Reverse Causation and Illness-related Weight Loss in Observational Studies of Body Weight and Mortality

Flegal, K. M.; Graubard, B. I.; Williamson, D. F.; Cooper, R. S.

doi:10.1093/aje/kwq341

Cited by 223Statistical Methods in EpidemiologyObesity, Physical Activity, DietCancer Risks and Factors

Reverse Causation and Illness-related Weight Loss in Observational Studies of Body Weight and Mortality

Flegal, K. M., Graubard, B. I., Williamson, D. F., Cooper, R. S.·2011·American Journal of Epidemiology

DOI 10.1093/aje/kwq341

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Abstract

In studies of weight and mortality, the construct of reverse causation has come to be used to imply that the exposure-outcome relation is biased by weight loss due to preexisting illness. Observed weight-mortality associations are sometimes thought to result from this bias. Evidence for the occurrence of such bias is weak and inconsistent, suggesting that either the analytical methods used have been inadequate or else illness-related weight loss is not an important source of bias. Deleting participants has been the most frequent approach to control possible bias. As implemented, this can lead to deletion of almost 90% of all deaths in a sample and to deletion of more overweight and obese participants than participants with normal or below normal weight. Because it has not been demonstrated that the procedures used to adjust for reverse causation increase validity or have large or systematic effects on relative risks, it is premature to consider reverse causation as an important cause of bias. Further research would be useful to elucidate the potential effects and importance of reverse causation or illness-related weight loss as a source of bias in the observed associations between weight and mortality in cohort studies.

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Applying extensive exclusions to the analysis of weight and mortality data is a flawed process.
“Flegal et al 16 have emphasized that applying extensive exclusions to the analysis of weight and mortality data is a flawed process.”
From Obesity Paradox in Hypertension: Is This Because Sympathetic Activation in Obesity-Hypertension Takes a Benign Form? (2018) · cites this paper as [16]

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Authors: Flegal, K. M., Graubard, B. I., Williamson, D. F., & Cooper, R. S.
Affiliations: Centers for Disease Control and Prevention (US)
Corresponding author: Flegal, K. M.
ORCID: Flegal, K. M.
Cooper, R. S.
Venue: American Journal of Epidemiology
Publisher: Oxford University Press (OUP)
Published: 2010-11-08
Volume: 173
Issue: 1
Pages: 1-9
ISSN: 0002-9262 (ISSN-L)
1476-6256
DOI: 10.1093/aje/kwq341
OpenAlex: W2150218756
Cited by: 223
References: 119
Citations by year: 2026: 9 · 2025: 15 · 2024: 8 · 2023: 13 · 2022: 13 · 2021: 18 · 2020: 14 · 2019: 12 · 2018: 16 · 2017: 13 · 2016: 15 · 2015: 22 · 2014: 16 · 2013: 17 · 2012: 10
FWCI: 1.82
Type: journal article
Language: en
Open access: closed
Locations: American Journal of Epidemiology (publishedVersion)
PubMed (publishedVersion)
Civil War Book Review (submittedVersion)
Topics: Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
Health Sciences › Medicine › Oncology › Cancer Risks and Factors
Keywords: reverse causality, body weight, mortality, bias in observational studies, cohort studies, overweight, obesity, exposure-outcome association
MeSH terms: Body Weight, Cause of Death, Humans, Obesity, Risk Factors, Weight Loss, Causality, Survival Rate

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Reverse Causation and Illness-related Weight Loss in Observational Studies of Body Weight and Mortality

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