title: The obesity paradox: understanding the effect of obesity on mortality among individuals with cardiovascular disease.
abstract: OBJECTIVE
  To discuss possible explanations for the obesity paradox and explore whether the paradox can be attributed to a form of selection bias known as collider stratification bias.
  
  
  METHODS
  The paper is divided into three parts. First, possible explanations for the obesity paradox are reviewed. Second, a simulated example is provided to describe collider stratification bias and how it could generate the obesity paradox. Finally, an example is provided using data from 17,636 participants in the US National and Nutrition Examination Survey (NHANES III). Generalized linear models were fit to assess the effect of obesity on mortality both in the general population and among individuals with diagnosed cardiovascular disease (CVD). Additionally, results from a bias analysis are presented.
  
  
  RESULTS
  In the general population, the adjusted risk ratio relating obesity and all-cause mortality was 1.24 (95% CI 1.11, 1.39). Adjusted risk ratios comparing obese and non-obese among individuals with and without CVD were 0.79 (95% CI 0.68, 0.91) and 1.30 (95% CI=1.12, 1.50), indicating that obesity has a protective association among individuals with CVD.
  
  
  CONCLUSIONS
  Results demonstrate that collider stratification bias is one plausible explanation for the obesity paradox. After conditioning on CVD status in the design or analysis, obesity can appear protective among individuals with CVD.
authors: McGill University, Department of Epidemiology, Biostatistics, and Occupational Health, Canada. Electronic address: hailey.banack@mail.mcgill.ca.
authors: Hailey R
authors: HR
authors: Banack
authors: McGill University, Department of Epidemiology, Biostatistics, and Occupational Health, Canada.
authors: Jay S
authors: JS
authors: Kaufman
mesh_terms: D000465:Algorithms; D015982:Bias; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000401:mortality*; D015984:Causality; D015986:Confounding Factors, Epidemiologic; D005260:Female; D006801:Humans; D016014:Linear Models; D008297:Male; D015233:Models, Statistical; D009749:Nutrition Surveys; D009765:Obesity / Q000453:epidemiology / Q000401:mortality*; D012307:Risk Factors; D014481:United States / Q000453:epidemiology
keywords: Cardiovascular disease; Epidemiology; Obesity paradox; Selection bias