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Comment & Response |

Nonlinear Exposure-Outcome Associations and Public Health Policy

Amit Kiran, PhD1; Nathalie Conrad, MSc1; Kazem Rahimi, DM, MPH1
[+] Author Affiliations
1George Institute for Global Health, University of Oxford, Oxford, United Kingdom
JAMA. 2016;315(12):1287-1288. doi:10.1001/jama.2015.18026.
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To the Editor The Viewpoint by Dr Chokshi and colleagues1 discussed apparent nonlinear associations often reported in studies. However, the examples used to highlight the inherently paradoxical nature of J-shaped curves were misleading, especially in the context of a risk factor such as blood pressure.

Studies have shown an erosion of the J-shaped curve when a more informed analytical approach is taken and the risk of confounding is rigorously mitigated.2 For example, in a large cohort of approximately 5000 men with a history of myocardial infarction,3 a J-shaped curve was observed between blood pressure and risk of all-cause and CHD mortality. But after accounting for reverse causality (2-year wash out), the same study reported linear associations.

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March 22, 2016
Dave A. Chokshi, MD, MSc; Abdulrahman M. El-Sayed, MD, DPhil; Nicholas W. Stine, MD
1New York City Health + Hospitals, New York, New York
2City of Detroit Department of Health and Wellness Promotion, Detroit, Michigan
JAMA. 2016;315(12):1288. doi:10.1001/jama.2015.18035.
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