Individual and combined associations of modifiable metabolic health and lifestyle with low back pain, neck pain, and functional limitation: evidence from a nationally cross-sectional study

BACKGROUND: Although healthy lifestyles are prioritized for the self-management of chronic low back pain (LBP) and neck pain (NP), the individual and combined associations of metabolic health and lifestyle with LBP, NP, and related functional limitations remain unclear. This study aimed to evaluate these associations and support risk stratification across different metabolic and lifestyle profiles. METHODS: This cross-sectional study used data from the US National Health and Nutrition Examination Survey (1999-2018) to analyze two cohorts: pain cohort (n = 10286) and functional limitation cohort (n = 28513). Metabolic factors included abdominal obesity, hyperglycemia, hypertension, and dyslipidemia. Lifestyle factors included smoking, alcohol consumption, diet, and physical activity. Outcomes, including LBP, NP, and back- or neck-related functional limitation (BN-FL), were assessed by self-reported questionnaires. Associations between risk factors and outcomes were assessed using multivariable logistic regression. RESULTS: Individuals with poor metabolic-lifestyle status had the highest prevalence of LBP (42.6%), NP (21.4%), and BN-FL (17.6%). Physical inactivity showed the largest estimated population-attributable fraction (PAF) for LBP and NP (20.8% and 20.5%, respectively), while abdominal obesity (15.1%) and smoking (14.0%) showed the largest estimated PAFs for BN-FL. Poor metabolic status was associated with higher odds of LBP (OR = 1.470, 95% CI: 1.227-1.760) and BN-FL (OR = 2.404, 95% CI: 1.977-2.923), while poor lifestyle was associated with higher odds across all outcomes. Worsening lifestyle status was consistently associated with higher odds of LBP across all metabolic strata. The combination of poor metabolic-lifestyle status was associated with the highest odds of LBP (OR = 3.435, 95% CI: 2.026-5.824) and BN-FL (OR = 4.378, 95% CI: 2.347-8.167). CONCLUSIONS: Both metabolic health and lifestyles were associated with LBP and BN-FL, while only lifestyles were linked to NP. Combined unfavorable metabolic and lifestyle profiles were associated with higher odds of LBP and BN-FL, underscoring the importance of both metabolic and lifestyle modification.