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In Reply: Dr Willett and colleagues assert that our analysis is flawed because it is based on the entire study sample rather than on a highly restricted subgroup. Their example of how to cull out a subgroup that is not subject to confounding by unhealthy lean study participants ("reverse causation")¹ was based on only 531 (11%) of the 4726 deaths that occurred in the cohort. This approach would not satisfy a central aim of our study, which was to describe the numbers of deaths associated with BMI values outside the reference range of 18.5 to less than 25 in the entire US population rather than in a small subgroup.

To determine if reverse causation might be affecting our results, we performed extensive supplemental analyses of our data, stratifying by baseline health status and using multiple simultaneous exclusions for smoking, early deaths, and involuntary weight loss.² The relative risks were little . . . [Full Text of this Article]

Katherine M. Flegal, PhD
kflegal@cdc.gov
National Center for Health Statistics
Centers for Disease Control and Prevention
Hyattsville, Md

Barry I. Graubard, PhD; Mitchell H. Gail, MD, PhD
Division of Cancer Epidemiology and Genetics
National Cancer Institute
Bethesda, Md

David F. Williamson, PhD
Division of Diabetes Translation
Centers for Disease Control and Prevention
Atlanta, Ga

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