Use of self-reported height and weight biases the body mass index-mortality association

Background: Many large-scale epidemiological data sources used to evaluate the body mass index (BMI: kg/m(2)) mortality association have relied on BMI derived from self-reported height and weight. Although measured BMI (BMIM) and self-reported BMI (BMISR) correlate highly, self-reports are systematically biased. Objective: To rigorously examine how self-reporting bias influences the association between BMI and mortality rate. Subjects: Samples representing the US non-institutionalized civilian population. Design and Methods: National Health and Nutrition Examination Survey data (NHANES II: 1976-80; NHANES III: 1988-94) contain BMIM and BMISR. We applied Cox regression to estimate mortality hazard ratios (HRs) for BMIM and BMISR categories, respectively, and compared results. We similarly analyzed subgroups of ostensibly healthy never-smokers. Results: Misclassification by BMISR among the underweight and obesity ranged from 30-40% despite high correlations between BMIM and BMISR (r > 0.9). The reporting bias was moderately correlated with BMIM (r > 0.35), but not BMISR (r < 0.15). Analyses using BMISR failed to detect six of eight significant mortality HRs detected by BMIM. Significantly biased HRs were detected in the NHANES II full data set (chi(2) = 12.49; P = 0.01) and healthy subgroup (chi(2) = 9.93; P = 0.04), but not in the NHANES III full data set (chi(2) = 5.63; P = 0.23) or healthy subgroup (chi(2) = 1.52; P = 0.82). Conclusions: BMISR should not be treated as interchangeable with BMIM in BMI mortality analyses. Bias and inconsistency introduced by using BMISR in place of BMIM in BMI mortality estimation and hypothesis tests may account for important discrepancies in published findings. International Journal of Obesity (2011) 35, 401-408; doi:10.1038/ijo.2010.148; published online 3 August 2010