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To the Editor: In their study of deaths associated with underweight, overweight, and obesity, Dr Flegal and colleagues¹ conclude that excess mortality due to obesity and overweight is much lower than previously reported. We believe that their analysis is flawed and misleading.

A major challenge in such studies is that low weight is often due to underlying chronic disease, which may exist for many years before death. Thus, lean persons are a mix of smokers, healthy active persons, and those with chronic illness (due to the direct effects of disease on weight and sometimes purposeful weight loss motivated by diagnosis of a serious illness). Their analysis does not successfully disentangle this diverse group. In the main analyses, the study apparently did not exclude persons with known chronic disease at baseline. The authors did conduct some analyses to address reverse causation, such as excluding early follow-up and those persons who had . . . [Full Text of this Article]

Walter C. Willett, MD, DrPH
walter.willett@channing.harvard.edu

Frank B. Hu, MD, PhD; Graham A. Colditz, MD, DrPH; JoAnn E. Manson, MD, DrPH
Harvard University
Brigham and Women’s Hospital
Boston, Mass

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