title: Sources of differences in estimates of obesity-associated deaths from first National Health and Nutrition Examination Survey (NHANES I) hazard ratios.
abstract: BACKGROUND
  Estimates of obesity-associated deaths in the United States for 1991 were published by Allison et al (JAMA 1999;282:1530-8) and subsequently for 2000 by Mokdad et al (JAMA 2004;291:1238-45). Flegal et al (JAMA 2005;293:1861-7) then published lower estimates of obesity-associated deaths for 2000. All 3 studies incorporated data from the first National Health and Nutrition Examination Survey (NHANES I).
  
  
  OBJECTIVE
  The objective was to clarify the effects of methodologic differences between the 3 studies in estimates of obesity-associated deaths in the US population by using NHANES I hazard ratios.
  
  
  METHODS
  The earlier reports used imputed smoking data for much of the NHANES I sample rather than the available reported data and applied a method of calculating attributable fractions that did not adjust for the effects of age, sex, and smoking on mortality in the target US population and did not account for effect modification by age. The effects of these and other methodologic factors were examined.
  
  
  RESULTS
  The NHANES I hazard ratios in the earlier reports were too low, probably because of the imputed smoking data. The low hazard ratios obscured the magnitude and direction of the bias arising from the incompletely adjusted attributable fraction method. When corrected hazard ratios were used, the incompletely adjusted attributable fraction method overestimated obesity-associated mortality in the target population by >100,000 deaths.
  
  
  CONCLUSIONS
  Methodologic sources of bias in the reports by Allison et al and Mokdad et al include the assessment of smoking status in NHANES I and the method of calculating attributable fractions.
authors.affiliation: National Center for Health Statistics Centers for Disease Control Prevention, Hyattsville MD, USA. kmf2@cdc.gov
authors.forename: Katherine M
authors.initials: KM
authors.lastname: Flegal
authors.forename: Barry I
authors.initials: BI
authors.lastname: Graubard
authors.forename: David F
authors.initials: DF
authors.lastname: Williamson
authors.forename: Mitchell H
authors.initials: MH
authors.lastname: Gail
mesh_terms: D015982:Bias; D005260:Female; D006801:Humans; D008297:Male; D009749:Nutrition Surveys; D009765:Obesity / Q000401:mortality*; D016016:Proportional Hazards Models; D012106:Research; D012307:Risk Factors; D012907:Smoking / Q000453:epidemiology*; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology