The Body Mass Index-Mortality Link across the Life Course: Two Selection Biases and Their Effects

In this study, we investigated two selection biases that may affect the obesity-mortality link over the life course: mortality selection and healthy participant effects. If these selection mechanisms are stronger among obese adults than among non-obese adults, they may contribute to the weakening obesity-mortality link over the life course. We used data from the National Health and Nutrition Examination Survey 1988–2010 with linked mortality files from 1988–2011. We employed weighted Cox models to test and adjust for these two selection biases. We also used complementary log-log models, adjusted for a normal distribution of frailty, to test for mortality selection effects; accelerated failure-time models to mitigate the mortality selection effect; and ordinary least squares regression to test for healthy participant effects. The link between class II/III obesity and mortality weakens at older ages. We did not find evidence for significant mortality selection or healthy participant effects. Also, even if the healthy participant effects were stronger among obese adults, they are not strong enough to produce a weakening association between obesity and morbidity at higher ages at the time of the survey. Therefore, neither of these selection biases explains the diminishing effect of class II/III obesity on mortality over the life course.