 1.98 5.49 ± 1.47 6.02 ± 1.66 5.88 ± 1.97 0.610 CYC-C, mgdL, Mean ± SD 0.11 ± 0.25 0.17 ± 0.50 0.08 ± 0.02 0.10 ± 0.03 0.10 ± 0.04 0.463 ALP, U/L, Mean ± SD 88.35 ± 44.62 99.60 ± 53.49 82.80 ± 55.68 87.92 ± 36.88 83.11 ± 25.42 0.357 TG, mg/dL, Mean ± SD 121.57 ± 77.48 134.53 ± 104.27 118.23 ± 79.07 111.30 ± 49.10 122.50 ± 69.38 0.646 LDL-C, mg/dL, Mean ± SD 106.71 ± 34.63 108.42 ± 40.45 103.77 ± 31.03 107.70 ± 37.55 106.93 ± 29.59 0.948 eGFR, ml/min/1.73m 2 , Mean ± SD 92.24 ± 27.15 109.73 ± 34.63 91.46 ± 19.28 82.42 ± 19.76 85.64 ± 24.49 <0.001 Mg, mg/dL, M (Q₁, Q₃) 2.07 (1.97, 2.19) 2.14 (1.96,2.19) 2.11 (2.02,2.22) 2.05 (1.90,2.17) 2.02 (1.93,2.10) 0.099 TC, mg/dL, M (Q₁, Q₃) 176.72 (144.63,216.17) 167.05 (125.48,207.27) 180.20 (146.56,197.41) 178.27 (141.73,235.79) 179.43 (165.51,197.60) 0.373 HDL-C, mg/dL, M (Q₁, Q₃) 45.63 (37.90,53.36) 42.92 (34.22,50.08) 43.70 (37.90,55.30) 47.76 (40.22,53.56) 49.50 (38.48,54.52) 0.070 Cobb angle, Mean ± SD 20.11 o ± 12.42 o 28.00 o ± 17.05 o 17.40 o ± 9.69 o 19.41 o ± 8.65 o 15.65 o ± 9.01 o <0.001 SD: standard deviation, M: Median, Q₁: 1st Quartile, Q₃: 3st Quartile. Abbreciation: BMI, Body mass index; BMD, Bone mineral density; UREA, Urea; CREA, Creatinine; FPG, Fasting plasma glucose; UA, Uric acid; CYC-C, Cystatin C; Ca, Calcium; P, Phosphorus; Mg, Magnesium; ALP, Alkaline phosphatase; TC, Total cholesterol; TG, Triglycerides; HDL-C, High density lipoprotein cholesterol; LDL‑C, Low density lipoprotein cholesterol; FBG, Fasting blood glucose (); eGFR, estimated glomerular filtration rate. 3.2 Lower Calcium/Phosphorus Ratio is associated with the severity of deformity in scoliosis patients To investigate the relationship between serum Ca:P Ratio and spinal deformity severity, we built three multivariable logistic regression models (Table 2). In Model 1 (unadjusted), each unit increase in Ca:P Ratio yielded an OR of 0.29 (95% CI: 0.11–0.72, P = 0.007). Adjusting for demographic and clinical factors in Model 2 attenuated but preserved significance (OR = 0.33, 95% CI: 0.11–0.97, P = 0.044). Further inclusion of metabolic and renal markers in Model 3 maintained an independent inverse association (OR = 0.24, 95% CI: 0.07–0.87, P = 0.030). When stratified by quartiles, the highest Ca:P Ratio group (Q4) consistently showed reduced deformity severity versus Q1 across all models (OR = 0.22, 95% CI: 0.06–0.87, P = 0.031), whereas Q2 and Q3 did not differ significantly. These findings indicate that a higher serum Ca:P Ratio is independently linked to milder spinal deformities after comprehensive confounder adjustment. Table 2 Multivariable logistic regression for the correlation between Ca:P Ratio and the severity of deformity Variables Model 1 Model 2 Model 3 OR (95%CI) P OR (95%CI) P OR (95%CI) P Ca:P Ratio 0.29 (0.11 ~ 0.72) 0.007 0.33 (0.11 ~ 0.97) 0.044 0.24 (0.07 ~ 0.87) 0.030 Ca:P Ratio quartile Q1 1.00 (Reference) 1.00 (Reference) 1.00 (Reference) Q2 0.31 (0.11 ~ 0.82) 0.018 0.40 (0.13 ~ 1.22) 0.106 0.46 (0.12 ~ 1.70) 0.242 Q3 0.64 (0.24 ~ 1.70) 0.372 1.18 (0.36 ~ 3.89) 0.782 1.21 (0.31 ~ 4.72) 0.784 Q4 0.21 (0.08 ~ 0.58) 0.002 0.28 (0.09 ~ 0.93) 0.038 0.22 (0.06 ~ 0.87) 0.031 OR: Odds Ratio, CI: Confidence Interval Model 1: Crude Model 2: Adjust: Marital status, Hypertension, Diabetes, Gender, Education level, Age, Lumbar BMD, BMI Model 3: Adjust: Marital status, Hypertension, Diabetes, Gender, Education level, Age, Lumbar BMD, UREA, FBG, UA, CYC-C, Mg, ALP, TG, TC, HDL-C, LDL-C, eGFR, BMI 3.3 Restricted Cubic Splines analysis We performed restricted cubic spline (RCS) analysis to investigate the association between the Ca:P Ratio and the severity of spinal deformity, based on Model 3 (Figure 3). The results showed a significant overall association between the Ca:P Ratio and spinal deformity severity. The overall P value was 0.0105, confirming statistical significance. The nonlinear P value was 0.0495. This indicates that the relationship followed a nonlinear pattern. Figure 3 Nonlinear association between Ca:P Ratio and spinal deformity severity 3.5 Receiver Operating Characteristic curve The receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive performance of the Ca:P Ratio for the severity of spinal deformity (Figure 4). The results showed that the area under the curve (AUC) for the Ca:P Ratio was 0.618 (95%CI: 0.525–0.711). Figure 4 ROC curve for Ca:P Ratio predicting spinal deformity severity 3.6 The results of subgroup analysis In the subgroup analysis, the direction of the association between the Ca:P Ratio and the severity of spinal deformity was generally consistent across subgroups(Table 3). Notably, the protective association of the Ca:P Ratio defined as a higher ratio correlating with less severe deformities was statistically significant only in specific subgroups. These included patients without hypertension, without diabetes, males, those with junior high school education or lower, individuals aged ≤70 years, and participants with lumbar BMD ≤0.92 g/cm² or BMI ≤24 kg/m². No significant association was detected in any other subgroup analyzed. Although the significance patterns varied among different subgroups, all subgroup interaction tests yielded P values greater than 0.05. Table 3 Subgroup analysis of the association between Ca:P Ratio and spinal deformity severity Variables n (%) OR (95%CI) P P for interaction All patients 141 (100.00) 0.29 (0.11 ~ 0.72) 0.007 Marital status 0.619 Married 108 (76.60) 0.39 (0.11 ~ 1.32) 0.129 Other 33 (23.40) 0.23 (0.05 ~ 1.16) 0.075 Hypertension 0.100 Yes 52 (36.88) 0.98 (0.18 ~ 5.41) 0.984 No 89 (63.12) 0.17 (0.05 ~ 0.56) 0.004 Diabetes 0.139 Yes 19 (13.48) 1.30 (0.15 ~ 11.56) 0.813 No 122 (86.52) 0.22 (0.08 ~ 0.62) 0.004 Gender 0.059 Male 34 (24.11) 0.04 (0.01 ~ 0.61) 0.020 Female 107 (75.89) 0.48 (0.18 ~ 1.30) 0.150 Education level 0.285 Primary school or below 61 (43.26) 0.19 (0.04 ~ 0.89) 0.035 Middle school 45 (31.91) 0.17 (0.03 ~ 0.88) 0.035 High school or above 35 (24.82) 0.97 (0.17 ~ 5.67) 0.975 Age, years 0.326 ≤70 72 (51.06) 0.17 (0.04 ~ 0.65) 0.010 >70 69 (48.94) 0.48 (0.10 ~ 2.26) 0.350 Lumbar BMD, g/cm 2 0.826 ≤0.92 70 (49.65) 0.25 (0.07 ~ 0.88) 0.031 >0.92 71 (50.35) 0.31 (0.08 ~ 1.23) 0.096 BMI, kg/m 2 0.508 ≤24 92 (65.25) 0.24 (0.08 ~ 0.71) 0.010 >24 49 (34.75) 0.48 (0.08 ~ 2.90) 0.427 OR: Odds Ratio, CI: Confidence Interval 4 Discussion The present retrospective cohort study systematically explored the association between serum Ca/P Ratio and the severity of spinal deformity in 141 scoliosis patients. The core findings revealed that a lower serum Ca/P Ratio was independently associated with more severe spinal curvature. After adjusting for demographic, clinical, metabolic, and renal confounders, each unit increase in Ca/P Ratio was linked to a reduced risk of severe deformity (OR = 0.24, 95%CI: 0.07–0.87, P = 0.030). And patients in the highest Ca/P Ratio quartile (Q4) exhibited significantly milder deformity compared with the lowest quartile (Q1). Restricted cubic spline analysis confirmed a nonlinear relationship between Ca/P ratio and deformity severity, while subgroup analysis identified specific populations where this association was most pronounced. These findings deepen the understanding of metabolic mechanisms underlying scoliosis progression by linking systemic mineral balance to spinal structural stability. Unlike isolated calcium or phosphorus levels, the serum Ca/P Ratio integrates the synergistic regulation of PTH, FGF-23, and vitamin D, offering a more holistic reflection of bone metabolic status[ 18 ]. Our restricted cubic spline analysis (nonlinear P = 0.0495) further uncovered that the Ca/P ratio exerts a non-proportional effect on deformity severity. This pattern implies that there may be a threshold range where mineral imbalance triggers more pronounced vertebral structural impairment. Animal studies have shown that disrupted Ca/P balance alters osteoblast-osteoclast activity, leading to uneven bone remodeling[ 19 ]. In scoliosis., this imbalance may amplify the asymmetric bone loss induced by abnormal spinal loading, thereby accelerating curve progression[ 20 ]. This mechanism explains why the Ca/P Ratio provides more predictive value for deformity severity than static BMD measurements. Notably, our study extends beyond previous research by clarifying the population-specific relevance of Ca/P Ratio in scoliosis. While prior studies have inconsistently linked BMD to scoliosis, few have explored mineral balance as a modifiable factor, and none have systematically analyzed subgroup differences[ 20 , 21 ]. Our subgroup results showed that the protective effect of higher Ca/P Ratio was most prominent in patients without hypertension/diabetes, males, those with lower education, aged ≤ 70 years, and with lumbar BMD ≤ 0.92 g/cm² or BMI ≤ 24 kg/m². This heterogeneity may be attributed to the following. Patients without chronic comorbidities have fewer metabolic disturbances, making the impact of Ca/P imbalance more salient[ 22 ]. Younger patients (≤ 70 years) still retain some bone remodeling capacity, so mineral imbalance exerts a more direct effect on vertebral quality[ 23 ]. And individuals with lower BMD or normal BMI lack the "buffering" effect of adequate bone mass or adipose tissue-related hormone regulation, rendering them more susceptible to mineral metabolism disorders[ 24 ]. These findings highlight the need for stratified monitoring of Ca/P Ratio in high risk subgroups. Clinically, our findings offer a novel metabolic intervention target for scoliosis management. Current strategies for mild-to-moderate scoliosis rely heavily on bracing and rehabilitation, with limited metabolic interventions. The independent association between Ca/P Ratio and deformity severity suggests that monitoring and optimizing serum Ca/P balance could complement conventional treatments, particularly in high risk subgroups. For example, nutritional counseling to adjust calcium and phosphorus intake or vitamin D supplementation to enhance mineral absorption may help mitigate curve progression, providing a noninvasive adjunct to standard care. This study has several limitations. First, the retrospective design and single center sample (141 patients) may introduce selection bias and limit generalizability to other populations. Second, unmeasured confounders such as vitamin D levels, physical activity, and dietary habits could not be fully adjusted for, potentially affecting result validity. Third, serum Ca/P ratio was measured at a single time point, failing to capture dynamic changes over time and their impact on deformity progression. 5 Conclusion Serum Ca/P Ratio is independently and negatively associated with the severity of spinal deformity in scoliosis patients. This association shows a nonlinear relationship and has population specific effects. Maintaining an optimal serum Ca/P balance may contribute to mitigating deformity progression, especially in high risk subgroups. Declarations Author Contribution ContributionsLRC&WM: Data curation, Formal analysis, Methodology, Software, Visualization, Writing, original draft, Writing – review & editing. WHY: Conceptualization, Resources, Visualization, Writing, original draft. WSF: Conceptualization, Methodology, Supervision, Validation, Visualization, Writing – review & editing. References Yu P, Tang Z, Chang W, Jia L, Ma Z, Li H, et al. Degenerative scoliosis may trigger higher incidence of adjacent vertebral fractures following percutaneous vertebroplasty: a clinical evidence-based biomechanical research. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2025. Petrosyan E, Fares J, Lesniak MS, Koski TR, El Tecle NE. Biological principles of adult degenerative scoliosis. Trends in molecular medicine. 2023;29(9):740-52. 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Goodman WG, Ward DT, Martin KJ, Drayer D, Moore C, Xu J, et al. Activation of the Calcium Receptor by Calcimimetic Agents Is Preserved Despite Modest Attenuating Effects of Hyperphosphatemia. Journal of the American Society of Nephrology : JASN. 2022;33(1):201-12. Shroff R, Lalayiannis AD, Fewtrell M, Schmitt CP, Bayazit A, Askiti V, et al. Naturally occurring stable calcium isotope ratios are a novel biomarker of bone calcium balance in chronic kidney disease. Kidney international. 2022;102(3):613-23. Hariri H, Kose O, Bezdjian A, Daniel SJ, St-Arnaud R. USP53 Regulates Bone Homeostasis by Controlling Rankl Expression in Osteoblasts and Bone Marrow Adipocytes. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2023;38(4):578-96. Uehara A, Mok Y, Matsushita K, Lutsey PL, Ishigami J. Serum Sodium, Potassium, Magnesium, Calcium, and Phosphorus Levels and Risk of Fracture in the Community. The Journal of clinical endocrinology and metabolism. 2025;110(11):e3818-e26. Eastell R, Brown JP, Adler RA, Lewiecki EM, Binkley N, Orwoll ES, et al. Bone turnover markers predict changes in bone mineral density in men treated with abaloparatide: results from the abaloparatide for the treatment of men with osteoporosis (ATOM) study. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2025;40(3):315-22. Shibata T, Takeda K, Suzuki S, Iga T, Okubo T, Ozaki M, et al. Lower Bone Mineral Density is Associated with Severity of Deformity in Adolescent Idiopathic Scoliosis. Spine. 2025. Zechner C, Adams-Huet B, Gregory B, Neyra JA, Rule JA, Li X, et al. Hypophosphatemia in acute liver failure of a broad range of etiologies is associated with phosphaturia without kidney damage or phosphatonin elevation. Translational research : the journal of laboratory and clinical medicine. 2021;238:1-11. Khan S, Khan AA. Hypoparathyroidism: diagnosis, management and emerging therapies. Nature reviews Endocrinology. 2025;21(6):360-74. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Annals of internal medicine. 2007;147(8):573-7. Zhang K, Xu N, Guo C, Wu J. MPF-net: An effective framework for automated cobb angle estimation. Medical image analysis. 2022;75:102277. Shah FA. Revisiting the physical and chemical nature of the mineral component of bone. Acta biomaterialia. 2025;196:1-16. Jia M, Luo J, Gao B, Huangfu Y, Bao Y, Li D, et al. Preparation of synbiotic milk powder and its effect on calcium absorption and the bone microstructure in calcium deficient mice. Food & function. 2023;14(7):3092-106. Yang KG, Lee WY, Hung AL, Kumar A, Chui EC, Hung VW, et al. Distinguishing risk of curve progression in adolescent idiopathic scoliosis with bone microarchitecture phenotyping: a 6-year longitudinal study. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2024;39(7):956-66. Wang FM, Ruby JG, Sethi A, Veras MA, Telis N, Melamud E. Characterizing aging-related genetic and physiological determinants of spinal curvature. Communications medicine. 2025;5(1):291. Zeng H, Ge J, Xu W, Ma H, Chen L, Xia M, et al. Type 2 Diabetes Is Causally Associated With Reduced Serum Osteocalcin: A Genomewide Association and Mendelian Randomization Study. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2021;36(9):1694-707. Liu Y, Le S, Liu Y, Jiang H, Ruan B, Huang Y, et al. The effect of calcium supplementation in people under 35 years old: A systematic review and meta-analysis of randomized controlled trials. eLife. 2022;11. The global, regional, and national burden attributable to low bone mineral density, 1990-2020: an analysis of a modifiable risk factor from the Global Burden of Disease Study 2021. The Lancet Rheumatology. 2025;7(12):e873-e94. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Published Journal Publication published 20 Apr, 2026 Read the published version in European Spine Journal → Version 1 posted Editorial decision: Revision requested 29 Mar, 2026 Reviews received at journal 23 Feb, 2026 Reviewers agreed at journal 10 Feb, 2026 Reviewers invited by journal 03 Feb, 2026 Editor assigned by journal 02 Feb, 2026 Submission checks completed at journal 02 Feb, 2026 First submitted to journal 31 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8748126","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":585337040,"identity":"675f88d1-77ad-41a4-86d3-e921d3f8f025","order_by":0,"name":"Ruicong Li","email":"","orcid":"","institution":"Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ruicong","middleName":"","lastName":"Li","suffix":""},{"id":585337045,"identity":"36c0aade-40f6-4516-9181-be1f1ae05487","order_by":1,"name":"Min Wang","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Wang","suffix":""},{"id":585337050,"identity":"16440b9e-f67c-486e-9601-b713d38d86b5","order_by":2,"name":"Huiying Wang","email":"","orcid":"","institution":"Guangzhou United Family Hospital","correspondingAuthor":false,"prefix":"","firstName":"Huiying","middleName":"","lastName":"Wang","suffix":""},{"id":585337053,"identity":"accd4955-96bf-4e60-a413-bc56890edb5c","order_by":3,"name":"Shifeng Wen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYBACfv7G9h8JFRJy8kRrkZxx+IDEgzMWxoYNxGoxOJCWIPmwrSKR4QDxWs4YGCTOk0hgbGB++OgGUQ473GOQkLhNIo+dgc3YOIcYLXxAWw4AtRQzNvCwSROlheFAjmFD4hyJxIYDxGoROJCWzJDYQIoWYCAfY0g4JmFs2EysX4BR2cb4o6ZOTp69+eFj4vwCB8ykKR8Fo2AUjIJRgA8AAIwYMtyUCbYvAAAAAElFTkSuQmCC","orcid":"","institution":"Guangzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Shifeng","middleName":"","lastName":"Wen","suffix":""}],"badges":[],"createdAt":"2026-01-31 08:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8748126/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8748126/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00586-026-09933-x","type":"published","date":"2026-04-20T15:57:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101941177,"identity":"8be85995-bfd7-4c06-ba00-f814f543ea47","added_by":"auto","created_at":"2026-02-05 09:19:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":171106,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow chart of study patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8748126/v1/12c23b2cbb38d69d96f15d91.png"},{"id":101943717,"identity":"443a828b-76c0-4cf8-b28e-e9185a25e509","added_by":"auto","created_at":"2026-02-05 09:42:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":253817,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic diagram of Cobb angle measurement\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8748126/v1/cc81feb4b81a9128bf83f20e.png"},{"id":101943576,"identity":"1d498c05-1200-451f-b698-a42d9208cbfc","added_by":"auto","created_at":"2026-02-05 09:42:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":36531,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNonlinear association between Ca:P Ratio and spinal deformity severity\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8748126/v1/958d81f49adba10fca74471f.png"},{"id":101941180,"identity":"30d770dd-5dde-4d0c-9383-aaf7e359b271","added_by":"auto","created_at":"2026-02-05 09:19:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":35692,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curve for Ca:P Ratio predicting spinal deformity severity\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8748126/v1/a9d8a31b41705dc537da3efb.png"},{"id":107927797,"identity":"1b36b4c2-f83d-4b0b-8c03-c4d8306a6279","added_by":"auto","created_at":"2026-04-27 16:04:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":947440,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8748126/v1/a1e1c349-8653-4a9e-bb72-4d6501d9eb3b.pdf"},{"id":101941181,"identity":"7426b975-8bc9-448d-b8e4-8330ce375d67","added_by":"auto","created_at":"2026-02-05 09:19:54","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17644,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-8748126/v1/f0d752d61c83e90a0e7aaf31.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lower Calcium/Phosphorus Ratio is Associated with the Severity of Deformity in Patients with Scoliosis","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eScoliosis is defined as a lateral spinal curvature exceeding 10\u0026deg;[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It comprises a heterogeneous group of spinal deformities with diverse etiologies, including congenital anomalies, neuromuscular disorders, degenerative processes, and idiopathic forms[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although adolescent idiopathic scoliosis (AIS) represents the largest subgroup, scoliosis also affects adults due to residual deformity from childhood or age-related degenerative changes. Across all forms, increasing curvature magnitude is measured by the Cobb angle. This magnitude correlates with mechanical instability, functional limitations, pain, and, in severe cases, cardiopulmonary compromise[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Identifying modifiable systemic factors that influence the progression of spinal deformity is critical for improving patient outcomes.\u003c/p\u003e \u003cp\u003eAmong systemic regulators of bone health, calcium (Ca) and phosphorus (P) are fundamental to bone matrix mineralization and vertebral strength[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the bloodstream, the serum Ca/P ratio reflects the dynamic balance between intestinal absorption, renal excretion, and hormonal regulation mediated by parathyroid hormone (PTH), active vitamin D, and fibroblast growth factor-23 (FGF-23)[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Unlike static dietary intake, serum concentrations integrate both external supply and internal homeostatic adjustments. They provide a real-time physiological indicator of mineral status[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A low serum Ca/P ratio may arise from excessive renal phosphate retention, impaired calcium mobilization from bone, or dysregulated hormonal signaling[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It has been associated with reduced bone mineral density (BMD) and increased fracture risk in various populations[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnimal studies demonstrate that experimentally induced reductions in serum Ca/P ratio lead to decreased trabecular bone volume and compromised mechanical properties[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Human observational studies have linked low serum Ca/P ratios with diminished BMD in postmenopausal women and older men, as well as with elevated bone turnover markers[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, whether alterations in serum Ca/P ratio influence spinal deformity severity in scoliosis patients remains unexplored. Unlike generalized osteopenia, scoliosis progression depends not only on overall BMD but also on localized vertebral competence under asymmetric loading[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. If a persistently low serum Ca/P ratio weakens vertebral bone quality or reduces resistance to mechanical stress, it could facilitate curve progression.\u003c/p\u003e \u003cp\u003ePrevious investigations into scoliosis have frequently measured BMD in the lumbar spine and hip, with inconsistent findings. Some studies report reduced BMD in scoliosis patients compared with controls, particularly on the concave side of curves[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This finding suggests asymmetric bone remodeling driven by altered loading patterns. Others find no significant differences, attributing variations to confounding factors such as physical activity, muscle mass, or nutritional status. Importantly, few studies have evaluated serum Ca/P ratio as a potential biomarker of deformity severity. Given its ability to reflect integrated mineral metabolism and endocrine regulation, the serum Ca/P ratio may offer unique insight into the biological pathways linking systemic mineral status to spinal structural integrity.\u003c/p\u003e \u003cp\u003eLarge scale epidemiological data show that serum phosphate levels are influenced by dietary habits, renal function, and hormonal factors, while serum calcium is tightly regulated within a narrow range[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Nevertheless, interindividual variability in serum Ca/P ratio is substantial. Certain subgroups, including those with chronic kidney disease, vitamin D deficiency, or endocrine disorders, may exhibit ratios skewed toward lower values. In scoliosis patients, such imbalance could theoretically impair vertebral bone remodeling, especially during periods of rapid growth or hormonal fluctuation. If a low serum Ca/P ratio is indeed associated with weaker vertebral bone, then monitoring and correcting this parameter might represent a novel strategy to mitigate deformity progression.\u003c/p\u003e \u003cp\u003eTo examine this question, we conducted a retrospective analysis of scoliosis patients to investigate the association between serum Ca/P ratio and the severity of spinal deformity, quantified by Cobb angle. Unlike studies focused solely on dietary intake, our analysis utilized directly measured laboratory values obtained from clinical records. This approach captured the biologically active fraction of calcium and phosphorus available for bone metabolism. We hypothesized that a lower serum Ca/P ratio would be independently associated with greater Cobb angles, after adjusting for potential confounders such as age, sex, BMI, and renal function.\u003c/p\u003e \u003cp\u003eThis study investigates how systemic calcium and phosphorus balance, as reflected in serum measurements, relates to clinical measures of deformity severity in scoliosis patients. The findings may inform future risk stratification approaches and support the development of targeted metabolic interventions to preserve spinal bone quality alongside conventional treatments such as bracing, physiotherapy, and surgery.\u003c/p\u003e"},{"header":"2 Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design and population\u003c/h2\u003e \u003cp\u003eThis investigation employed a retrospective cohort design, utilizing the medical records of scoliosis patients treated at the Department of Spine Surgery, Guangzhou First People\u0026rsquo;s Hospital, from January 1, 2019, to December 31, 2025, all of whom did not receive surgical intervention. Ethical approval was granted by the Institutional Review Board (Ethics Committee) of the participating hospital, and the study was carried out and documented in full compliance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Because the study relied solely on anonymized clinical data collected retrospectively, the ethics committee waived the requirement for written informed consent. The flowchart illustrates the application of rigorous inclusion and exclusion criteria. Inclusion criteria were as follows(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients were diagnosed with scoliosis, defined by a Cobb angle of ten degrees or greater on radiographic imaging. They also visited the Department of Spine Surgery at Guangzhou First People\u0026rsquo;s Hospital between January first, twenty nineteen, and December thirty first, twenty twenty five, and did not undergo surgical treatment. Exclusion criteria included the following. There was a history of spinal surgery, including instrumentation or fusion. Data for calcium and phosphorus were missing. Medical records contained obvious errors or inconsistent information that could not be resolved upon verification. Full length anteroposterior and lateral spine radiographs were not available, or the image quality was insufficient for reliable Cobb angle measurement.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measurement of Cobb angle\u003c/h2\u003e \u003cp\u003eCobb angle was measured on full‑length anteroposterior and lateral spine radiographs using a standardized protocol(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The selection of the upper and lower end vertebrae was performed by identifying the vertebrae most tilted at the superior and inferior ends of the primary curve. Lines were drawn along the superior endplate of the upper end vertebra and the inferior endplate of the lower end vertebra. Perpendicular lines were then constructed from each of these lines, and the angle formed at their intersection was recorded as the Cobb angle[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. All measurements were performed by two independent observers experienced in spinal deformity assessment. And discrepancies were resolved by consensus review.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection\u003c/h2\u003e \u003cp\u003eFor the present study, the data were collected retrospectively. The dataset encompassed demographic and clinical characteristics, including sex, age, height, weight, body mass index (BMI), marital status, history of hypertension, history of diabetes, and educational level. In addition to the Cobb angle, calcium (Ca), and phosphorus (P), laboratory measurements were obtained, including urea (UREA), creatinine (CREA), glucose (GLU), uric acid (UA), cystatin C (CYC‑C), magnesium (Mg), alkaline phosphatase (ALP), total cholesterol (TC), triglycerides (TG), high‑density lipoprotein cholesterol (HDL‑C), low‑density lipoprotein cholesterol (LDL‑C), fasting blood glucose (FBG), and estimated glomerular filtration rate (eGFR).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analysis\u003c/h2\u003e \u003cp\u003eFor continuous variables following a normal distribution, data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), and intergroup comparisons were performed using the independent samples t-test. For non-normally distributed continuous variables, data are expressed as median and interquartile range, with group differences assessed using the Mann\u0026ndash;Whitney U test. Categorical variables are reported as frequencies (percentages), and differences between groups were evaluated using the chi-square test or Fisher\u0026rsquo;s exact test, depending on data distribution and sample size. Patients were categorized into quartiles based on the Ca:P Ratio. To enhance the robustness of the findings, the Ca:P Ratio was analyzed both as a categorical and a continuous variable. Multivariable logistic regression models were constructed to evaluate the association between the Ca:P Ratio and the severity of spinal deformity, estimating odds ratios (OR) and corresponding 95% confidence intervals (95%CI). From a clinical specialty perspective, three logistic regression models were developed. Model 1 was unadjusted. Model 2 was adjusted for sex, age, marital status, history of diabetes, history of hypertension, education level, lumbar BMD, and BMI. Model 3 further adjusted for UREA, FBG, UA, CYC-C, Mg, ALP, TC, TG, HDL-C, LDL-C, and eGFR. Multicollinearity diagnostics revealed that the variance inflation factor (VIF) for all variables were below 5, except for CREA(Supplementary Table\u0026nbsp;1). Restricted cubic spline (RCS) logistic regression was additionally employed to explore potential nonlinear associations between the Ca:P Ratio and spinal deformity severity. Receiver operating characteristic (ROC) curves were plotted to assess the predictive value of the Ca:P Ratio for spinal deformity severity, with the area under the curve (AUC) used as a quantitative metric. Finally, subgroup analyses were conducted to examine result heterogeneity across strata defined by sex, age, marital status, education level, history of diabetes, history of hypertension, lumbar BMD (\u0026le;\u0026thinsp;0.92 g/cm\u0026sup2; vs. \u0026gt;0.92 g/cm\u0026sup2;), and BMI. Interaction terms were also incorporated to evaluate the potential influence of effect modification among different factors on the study outcomes. Statistical analyses were performed using R software (version 4.5.0). Statistical significance was defined as a two‑sided P value of less than 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Baseline characteristics of the patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 displays the characteristics of the study patients stratified by quartiles of the Ca:P Ratio. The final analysis included 141 patients with scoliosis. Significant differences were observed between the highest and lowest Ca:P Ratio quartiles across multiple indicators. Participants in the higher Ca:P Ratio group were older. In addition, the prevalence of hypertension and the proportion of married individuals were significantly higher in the high Ca:P Ratio group, whereas levels of CREA, eGFR, and Cobb angle were relatively lower in this group.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 68.0434%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1 Baseline characteristics of the study patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"21\" style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10.323%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n = 141)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10.323%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ1\u003c/strong\u003e\u003cstrong\u003e\u0026le;\u003c/strong\u003e\u003cstrong\u003e2.22\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10.323%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.22\u0026lt;Q2\u003c/strong\u003e\u003cstrong\u003e\u0026le;\u003c/strong\u003e\u003cstrong\u003e2.48\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10.323%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.48\u0026lt;Q3\u003c/strong\u003e\u003cstrong\u003e\u0026le;\u003c/strong\u003e\u003cstrong\u003e2.72\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 36)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10.323%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ4\u0026gt;2.72\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"21\" style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eAge, years, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e64.53 \u0026plusmn; 20.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e49.64 \u0026plusmn; 27.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e64.89 \u0026plusmn; 16.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e71.97 \u0026plusmn; 13.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e71.41 \u0026plusmn; 12.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eHeight, cm, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e154.35 \u0026plusmn; 14.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e150.34 \u0026plusmn; 17.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e154.60 \u0026plusmn; 7.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e158.14 \u0026plusmn; 9.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e154.20 \u0026plusmn; 19.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.166\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eWeight, kg, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e55.42 \u0026plusmn; 15.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e53.85 \u0026plusmn; 20.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e53.70 \u0026plusmn; 8.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e57.64 \u0026plusmn; 9.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e56.41 \u0026plusmn; 18.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.635\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eMarital status, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e108 (76.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e20 (57.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e31 (88.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e31 (86.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e26 (74.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e33 (23.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e15 (42.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e4 (11.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e5 (13.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e9 (25.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eHypertension, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e52 (36.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e6 (17.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e12 (34.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e20 (55.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e14 (40.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e89 (63.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e29 (82.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e23 (65.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e16 (44.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e21 (60.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eDiabetes, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.695\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e19 (13.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e3 (8.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e4 (11.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e6 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e6 (17.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e122 (86.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e32 (91.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e31 (88.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e30 (83.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e29 (82.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eGender, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.134\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e34 (24.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e6 (17.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e5 (14.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e11 (30.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e12 (34.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e107 (75.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e29 (82.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e30 (85.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e25 (69.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e23 (65.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eEducation level, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.987\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; Primary school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e61 (43.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e15 (42.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e14 (40.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e16 (44.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e16 (45.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; Middle school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e45 (31.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e10 (28.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e12 (34.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e11 (30.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e12 (34.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003e\u0026nbsp; High school or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e35 (24.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e10 (28.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e9 (25.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e9 (25.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e7 (20.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eLumbar BMD, g/cm\u003csup\u003e2\u003c/sup\u003e, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.95 \u0026plusmn; 0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.92 \u0026plusmn; 0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.97 \u0026plusmn; 0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e1.01 \u0026plusmn; 0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.91 \u0026plusmn; 0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.255\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e29.01 \u0026plusmn; 57.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e32.46 \u0026plusmn; 63.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e22.43 \u0026plusmn; 3.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e23.16 \u0026plusmn; 3.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e38.15 \u0026plusmn; 97.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.612\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eUREA, mg/dL, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e34.56 \u0026plusmn; 11.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e33.81 \u0026plusmn; 13.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e31.61 \u0026plusmn; 8.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e35.57 \u0026plusmn; 12.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e37.24 \u0026plusmn; 12.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.223\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eCREA, mg/dL, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.76 \u0026plusmn; 0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.69 \u0026plusmn; 0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.72 \u0026plusmn; 0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.82 \u0026plusmn; 0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.83 \u0026plusmn; 0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.016\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eFBG, mg/dL, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e100.58 \u0026plusmn; 27.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e94.80 \u0026plusmn; 21.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e100.15 \u0026plusmn; 27.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e100.28 \u0026plusmn; 21.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e107.08 \u0026plusmn; 37.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.326\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eUA mgdL, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e5.83 \u0026plusmn; 1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e5.92 \u0026plusmn; 1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e5.49 \u0026plusmn; 1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e6.02 \u0026plusmn; 1.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e5.88 \u0026plusmn; 1.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.610\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eCYC-C, mgdL, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.11 \u0026plusmn; 0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.17 \u0026plusmn; 0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.08 \u0026plusmn; 0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.10 \u0026plusmn; 0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e0.10 \u0026plusmn; 0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.463\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eALP, U/L, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e88.35 \u0026plusmn; 44.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e99.60 \u0026plusmn; 53.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e82.80 \u0026plusmn; 55.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e87.92 \u0026plusmn; 36.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e83.11 \u0026plusmn; 25.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.357\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eTG, mg/dL, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e121.57 \u0026plusmn; 77.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e134.53 \u0026plusmn; 104.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e118.23 \u0026plusmn; 79.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e111.30 \u0026plusmn; 49.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e122.50 \u0026plusmn; 69.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.646\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eLDL-C, mg/dL, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e106.71 \u0026plusmn; 34.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e108.42 \u0026plusmn; 40.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e103.77 \u0026plusmn; 31.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e107.70 \u0026plusmn; 37.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e106.93 \u0026plusmn; 29.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.948\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eeGFR, ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e92.24 \u0026plusmn; 27.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e109.73 \u0026plusmn; 34.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e91.46 \u0026plusmn; 19.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e82.42 \u0026plusmn; 19.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e85.64 \u0026plusmn; 24.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eMg, mg/dL, M (Q₁, Q₃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e2.07 (1.97, 2.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e2.14 (1.96,2.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e2.11 (2.02,2.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e2.05 (1.90,2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e2.02 (1.93,2.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.099\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eTC, mg/dL, M (Q₁, Q₃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e176.72 (144.63,216.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e167.05 (125.48,207.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e180.20 (146.56,197.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e178.27 (141.73,235.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e179.43 (165.51,197.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.373\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eHDL-C, mg/dL, M (Q₁, Q₃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e45.63 (37.90,53.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e42.92 (34.22,50.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e43.70 (37.90,55.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e47.76 (40.22,53.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e49.50 (38.48,54.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e0.070\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12.7149%;\"\u003e\n \u003cp\u003eCobb angle, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e20.11\u003csup\u003eo\u003c/sup\u003e \u0026plusmn; 12.42\u003csup\u003eo\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e28.00\u003csup\u003eo\u003c/sup\u003e \u0026plusmn; 17.05\u003csup\u003eo\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e17.40\u003csup\u003eo\u003c/sup\u003e \u0026plusmn; 9.69\u003csup\u003eo\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e19.41\u003csup\u003eo\u003c/sup\u003e \u0026plusmn; 8.65\u003csup\u003eo\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.323%;\"\u003e\n \u003cp\u003e15.65\u003csup\u003eo\u003c/sup\u003e \u0026plusmn; 9.01\u003csup\u003eo\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9026%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 68.0434%;\"\u003e\n \u003cp\u003e\u0026nbsp;SD: standard deviation, M: Median, Q₁: 1st Quartile, Q₃: 3st Quartile.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 68.0434%;\"\u003e\n \u003cp\u003eAbbreciation: BMI, Body mass index; BMD, Bone mineral density; UREA, Urea; CREA, Creatinine; FPG, Fasting plasma glucose; UA, Uric acid; CYC-C, Cystatin C; Ca, Calcium; P, Phosphorus; Mg, Magnesium; ALP, Alkaline phosphatase; TC, Total cholesterol; TG, Triglycerides; HDL-C, High density lipoprotein cholesterol; LDL‑C, Low density lipoprotein cholesterol; FBG, Fasting blood glucose (); eGFR, estimated glomerular filtration rate.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3777%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Lower Calcium/Phosphorus Ratio is associated with the severity of deformity in scoliosis patients\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo investigate the relationship between serum Ca:P Ratio and spinal deformity severity, we built three multivariable logistic regression models (Table 2). In Model 1 (unadjusted), each unit increase in Ca:P Ratio yielded an OR of 0.29 (95% CI: 0.11\u0026ndash;0.72, P = 0.007). Adjusting for demographic and clinical factors in Model 2 attenuated but preserved significance (OR = 0.33, 95% CI: 0.11\u0026ndash;0.97, P = 0.044). Further inclusion of metabolic and renal markers in Model 3 maintained an independent inverse association (OR = 0.24, 95% CI: 0.07\u0026ndash;0.87, P = 0.030). When stratified by quartiles, the highest Ca:P Ratio group (Q4) consistently showed reduced deformity severity versus Q1 across all models (OR = 0.22, 95% CI: 0.06\u0026ndash;0.87, P = 0.031), whereas Q2 and Q3 did not differ significantly. These findings indicate that a higher serum Ca:P Ratio is independently linked to milder spinal deformities after comprehensive confounder adjustment.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2 Multivariable logistic regression for the correlation between Ca:P Ratio and the severity of deformity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCa:P Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.29 (0.11 ~ 0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.33 (0.11 ~ 0.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.044\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.24 (0.07 ~ 0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.030\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCa:P Ratio quartile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.00 (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.00 (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.00 (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.31 (0.11 ~ 0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.40 (0.13 ~ 1.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.46 (0.12 ~ 1.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.242\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.64 (0.24 ~ 1.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.372\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.18 (0.36 ~ 3.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.21 (0.31 ~ 4.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.784\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.21 (0.08 ~ 0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.28 (0.09 ~ 0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.038\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.22 (0.06 ~ 0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\n \u003cp\u003eOR: Odds Ratio, CI: Confidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\n \u003cp\u003eModel 1: Crude\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\n \u003cp\u003eModel 2: Adjust: Marital status, Hypertension, Diabetes, Gender, Education level, Age, Lumbar BMD, BMI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\n \u003cp\u003eModel 3: Adjust: Marital status, Hypertension, Diabetes, Gender, Education level, Age, Lumbar BMD, UREA, FBG, UA, CYC-C, Mg, ALP, TG, TC, HDL-C, LDL-C, eGFR, BMI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Restricted Cubic Splines analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe performed restricted cubic spline (RCS) analysis to investigate the association between the Ca:P Ratio and the severity of spinal deformity, based on Model 3 (Figure 3). The results showed a significant overall association between the Ca:P Ratio and spinal deformity severity. The overall P value was 0.0105, confirming statistical significance. The nonlinear P value was 0.0495. This indicates that the relationship followed a nonlinear pattern.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3 Nonlinear association between Ca:P Ratio and spinal deformity severity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5 Receiver Operating Characteristic curve\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive performance of the Ca:P Ratio for the severity of spinal deformity (Figure 4). The results showed that the area under the curve (AUC) for the Ca:P Ratio was 0.618 (95%CI: 0.525\u0026ndash;0.711).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 4\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;ROC curve for Ca:P Ratio predicting spinal deformity severity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6 The results of subgroup analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the subgroup analysis, the direction of the association between the Ca:P Ratio and the severity of spinal deformity was generally consistent across subgroups(Table 3). Notably, the protective association of the Ca:P Ratio defined as a higher ratio correlating with less severe deformities was statistically significant only in specific subgroups. These included patients without hypertension, without diabetes, males, those with junior high school education or lower, individuals aged \u0026le;70 years, and participants with lumbar BMD \u0026le;0.92 g/cm\u0026sup2; or BMI \u0026le;24 kg/m\u0026sup2;. No significant association was detected in any other subgroup analyzed. Although the significance patterns varied among different subgroups, all subgroup interaction tests yielded P values greater than 0.05.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" style=\"margin-right: calc(40%); width: 60%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 78.3691%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Subgroup analysis of the association between Ca:P Ratio and spinal deformity severity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"19\" style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 23.9258%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP for interaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"21\" style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eAll patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e141 (100.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.29 (0.11 ~ 0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e0.619\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e108 (76.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.39 (0.11 ~ 1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e0.129\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e33 (23.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.23 (0.05 ~ 1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e0.075\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e0.100\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e52 (36.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.98 (0.18 ~ 5.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e0.984\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e89 (63.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.17 (0.05 ~ 0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e0.139\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e19 (13.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e1.30 (0.15 ~ 11.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e0.813\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e122 (86.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.22 (0.08 ~ 0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e0.059\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e34 (24.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.04 (0.01 ~ 0.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.020\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e107 (75.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.48 (0.18 ~ 1.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e0.150\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e0.285\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003ePrimary school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e61 (43.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.19 (0.04 ~ 0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.035\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eMiddle school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e45 (31.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.17 (0.03 ~ 0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.035\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eHigh school or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e35 (24.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.97 (0.17 ~ 5.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e0.975\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e0.326\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003e\u0026le;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e72 (51.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.17 (0.04 ~ 0.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003e\u0026gt;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e69 (48.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.48 (0.10 ~ 2.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e0.350\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eLumbar BMD, g/cm\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e0.826\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003e\u0026le;0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e70 (49.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.25 (0.07 ~ 0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003e\u0026gt;0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e71 (50.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.31 (0.08 ~ 1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e0.096\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e0.508\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003e\u0026le;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e92 (65.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.24 (0.08 ~ 0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.9258%;\"\u003e\n \u003cp\u003e\u0026gt;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.5732%;\"\u003e\n \u003cp\u003e49 (34.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.6768%;\"\u003e\n \u003cp\u003e0.48 (0.08 ~ 2.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.2256%;\"\u003e\n \u003cp\u003e0.427\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.9678%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 78.3691%;\"\u003e\n \u003cp\u003eOR: Odds Ratio, CI: Confidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7324%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe present retrospective cohort study systematically explored the association between serum Ca/P Ratio and the severity of spinal deformity in 141 scoliosis patients. The core findings revealed that a lower serum Ca/P Ratio was independently associated with more severe spinal curvature. After adjusting for demographic, clinical, metabolic, and renal confounders, each unit increase in Ca/P Ratio was linked to a reduced risk of severe deformity (OR\u0026thinsp;=\u0026thinsp;0.24, 95%CI: 0.07\u0026ndash;0.87, P\u0026thinsp;=\u0026thinsp;0.030). And patients in the highest Ca/P Ratio quartile (Q4) exhibited significantly milder deformity compared with the lowest quartile (Q1). Restricted cubic spline analysis confirmed a nonlinear relationship between Ca/P ratio and deformity severity, while subgroup analysis identified specific populations where this association was most pronounced.\u003c/p\u003e \u003cp\u003eThese findings deepen the understanding of metabolic mechanisms underlying scoliosis progression by linking systemic mineral balance to spinal structural stability. Unlike isolated calcium or phosphorus levels, the serum Ca/P Ratio integrates the synergistic regulation of PTH, FGF-23, and vitamin D, offering a more holistic reflection of bone metabolic status[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our restricted cubic spline analysis (nonlinear P\u0026thinsp;=\u0026thinsp;0.0495) further uncovered that the Ca/P ratio exerts a non-proportional effect on deformity severity. This pattern implies that there may be a threshold range where mineral imbalance triggers more pronounced vertebral structural impairment. Animal studies have shown that disrupted Ca/P balance alters osteoblast-osteoclast activity, leading to uneven bone remodeling[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In scoliosis., this imbalance may amplify the asymmetric bone loss induced by abnormal spinal loading, thereby accelerating curve progression[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This mechanism explains why the Ca/P Ratio provides more predictive value for deformity severity than static BMD measurements.\u003c/p\u003e \u003cp\u003eNotably, our study extends beyond previous research by clarifying the population-specific relevance of Ca/P Ratio in scoliosis. While prior studies have inconsistently linked BMD to scoliosis, few have explored mineral balance as a modifiable factor, and none have systematically analyzed subgroup differences[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our subgroup results showed that the protective effect of higher Ca/P Ratio was most prominent in patients without hypertension/diabetes, males, those with lower education, aged\u0026thinsp;\u0026le;\u0026thinsp;70 years, and with lumbar BMD\u0026thinsp;\u0026le;\u0026thinsp;0.92 g/cm\u0026sup2; or BMI\u0026thinsp;\u0026le;\u0026thinsp;24 kg/m\u0026sup2;. This heterogeneity may be attributed to the following. Patients without chronic comorbidities have fewer metabolic disturbances, making the impact of Ca/P imbalance more salient[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Younger patients (\u0026le;\u0026thinsp;70 years) still retain some bone remodeling capacity, so mineral imbalance exerts a more direct effect on vertebral quality[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. And individuals with lower BMD or normal BMI lack the \"buffering\" effect of adequate bone mass or adipose tissue-related hormone regulation, rendering them more susceptible to mineral metabolism disorders[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These findings highlight the need for stratified monitoring of Ca/P Ratio in high risk subgroups.\u003c/p\u003e \u003cp\u003eClinically, our findings offer a novel metabolic intervention target for scoliosis management. Current strategies for mild-to-moderate scoliosis rely heavily on bracing and rehabilitation, with limited metabolic interventions. The independent association between Ca/P Ratio and deformity severity suggests that monitoring and optimizing serum Ca/P balance could complement conventional treatments, particularly in high risk subgroups. For example, nutritional counseling to adjust calcium and phosphorus intake or vitamin D supplementation to enhance mineral absorption may help mitigate curve progression, providing a noninvasive adjunct to standard care.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the retrospective design and single center sample (141 patients) may introduce selection bias and limit generalizability to other populations. Second, unmeasured confounders such as vitamin D levels, physical activity, and dietary habits could not be fully adjusted for, potentially affecting result validity. Third, serum Ca/P ratio was measured at a single time point, failing to capture dynamic changes over time and their impact on deformity progression.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eSerum Ca/P Ratio is independently and negatively associated with the severity of spinal deformity in scoliosis patients. This association shows a nonlinear relationship and has population specific effects. Maintaining an optimal serum Ca/P balance may contribute to mitigating deformity progression, especially in high risk subgroups.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eContributionsLRC\u0026amp;WM: Data curation, Formal analysis, Methodology, Software, Visualization, Writing, original draft, Writing \u0026ndash; review \u0026amp; editing. WHY: Conceptualization, Resources, Visualization, Writing, original draft. WSF: Conceptualization, Methodology, Supervision, Validation, Visualization, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eYu P, Tang Z, Chang W, Jia L, Ma Z, Li H, et al. Degenerative scoliosis may trigger higher incidence of adjacent vertebral fractures following percutaneous vertebroplasty: a clinical evidence-based biomechanical research. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2025.\u003c/li\u003e\n \u003cli\u003ePetrosyan E, Fares J, Lesniak MS, Koski TR, El Tecle NE. Biological principles of adult degenerative scoliosis. Trends in molecular medicine. 2023;29(9):740-52.\u003c/li\u003e\n \u003cli\u003eSuri A, Tang S, Kargilis D, Taratuta E, Kneeland BJ, Choi G, et al. Conquering the Cobb Angle: A Deep Learning Algorithm for Automated, Hardware-Invariant Measurement of Cobb Angle on Radiographs in Patients with Scoliosis. Radiology Artificial intelligence. 2023;5(4):e220158.\u003c/li\u003e\n \u003cli\u003eQin W, Yu SY, Gao JL, Yan JF, Wan QQ, Jia SL, et al. Phosphate in Physiological and Pathological Mineralization: Important yet Often Unheeded. MedComm. 2025;6(7):e70298.\u003c/li\u003e\n \u003cli\u003eBonnet AL, Aboishava L, Mannstadt M. Advances in Parathyroid Hormone-based medicines. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2025;40(11):1195-206.\u003c/li\u003e\n \u003cli\u003eAgoro R, White KE. Regulation of FGF23 production and phosphate metabolism by bone-kidney interactions. Nature reviews Nephrology. 2023;19(3):185-93.\u003c/li\u003e\n \u003cli\u003eHill Gallant KM, Zheng XY. Natural stable calcium isotope ratios: a new gold standard for bone balance? Kidney international. 2022;102(3):473-6.\u003c/li\u003e\n \u003cli\u003eGoodman WG, Ward DT, Martin KJ, Drayer D, Moore C, Xu J, et al. Activation of the Calcium Receptor by Calcimimetic Agents Is Preserved Despite Modest Attenuating Effects of Hyperphosphatemia. Journal of the American Society of Nephrology : JASN. 2022;33(1):201-12.\u003c/li\u003e\n \u003cli\u003eShroff R, Lalayiannis AD, Fewtrell M, Schmitt CP, Bayazit A, Askiti V, et al. Naturally occurring stable calcium isotope ratios are a novel biomarker of bone calcium balance in chronic kidney disease. Kidney international. 2022;102(3):613-23.\u003c/li\u003e\n \u003cli\u003eHariri H, Kose O, Bezdjian A, Daniel SJ, St-Arnaud R. USP53 Regulates Bone Homeostasis by Controlling Rankl Expression in Osteoblasts and Bone Marrow Adipocytes. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2023;38(4):578-96.\u003c/li\u003e\n \u003cli\u003eUehara A, Mok Y, Matsushita K, Lutsey PL, Ishigami J. Serum Sodium, Potassium, Magnesium, Calcium, and Phosphorus Levels and Risk of Fracture in the Community. The Journal of clinical endocrinology and metabolism. 2025;110(11):e3818-e26.\u003c/li\u003e\n \u003cli\u003eEastell R, Brown JP, Adler RA, Lewiecki EM, Binkley N, Orwoll ES, et al. Bone turnover markers predict changes in bone mineral density in men treated with abaloparatide: results from the abaloparatide for the treatment of men with osteoporosis (ATOM) study. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2025;40(3):315-22.\u003c/li\u003e\n \u003cli\u003eShibata T, Takeda K, Suzuki S, Iga T, Okubo T, Ozaki M, et al. Lower Bone Mineral Density is Associated with Severity of Deformity in Adolescent Idiopathic Scoliosis. Spine. 2025.\u003c/li\u003e\n \u003cli\u003eZechner C, Adams-Huet B, Gregory B, Neyra JA, Rule JA, Li X, et al. Hypophosphatemia in acute liver failure of a broad range of etiologies is associated with phosphaturia without kidney damage or phosphatonin elevation. Translational research : the journal of laboratory and clinical medicine. 2021;238:1-11.\u003c/li\u003e\n \u003cli\u003eKhan S, Khan AA. Hypoparathyroidism: diagnosis, management and emerging therapies. Nature reviews Endocrinology. 2025;21(6):360-74.\u003c/li\u003e\n \u003cli\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Annals of internal medicine. 2007;147(8):573-7.\u003c/li\u003e\n \u003cli\u003eZhang K, Xu N, Guo C, Wu J. MPF-net: An effective framework for automated cobb angle estimation. Medical image analysis. 2022;75:102277.\u003c/li\u003e\n \u003cli\u003eShah FA. Revisiting the physical and chemical nature of the mineral component of bone. Acta biomaterialia. 2025;196:1-16.\u003c/li\u003e\n \u003cli\u003eJia M, Luo J, Gao B, Huangfu Y, Bao Y, Li D, et al. Preparation of synbiotic milk powder and its effect on calcium absorption and the bone microstructure in calcium deficient mice. Food \u0026amp; function. 2023;14(7):3092-106.\u003c/li\u003e\n \u003cli\u003eYang KG, Lee WY, Hung AL, Kumar A, Chui EC, Hung VW, et al. Distinguishing risk of curve progression in adolescent idiopathic scoliosis with bone microarchitecture phenotyping: a 6-year longitudinal study. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2024;39(7):956-66.\u003c/li\u003e\n \u003cli\u003eWang FM, Ruby JG, Sethi A, Veras MA, Telis N, Melamud E. Characterizing aging-related genetic and physiological determinants of spinal curvature. Communications medicine. 2025;5(1):291.\u003c/li\u003e\n \u003cli\u003eZeng H, Ge J, Xu W, Ma H, Chen L, Xia M, et al. Type 2 Diabetes Is Causally Associated With Reduced Serum Osteocalcin: A Genomewide Association and Mendelian Randomization Study. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2021;36(9):1694-707.\u003c/li\u003e\n \u003cli\u003eLiu Y, Le S, Liu Y, Jiang H, Ruan B, Huang Y, et al. The effect of calcium supplementation in people under 35 years old: A systematic review and meta-analysis of randomized controlled trials. eLife. 2022;11.\u003c/li\u003e\n \u003cli\u003eThe global, regional, and national burden attributable to low bone mineral density, 1990-2020: an analysis of a modifiable risk factor from the Global Burden of Disease Study 2021. The Lancet Rheumatology. 2025;7(12):e873-e94.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8748126/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8748126/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective To explore the association between the serum calcium/phosphorus Ratio and the severity of spinal deformity in scoliosis patients and its clinical significance. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods Based on retrospective cohort data from 141 non-surgically treated scoliosis patients at Department of Spine Surgery at Guangzhou First People’s Hospital between 2019 and 2025, the Ca/P Ratio and spinal deformity severity were analyzed. Multivariable logistic regression, restricted cubic spline (RCS) analysis, and subgroup analyses were conducted to assess the independent association between the Ca/P Ratio and deformity severity. Adjustments were performed for confounders to improve the validity of the findings. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults Patients in the highest Ca/P Ratio quartile (Q4) exhibited significantly milder spinal deformity (P\u0026lt;0.001). Multivariable analysis demonstrated that each unit increase in the Ca/P Ratio was associated with a reduced risk of severe deformity (OR=0.24, 95% CI: 0.07-0.87, P=0.030). RCS analysis revealed a nonlinear association between the Ca/P Ratio and deformity severity (nonlinear P=0.0495). Subgroup analyses indicated that the protective effect was more pronounced in patients without hypertension/diabetes, males, those with lower BMI, or lower bone mineral density. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusion The serum Ca/P Ratio is an independent predictor of spinal deformity severity in scoliosis patients. Its imbalance may exacerbate spinal structural abnormalities by affecting bone metabolism, providing a novel target for metabolic interventions.\u003c/p\u003e","manuscriptTitle":"Lower Calcium/Phosphorus Ratio is Associated with the Severity of Deformity in Patients with Scoliosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-05 09:19:50","doi":"10.21203/rs.3.rs-8748126/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-29T10:06:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-23T13:12:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155968097091287613647329633424851270911","date":"2026-02-10T10:52:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-03T16:01:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-02T11:43:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-02T11:35:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2026-01-31T08:42:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ac28d97a-bd63-46dd-b6b4-d7fa58883a0d","owner":[],"postedDate":"February 5th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:02:25+00:00","versionOfRecord":{"articleIdentity":"rs-8748126","link":"https://doi.org/10.1007/s00586-026-09933-x","journal":{"identity":"european-spine-journal","isVorOnly":false,"title":"European Spine Journal"},"publishedOn":"2026-04-20 15:57:17","publishedOnDateReadable":"April 20th, 2026"},"versionCreatedAt":"2026-02-05 09:19:50","video":"","vorDoi":"10.1007/s00586-026-09933-x","vorDoiUrl":"https://doi.org/10.1007/s00586-026-09933-x","workflowStages":[]},"version":"v1","identity":"rs-8748126","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8748126","identity":"rs-8748126","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}