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Photo of Shai Mulinari. Private photo.

Shai Mulinari

Associate Professor | Senior Lecturer

Photo of Shai Mulinari. Private photo.

The tyranny of the averages and the indiscriminate use of risk factors in public health : The case of coronary heart disease


  • Juan Merlo
  • Shai Mulinari
  • Maria Wemrell
  • S V Subramanian
  • Bo Hedblad

Summary, in English

Modern medicine is overwhelmed by a plethora of both established risk factors and novel biomarkers for diseases. The majority of this information is expressed by probabilistic measures of association such as the odds ratio (OR) obtained by calculating differences in average "risk" between exposed and unexposed groups. However, recent research demonstrates that even ORs of considerable magnitude are insufficient for assessing the ability of risk factors or biomarkers to distinguish the individuals who will develop the disease from those who will not. In regards to coronary heart disease (CHD), we already know that novel biomarkers add very little to the discriminatory accuracy (DA) of traditional risk factors. However, the value added by traditional risk factors alongside simple demographic variables such as age and sex has been the subject of less discussion. Moreover, in public health, we use the OR to calculate the population attributable fraction (PAF), although this measure fails to consider the DA of the risk factor it represents. Therefore, focusing on CHD and applying measures of DA, we re-examine the role of individual demographic characteristics, risk factors, novel biomarkers and PAFs in public health and epidemiology. In so doing, we also raise a more general criticism of the traditional risk factors' epidemiology. We investigated a cohort of 6103 men and women who participated in the baseline (1991-1996) of the Malmö Diet and Cancer study and were followed for 18 years. We found that neither traditional risk factors nor biomarkers substantially improved the DA obtained by models considering only age and sex. We concluded that the PAF measure provided insufficient information for the planning of preventive strategies in the population. We need a better understanding of the individual heterogeneity around the averages and, thereby, a fundamental change in the way we interpret risk factors in public health and epidemiology.


  • Social Epidemiology
  • Sociology
  • Cardiovascular Research - Epidemiology
  • EpiHealth: Epidemiology for Health

Publishing year







SSM - Population Health



Document type

Journal article




  • Public Health, Global Health, Social Medicine and Epidemiology


  • coronary
  • Heart disease
  • Risk factors




  • Flernivåanalyser av individuell heterogenitet: innovativa koncepter och metodologiska ansatser inom Folkhälsa och Socialepidemiologi
  • Multilevel analysis of individual heterogeneity

Research group

  • Social Epidemiology
  • Cardiovascular Research - Epidemiology


  • ISSN: 2352-8273