Abstract
Purpose:
While fluid intake and trace elements are known to influence kidney stone risk, the impact of drinking water type remains unclear. This study aimed to systematically evaluate the association between water source and kidney stone prevalence.
Methods:
This analysis included 10 246 adults (≥20 years) from the National Health and Nutrition Examination Survey database (2009–2016). Kidney stone history was self-reported, and drinking water sources were assessed through 24-hour dietary recalls.
We employed multivariable-adjusted logistic regression models, adjusting for potential confounders including age, sex, race, body mass index (BMI), physical activity, calcium intake, smoking status, alcohol consumption, diabetes, and hypertension, to evaluate the association between drinking water type and kidney stone occurrence. To assess potential nonlinear relationships, restricted cubic spline (RCS) models were utilized. Additionally, cluster analysis was performed to categorize participants into distinct subgroups based on water consumption patterns. Finally, propensity score matching (PSM) and subgroup analyses were conducted to further validate the robustness of the findings.
Results:
Logistic regression suggested that higher tap water intake was significantly inversely related with kidney stone prevalence [adjusted odds ratio (OR) = 0.678, 95% confidence interval (CI): 0.491–0.938, P for trend = 0.0177], suggesting a 32% lower odds of kidney stones with increased tap water consumption. However, bottled water intake was not significantly associated with kidney stone risk. The RCS model revealed a linear decreasing trend between tap water intake and kidney stone risk (P for all <0.0001, P for nonlinear = 0.8505). Cluster analysis showed that high tap water intake and low bottled water intake were associated with a lower prevalence of kidney stones. This association persisted in the propensity score-matched models and subgroup analyses after adjustment for bottled water intake.
Conclusion:
Our study revealed an inverse association between tap water intake and kidney stone prevalence among U.S. adults. Bottled water intake had no statistically significant effect on stone formation. These results suggest that higher tap water intake may confer a protective effect against kidney stone formation. These findings could guide public health recommendations on hydration habits.
Keywords: bottled water, drinking water, fluid intake, kidney stone, NHANES, tap water
HIGHLIGHTS
This article presents the first large-scale evidence delineating the dose‒response relationship between drinking water type (tap vs. bottled) and nephrolithiasis incidence using big-data analytics.
Through an integrated analytical approach combining cluster analysis, restricted cubic spline (RCS) modelling, and propensity score matching (PSM), we demonstrated a consistent inverse association between tap water intake and nephrolithiasis risk.
These findings provide clinically actionable guidance for both reducing recurrence in both stone formers and the general population, underscoring the importance of personalized water selection strategies on the basis of mineral composition.
Introduction
Kidney stones have emerged as a globally prevalent health concern, with prevalence rates demonstrating a marked increase over recent decades[1]. Over the past decade, prevalence rates remained stable in males (11.9% in 2017–2018) while showing a significant increase in females (rising from 6.5% to 9.4% during the same period)[2,3]. The management of kidney stones imposes a dual burden on healthcare systems and economies[4]. The pathogenesis involves multifactorial interactions, including metabolic disorders and dietary patterns (e.g., high sodium and animal protein intake)[5–8]. Notably, a bidirectional association exists between metabolic diseases (obesity, diabetes, hypertension) and kidney stones: these conditions not only serve as independent risk factors for stone formation but also predispose kidney stone patients to an elevated risk of developing chronic kidney disease (CKD)[9,10].
A well-established relationship exists between fluid intake and kidney stone risk. Substantial evidence indicates that adequate hydration reduces both the primary prevalence and recurrence rates of kidney stones by promoting urinary dilution and decreasing the supersaturation of lithogenic solutes[11–14]. While public attention to drinking water sources and their health implications has grown substantially, a significant proportion of adults fail to meet recommended daily fluid intake levels, posing both individual and public health challenges[15–17].
Recent studies indicate that certain mineral components in water, especially calcium and magnesium, may have either inhibitory or promotive effects on kidney stone formation. Additionally, bicarbonate-rich water appears to be linked to lower rates of uric acid stones[18,19]. Research has explored the potential roles of water components in modulating stone formation risk and preventing kidney stones[20–22]. However, whether different types of drinking water exert distinct effects on kidney stone development remains to be elucidated. Utilizing the nationally representative National Health and Nutrition Examination Survey (NHANES) data, our study provides robust epidemiological evidence comparing the effects of tap water versus bottled water consumption on kidney stone formation risk. These findings offer direct evidence to inform public health recommendations for stone prevention.
This cross-sectional has been reported in line with the STROCSS criteria[23].
Methods
Study population
The study sample was derived from the NHANES, a nationally representative cross-sectional program conducted by the Centers for Disease Control and Prevention (CDC). The NHANES is an ongoing biennial, nationally representative cross-sectional survey that comprehensively assesses the health and nutritional status of the U.S. population through standardized interviews, physical examinations, and laboratory tests. For this analysis, we included participants from four consecutive NHANES cycles (2009–2016), with a final cohort of 10 246 eligible adults after applying the following exclusion criteria (Fig. 1): (1) age <20 years; (2) missing kidney stone history data; (3) incomplete covariate information; and (4) unavailable drinking water intake data. The NHANES protocol was approved by the National Center for Health Statistics (NCHS) Research Ethics Review Board. All participants provided written informed consent. As this secondary analysis used de-identified public data, it was exempt from additional institutional review board approval[24].
Figure 1.
Flowchart of participant screening.
Drinking water source
Drinking water source served as the primary exposure variable in our analysis. Dietary intake data were collected through two 24-hour recall interviews: the first was conducted in person at mobile examination centers (MECs), followed by a telephone-administered second recall 3–10 days later. We calculated the mean daily water intake values by averaging the reported consumption from both interviews. The NHANES classifies drinking water sources into two categories: tap water (including filtered tap water and water from a drinking fountain) and bottled water.
Kidney stone history
The presence of kidney stones served as the primary outcome variable in our study. Trained interviewers ascertained kidney stone history using the computer-assisted personal interview (CAPI) system during MEC visits. Participants who responded affirmatively to the standardized question “Have you ever had kidney stones?” were classified as having a positive kidney stone history.
Definitions of variables
We adjusted for potential confounding factors through multivariable modelling, incorporating the following covariates: age (20–40 years, 40–60 years, >60 years); sex (male/female); race (Mexican American, other Hispanic, non-Hispanic White, non-Hispanic Black, other race); BMI (≤25 kg/m2, 25–30 kg/m2, > 30 kg/m2); physical activity (vigorous, moderate, or less than moderate exercise); calcium intake; smoking status (no/yes); alcohol consumption (no/yes); diabetes (no/yes); and hypertension (no/yes)[25,26].
Statistical analysis
This study employed weighted analyses to account for the complex multistage probability sampling design of the NHANES, ensuring national representativeness. Continuous variables are presented as the means ± standard deviations (SD), while categorical variables are expressed as percentages (%). Group comparisons were performed using analysis of variance (ANOVA) for continuous variables and chi-square tests for categorical variables. Drinking water consumption was categorized into quintiles (Q1–Q5) for both tap water and bottled water, with Q1 serving as the reference group. We conducted weighted multivariable logistic regression analyses using two models: a crude model without adjustments and a fully adjusted model incorporating age, sex, race/ethnicity, BMI, physical activity, calcium intake, smoking status, alcohol consumption, diabetes status, and hypertension. The results are reported as odds ratios (ORs) with 95% confidence intervals (CIs), with trend tests performed across water intake quintiles.
To examine potential nonlinear relationships, we employed restricted cubic splines (RCSs) with three knots. Cluster analysis using the k-means algorithm was performed to identify distinct patterns of water consumption behavior. For robustness assessment, we conducted propensity score matching (PSM) with 1:1 nearest-neighbor matching and a caliper width of 0.05 to balance potential confounders, followed by subgroup analyses to evaluate the consistency of the observed associations.
All the statistical analyses were performed using R software (version 4.3.3), with two-tailed P values <0.05 considered statistically significant.
Results
Baseline characteristics
The study included 10 246 participants with complete data (Table 1), of whom 980 (9.6%) had kidney stones. When participants were grouped by kidney stone status, most baseline characteristics were significantly different. Compared with the nonstone group, the stone-forming group was older (51% aged 60–80 years); was more likely to be male (56%); had a higher proportion of non-Hispanic whites (61%); had a higher BMI (46% with BMI > 30 kg/m2); had lower physical activity levels (62% with low activity); and had higher rates of smoking (48%), diabetes (3.2%), and hypertension (53%). More importantly, kidney stone patients had lower tap water intake (871 g) and higher bottled water consumption (954 g).
Table 1.
Baseline characteristics of participants between 2009 and 2016 (n = 10 246)
| Characteristic | Kidney stone | |||
|---|---|---|---|---|
| Total | No | Yes | P-value | |
| N | 10 246 | 9266 (90%) | 980 (9.6%) | |
| Age, n (%) | <0.001 | |||
| 20–40 years | 3243 (32%) | 3078 (33%) | 165 (17%) | |
| 40–60 years | 3307 (32%) | 2993 (32%) | 314 (32%) | |
| 60–80 years | 3696 (36%) | 3195 (34%) | 501 (51%) | |
| Gender, n (%) | <0.001 | |||
| Male | 5012 (49%) | 4461 (48%) | 551 (56%) | |
| Female | 5234 (51%) | 4805 (52%) | 429 (44%) | |
| Race/ethnicity, n (%) | <0.001 | |||
| Mexican American | 1093 (11%) | 988 (11%) | 105 (11%) | |
| Other Hispanic | 925 (9.0%) | 815 (8.8%) | 110 (11%) | |
| Non-Hispanic White | 5128 (50%) | 4535 (49%) | 593 (61%) | |
| Non-Hispanic Black | 1775 (17%) | 1672 (18%) | 103 (11%) | |
| Other race/Multiracial | 1325 (13%) | 1256 (14%) | 69 (7.0%) | |
| BMI (kg/m2) | <0.001 | |||
| <25 | 3070 (30%) | 2879 (31%) | 191 (19%) | |
| 25–30 | 3363 (33%) | 3027 (33%) | 336 (34%) | |
| >30 | 3813 (37%) | 3360 (36%) | 453 (46%) | |
| Physical Activity, n (%) | <0.001 | |||
| Vigorous | 1697 (17%) | 1585 (17%) | 112 (11%) | |
| Moderate | 2935 (29%) | 2673 (29%) | 262 (27%) | |
| Low | 5614 (55%) | 5008 (54%) | 606 (62%) | |
| Smoking status, n (%) | <0.001 | |||
| Never | 5940 (58%) | 5429 (59%) | 511 (52%) | |
| Ever | 4306 (42%) | 3837 (41%) | 469 (48%) | |
| Alcohol status, n (%) | 0.7 | |||
| No | 2743 (27%) | 2476 (27%) | 267 (27%) | |
| Yes | 7503 (73%) | 6790 (73%) | 713 (73%) | |
| Diabetes, n (%) | 0.12 | |||
| No | 9997 (98%) | 9048 (98%) | 949 (97%) | |
| Yes | 249 (2.4%) | 218 (2.4%) | 31 (3.2%) | |
| Hypertension, n (%) | <0.001 | |||
| No | 6419 (63%) | 5955 (64%) | 464 (47%) | |
| Yes | 3827 (37%) | 3311 (36%) | 516 (53%) | |
| Calcium intake (mg) | 936 ± 490 | 940 ± 493 | 903 ± 457 | 0.045 |
| Tap water intake (g) | 956 ± 931 | 965 ± 936 | 871 ± 878 | <0.001 |
| Bottled water intake (g) | 927 ± 827 | 924 ± 820 | 954 ± 894 | 0.8 |
Association between drinking water sources and kidney stone risk
The study categorized drinking water intake into quintiles, with tap water consumption divided as Q1 (≤262.5 g/day), Q2 (262.5–592.5 g/day), Q3 (592.5–982.5 g/day), Q4 (982.5–1672.5 g/day), and Q5 (>1672.5 g/day), and bottled water intake classified as Q1 (≤253.5 g/day), Q2 (253.5–507.0 g/day), Q3 (507.0–887.3 g/day), Q4 (887.3–1494.0 g/day), and Q5 (>1494.0 g/day).
Univariate logistic regression analysis revealed a significant inverse association between tap water consumption and kidney stone risk (crude OR = 0.983, P = 0.0017) (Table 2), demonstrating a clear dose‒response relationship with decreasing risk at higher intake levels (P for trend <0.001). This protective association remained statistically significant after multivariate adjustment for age, sex, race, BMI, physical activity, calcium intake, smoking status, diabetes, hypertension, and bottled water intake (adjusted OR = 0.986, 95% CI = 0.976–0.997, P = 0.0136). RCS analysis confirmed a linear relationship between tap water intake and kidney stone risk (P for all <0.0001, P for nonlinear = 0.8505, Fig. 2). Supplemental Digital Content Figure 1, available at: http://links.lww.com/JS9/E904 further supported a decreasing trend in kidney stone prevalence with increasing tap water intake. Notably, bottled water intake was not significantly associated with kidney stone risk according to either the unadjusted or adjusted model (Table 3).
Table 2.
Univariate and multivariate logistic regression analyses by the association between kidney stone and tap water intake, weighted
| Characteristic | Kidney stone infection crude OR (95% CI) | P for trend | Kidney stone infection adjusted OR (95% CI) | P for trend |
|---|---|---|---|---|
| Continuous tap water intake per 100 g increase | 0.983 (0.980, 0.996) | 0.0017 | 0.986 (0.976, 0.997) | 0.0136 |
| Categorical tap water intake | <0.001 | 0.0177 | ||
| Q1 | Ref | Ref | ||
| Q2 | 0.794 (0.604, 1.044) | 0.800 (0.600, 1.064) | ||
| Q3 | 0.689 (0.527, 0.900) | 0.714 (0.541, 0.941) | ||
| Q4 | 0.736 (0.555, 0.975) | 0.822 (0.632, 1.069) | ||
| Q5 | 0.603 (0.452, 0.805) | 0.678 (0.491, 0.938) |
Figure 2.
RCS curves describing the dose‒response relationship between tap water intake and kidney stone. The following covariates were adjusted for: age, sex, race, BMI, physical activity, calcium intake, smoking status, diabetes mellitus, hypertension, and bottled water intake. BMI, body mass index; RCS, restricted cubic spline.
Table 3.
Univariate and multivariate logistic regression analyses by the association between kidney stone and bottled water intake, weighted
| Characteristic | Kidney stone infection crude OR (95% CI) | P for trend | Kidney stone infection adjusted OR (95% CI) | P for trend |
|---|---|---|---|---|
| Continuous bottled water intake per 100 g increase | 1.005 (0.992, 1.018) | 0.463 | 1.009 (0.995, 1.023) | 0.222 |
| Categorical bottled water intake | 0.327 | 0.188 | ||
| Q1 | Ref | Ref | ||
| Q2 | 0.935 (0.681, 1.283) | 0.948 (0.670, 1.341) | ||
| Q3 | 1.077 (0.798, 1.454) | 1.104 (0.796, 1.531) | ||
| Q4 | 1.152 (0.847, 1.568) | 1.196 (0.859, 1.666) | ||
| Q5 | 1.105 (0.767, 1.591) | 1.194 (0.808, 1.765) |
Cluster analysis-derived drinking water patterns
Through k-means clustering analysis (k = 3), the participants were classified into groups representing three distinct drinking water patterns (Fig. 3). Cluster 1 was characterized as the “Double-Low Group.” Cluster 2 represented the “High Bottled Water Group,” whereas Cluster 3 was identified as the “High Tap Water Group.” The centroid values for each cluster are detailed in Supplemental Digital Content Table 1, available at: http://links.lww.com/JS9/E904.
Figure 3.
Visualization of k-mean clustering. Cluster 1 (red) double-low group; Cluster 2 (blue) high bottled water group; Cluster 3 (green) high tap water group; we defined Cluster 1 (red) with low tap water intake and low bottled water intake as the double-low group; Cluster 2 (blue) with low tap water intake and high bottled water intake as the high bottled water group; and Cluster 3 (green) with high tap water intake and low bottled water intake as the high tap water group.
Kidney stone risk associated with drinking water patterns
As demonstrated in Figure 4, the cluster with high tap water intake presented a significantly lower prevalence of kidney stones than the other groups did (Prevalence of kidney stones = 0.0611), Interestingly, the group with high bottled water intake presented a greater prevalence of kidney stones than the other groups did (Prevalence of kidney stones = 0.0981). In the unadjusted logistic regression model (Table 4) with Cluster 1 as a reference, Cluster 2 demonstrated a decreased risk of kidney stones (crude OR = 0.652, 95% CI = 0.442–0.963, P = 0.0315). These results suggest that increased tap water intake may confer protective effects against kidney stone formation. On the basis of cumulative evidence, we recommend prioritizing tap water over bottled water for daily hydration needs in kidney stone prevention strategies.
Figure 4.
Prevalence of the three clusters.
Table 4.
Univariate and multivariate logistic regression analyses by the association between the clusters
| Characteristic | Kidney stone infection crude OR (95% CI) | P-value | Kidney stone infection adjusted OR (95% CI) | P-value |
|---|---|---|---|---|
| Cluster 1 | Ref | Ref | ||
| Cluster 2 | 1.089 (0.790, 1.502) | 0.6009 | 1.237 (0.886, 1.725) | 0.2113 |
| Cluster 3 | 0.652 (0.442, 0.963) | 0.0315 | 0.764 (0.513, 1.137) | 0.1842 |
Sensitivity analyses
Comparison after PSM
To increase the robustness of our findings and better control for potential confounding effects of bottled water intake, we performed PSM on the basis of bottled water intake levels. Both univariate and multivariate logistic regression analyses conducted in the matched cohort replicated our primary results (Table 5). The persistent inverse association between tap water intake and kidney stones prevalence (adjusted OR = 0.563, 95% CI: 0.367–0.864, P for trend = 0.0022) reinforces the protective effect observed in our initial analyses.
Table 5.
Univariate and multivariate logistic regression analyses by the association between kidney stone and tap water intake after PSM, weighted
| Characteristic | Kidney stone infection crude OR (95% CI) | P for trend | Kidney stone infection adjusted OR (95% CI) | P for trend |
|---|---|---|---|---|
| Continuous tap water intake per 100 g increase | 0.983 (0.971, 0.996) | 0.01 | 0.987 (0.974, 0.999) | 0.0423 |
| Categorical tap water intake | <0.001 | 0.0022 | ||
| Q1 | Ref | Ref | ||
| Q2 | 0.903 (0.614, 1.329) | 0.891 (0.580, 1.370) | ||
| Q3 | 0.693 (0.506, 0.949) | 0.695 (0.502, 0.961) | ||
| Q4 | 0.679 (0.472, 0.976) | 0.732 (0.500, 1.070) | ||
| Q5 | 0.538 (0.366, 0.791) | 0.563 (0.360, 0.864) |
Subgroup analysis
We conducted comprehensive subgroup analyses with forest plot visualization (Fig. 5) to examine potential effect modifications between stone risk and categorical variables. The results demonstrated a consistent inverse association between tap water intake and kidney stones prevalence across the majority of subgroups stratified by demographic characteristics, lifestyle factors, and comorbid conditions (all P for interaction >0.05).
Figure 5.
Forest plots for subgroup analysis. Subgroup analysis was stratified by age, sex, race, BMI, physical activity, smoking status, diabetes, and hypertension. BMI, body mass index.
Discussion
This cross-sectional study investigated the associations between drinking water sources and kidney stones prevalence among 10 246 U.S. adults and revealed an overall stone prevalence of 9.6%. Multivariate logistic analyses revealed a significant independent inverse association between tap water intake and kidney stone risk, with strengthened protective effects observed across increasing intake quintiles (P for trend <0.001). Restricted cubic spline (RCS) analyses confirmed a dose‒dependent negative correlation. Cluster analysis further identified three distinct water intake patterns, with the “High Tap Water Group” showing the lowest stone risk. These findings remained robust in propensity score-matched analyses (caliper = 0.05) and subgroup analysis, whereas bottled water intake and kidney stone risk were not significantly associated. The consistent protective relationship suggests that choosing tap water for daily hydration may be a simple yet effective strategy for the primary prevention of kidney stones in the general population.
The protective effect of high fluid intake against kidney stones has been well documented in previous studies[27–30], with consistent evidence indicating that increased water intake is an effective preventive measure. Emerging research has further elucidated the dual role of drinking water components in both promoting and inhibiting the risk of stone formation[21,30–35]. Our findings may be explained by the differential mineral composition across water types: treated tap water typically contains optimal concentrations of calcium and magnesium, and calcium binds with dietary oxalate in the intestine to form insoluble calcium oxalate, thereby reducing oxalate absorption and subsequent urinary excretion[36–38]. In contrast, commercially available bottled water has substantial variability in mineral content, often lacking these protective components or containing imbalanced ratios that may negate potential benefits[18,39–41]. Furthermore, behavioural differences between healthy individuals and stone formers may contribute to this association, as patients with kidney stones tend to demonstrate lower thirst perceptions[42–44] and may preferentially consume bottled water for convenience, potentially compounding their risk through suboptimal hydration practices.
Our findings suggest that tap water may represent a healthier choice for kidney stone prevention, although several limitations warrant consideration. First, the generalizability of this conclusion may vary across regions due to differences in municipal water supplies and the prevalence of distinct bottled water brands with varying mineral compositions. Notably, our analysis lacked direct measurements of tap/bottled water mineral content. Second, as a cross-sectional study, our design cannot establish causality, highlighting the need for longitudinal studies to evaluate the long-term clinical outcomes associated with different drinking water sources. Third, residual confounding persists despite multivariable adjustment – key factors could partially explain the observed associations. While current evidence indicates that tap water may be superior to bottled water for kidney stones prevention, definitive confirmation of this association requires well-designed intervention studies with standardized water quality monitoring profiling to assess crystallization risk. Notably, breakthroughs in novel drug delivery systems (NDDS) provide complementary therapeutic approaches for stone management. These advanced delivery platforms have shown promise in improving the bioavailability, targeted delivery, and therapeutic efficacy of litholytic or anti-inflammatory agents, potentially reducing recurrence rates. The integration of these technological advancements with our findings may offer a more comprehensive strategy for stone prevention[45–48].
Our study leverages the nationally representative NHANES database, which employs standardized protocols and rigorous quality control measures conducted by trained professionals to ensure data reliability. The large sample size (n = 10 246) and appropriate sampling weights increase the statistical power and generalizability of our findings. These methodological advantages support the robustness of our primary conclusion regarding the associations between drinking water sources and kidney stones risk. From a public health perspective, these evidence-based findings provide meaningful guidance for hydration recommendations in kidney stone prevention.
Conclusion
Our study revealed a significant inverse association between tap water intake and the prevalence of kidney stones among U.S. adults, whereas no such protective effect was observed with bottled water intake. These findings suggest that increased tap water intake may serve as a modifiable protective factor against kidney stones. From a public health perspective, prioritizing tap water over bottled water for daily hydration may serve as a simple and practical strategy to prevent kidney stones in the general population.
Acknowledgements
We gratefully acknowledge the contributions of all participating members of the National Center for Health Statistics at the Centers for Disease Control and Prevention, as well as the valuable participation of individuals in the National Health and Nutrition Examination Survey. Their collective efforts made this research possible.
Footnotes
J.J.Q. is the first author.
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.lww.com/international-journal-of-surgery.
Published online 21 August 2025
Contributor Information
Jiajie Qin, Email: qinjiajieicloud@163.com.
Hedong Zhang, Email: 269610769@qq.com.
Hao Wen, Email: wenhao1@buaa.edu.cn.
Qiulin Luo, Email: 17878872053@163.com.
Jiawei Peng, Email: 434581900@qq.com.
Xiangqi Zhang, Email: 15622971363@163.com.
Rongzheng Nie, Email: 13357343230@163.com.
Longkai Peng, Email: plk3000@163.com.
Helong Dai, Email: helong68888@163.com.
Ethical approval
The National Health and Nutrition Examination Survey (NHANES) is a publicly available, de-identified dataset collected through a continuous cross-sectional survey conducted in 2-year cycles across the United States. As this study utilized only secondary analysis of anonymized NHANES data that are freely accessible for research purposes, no additional institutional review board approval or participant consent was required. The use of these open-source data presents no ethical concerns or conflicts of interest.
Consent
As this study utilized only secondary analysis of anonymized NHANES data that are freely accessible for research purposes, no additional institutional review board approval or participant consent was required.
Sources of funding
This work was supported by the National Natural Science Foundation of China (82270796, 82470789).
Author contributions
J.J.Q. designed and wrote the manuscript. H.L.D., J.Y.L., H.D.Z., and H.W. contributed to survey methodology and software. Y.X., Q.L.L., J.W.P. participated in manuscript review, editing, and supervision. All authors have read and approved the final manuscript.
Conflicts of interest disclosure
The authors declare no conflicts of interest.
Guarantor
Helong Dai.
Research registration unique identifying number (UIN)
In view of the fact that our research focuses on the analysis of public databases, there is no Unique Identifying Number (UIN) available for submission.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data availability statement
The data supporting the findings of this study were obtained from the National Health and Nutrition Examination Survey (NHANES) and are publicly accessible at: https://www.cdc.gov/nchs/nhanes/index.htm.
Consent for publication
The authors agreed to publication in the journal.
Declarations
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study were obtained from the National Health and Nutrition Examination Survey (NHANES) and are publicly accessible at: https://www.cdc.gov/nchs/nhanes/index.htm.