Association between non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and mortality in US adults: results from the NHANES 2011-2018

Mengmeng Yang; Junwei Zhang; Zhenyu Feng; Meiling Wang; Quanguan Feng; Runping Zhang; Chuanling Wu; Tian Wu; Genggeng Zhang; Yuanzhi Niu; Qiuju Dong; Qinghua Han; Tao Lin

doi:10.3389/fnut.2025.1576229

Association between non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and mortality in US adults: results from the NHANES 2011-2018

Front Nutr. 2025 Jun 19:12:1576229. doi: 10.3389/fnut.2025.1576229. eCollection 2025.

Authors

Mengmeng Yang¹, Junwei Zhang², Zhenyu Feng³, Meiling Wang⁴, Quanguan Feng⁵, Runping Zhang⁶, Chuanling Wu¹, Tian Wu¹, Genggeng Zhang¹, Yuanzhi Niu¹, Qiuju Dong⁷, Qinghua Han⁸, Tao Lin⁷

Affiliations

¹ The Third Clinical College, Shanxi University of Chinese Medicine, Taiyuan, China.
² School of Management, Shanxi Medical University, Jinzhong, China.
³ Department of Hospital President, Shanxi Provincial Integrated TCM and WM Hospital, Taiyuan, China.
⁴ Department of Scientific Research and Education, Shanxi Provincial Integrated TCM and WM Hospital, Taiyuan, China.
⁵ Preventive Treatment Department of Traditional Chinese Medicine, Shanxi Provincial Integrated TCM and WM Hospital, Taiyuan, China.
⁶ Department of Geriatrics, Shanxi Provincial Integrated TCM and WM Hospital, Taiyuan, China.
⁷ Department of Medical Administration, Shanxi Provincial Integrated TCM and WM Hospital, Taiyuan, China.
⁸ Department of Hospital President, The First Hospital of Shanxi Medical University, Taiyuan, China.

Abstract

Background: The NHHR, which is the ratio of non-high-density lipoprotein cholesterol (non-HDL-C) to high-density lipoprotein cholesterol (HDL-C), has been suggested to have a link to several metabolic diseases and cardiovascular diseases (CVD). However, its association with CVD mortality and all-cause mortality remains uncertain.

Methods and results: Analyzing HDL-C and non-HDL-C used to calculate NHHR were sourced from the National Health and Nutrition Examination Survey (2011-2018). In this experiment, we utilized subgroup analysis to examine the robustness of the results obtained. This study excluded participants under 20 years of age and those with missing NHHR or mortality data, resulting in a final sample of 20,294 participants. We employed logistic regression models to assess the association between NHHR and all-cause mortality and CVD mortality. The NHHR was categorized into four groups (Q1-Q4) according to their values from small to large. In model 3, considering all covariates, individuals in Q4 of NHHR exhibited a 41% higher CVD mortality compared to Q1 (HR = 1.41, 95% CI 1.14, 1.74). To explore the potential non-linear relationships between NHHR and mortality, restricted cubic spline (RCS) and threshold saturation techniques were used. About NHHR and all-cause mortality, the results indicated an L-shaped association, with a breakpoint (K) at 1.18. To the left of this threshold, a negative association was identified (OR = 0.30, 95% CI 0.13, 0.67). But when NHHR is greater than 1.18, the relationship was positive (HR = 1.12, 95% CI 1.06, 1.18).

Conclusion: All in all, maintaining NHHR within an optimal range in adults may help reduce the association connected with both all-cause and CVD mortality.

Keywords: NHANES; NHHR; cardiovascular disease; cross-sectional study; mortality.