The obesity paradox: understanding the effect of obesity on mortality among individuals with cardiovascular disease

Prev Med. 2014 May:62:96-102. doi: 10.1016/j.ypmed.2014.02.003. Epub 2014 Feb 10.


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.

Method: 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.

Conclusion: 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.

Keywords: Cardiovascular disease; Epidemiology; Obesity paradox; Selection bias.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Algorithms
  • Bias
  • Cardiovascular Diseases / epidemiology
  • Cardiovascular Diseases / mortality*
  • Causality
  • Confounding Factors, Epidemiologic
  • Female
  • Humans
  • Linear Models
  • Male
  • Models, Statistical
  • Nutrition Surveys
  • Obesity / epidemiology
  • Obesity / mortality*
  • Risk Factors
  • United States / epidemiology