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American Journal of Clinical Nutrition, Vol. 88, No. 5, 1449-1450, November 2008
© 2008 American Society for Nutrition

LETTER TO THE EDITOR

Reply to SB Kritchevsky

Luc Djoussé and J Michael Gaziano

The Division of Aging
Department of Medicine
Brigham and Women's Hospital and Harvard Medical School
1620 Tremont Street, 3rd floor
Boston, MA 02120
E-mail: ldjousse{at}rics.bwh.harvard.edu

Dear Sir:

My colleague and I would like to thank Dr Kritchevsky for his comments on our recent article in the Journal (1). Kritchevsky indicated that the "consumption of high-cholesterol foods could be considered nonadherent behavior" and that "nonadherer bias" may explain the greater risk of mortality observed with consumption of ≥7 eggs/wk among physicians with type 2 diabetes. Kritchevsky used the fact that egg consumption was associated with both smoking and a lower level of physical activity as evidence to support his theory. However, the positive association between egg consumption and fruit, vegetables, and multivitamins in the same data does not lend support to his hypothesis.

Furthermore, for a nonadherer bias to confound the relative risk, it must be associated with egg consumption and must be an independent predictor of mortality in subjects who do not consume eggs (ie, the unexposed group) (2). As presented in Table 1Go here, our data do not support any association between egg consumption and compliance with the intervention drug or placebo. As we discussed in our article (1), we have emphasized the inability to control for residual or unmeasured confounding in this observational analysis as a limitation of the study. We believe that, given the shortcomings that are inherent to observational studies, only a large randomized trial assessing the effects of egg consumption as compared with placebo on mortality could unequivocally answer the question as to whether egg consumption increases the risk of death.


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  		TABLE 1. Drug compliance over time according to egg consumption in US male physicians1

 
It remains important to obtain scientific evidence through a sound methodology. It is also important that the knowledge gap with respect to pathophysiologic mechanisms that may explain a particular association (as is the case for an egg-mortality relation) not be equated with the absence of a causal association between studied exposure and outcome.

ACKNOWLEDGMENTS

Neither of the authors had a personal or financial conflict of interest.

REFERENCES

  1. Djoussé L, Gaziano JM. Egg consumption in relation to cardiovascular disease and mortality: the Physicians' Health Study. Am J Clin Nutr 2008;87:964–9.[Abstract/Free Full Text]
  2. Rothman KJ, Greenland S. Modern epidemiology. Baltimore, MD: Lippincott Williams & Wilkins, 1998.




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