Role of a plausible nuisance contributor in the declining obesity-mortality risks over time

Context Recent analyses of epidemiological data including the National Health and Nutrition Examination Survey (NHANES) have suggested that the harmful effects of obesity may have decreased over calendar time. The shifting BMI distribution over time coupled with the application of fixed broad BMI categories in these analyses could be a plausible “nuisance contributor” to this observed change in the obesity-associated mortality over calendar time. Objective To evaluate the extent to which observed temporal changes in the obesity-mortality association may be due to a shifting population distribution for body mass index (BMI), coupled with analyses based on static, broad BMI categories. Design, setting, and participants Simulations were conducted using data from NHANES I and III linked with mortality data. Data from NHANES I were used to fit a “true” model treating BMI as a continuous variable. Coefficients estimated from this model were used to simulate mortality for participants in NHANES III. Hence, the population-level association between BMI and mortality in NHANES III was fixed to be identical to the association estimated in NHANES I. Hazard ratios (HRs) for obesity categories based on BMI for NHANES III with simulated mortality data were compared to the corresponding estimated HRs from NHANES I. Main outcome measures Change in hazard ratios for simulated data in NHANES III compared to observed estimates from NHANES I. Results On average, hazard ratios for NHANES III based on simulated mortality data were 29.3% lower than the estimates from NHANES I using observed mortality follow-up. This reduction accounted for roughly three-fourths of the apparent decrease in the obesity-mortality association observed in a previous analysis of these data. Conclusions Some of the apparent diminution of the association between obesity and mortality may be an artifact of treating BMI as a categorical variable.