EPID600

Introduction to Epidemiology

Lisa Mayer- section 003

Homework 2
DUE 09/24/18 at 1:30 pm

DAGs / ecologic studies

While you can discuss the homework with other students, you must submit your work individually and it should
reflect your own thinking and understanding of the questions. Do not type up the answers as a group, do it
individually, using your own wording. You may want to bring a copy of your homework to the lab discussion.

1. The DAG below represents a true causal system in which all known variables and connectors have been
drawn. Each variable is dichotomous, with possible values 0 or 1.

A
Y Z
L
U

Highlight in bold TRUE or FALSE for each expectation below. Highlight only one option for each.

1. True False Pr[A=1|L=0] ≠ Pr[A=1|L=1] Is there an association between A

and L? No- Y is a collider, path is blocked
2. True False A and U are associated Y is not a collider because line from L is
not part of the path
3. True False U and Z share a common direct cause Y has a direct path to
both of these variables; Y is a parent to both U and Z
4. True False There is a backdoor path from Y to Z backdoor because not
directed Y to A to Z
5. True False Z has an indirect effect on L L has indirect path to Z but not the
other way around
6. True False The DAG is partly incorrect because there is a feedback loop

7. True False Z is a collider on one path from A to U A to Z to Y to U; Z is a

collider
8. True False Y is a common cause of A and L Arrows point towards Y, so A
and L cause Y
9. True False Pr[Ua=1] ≠ Pr[Ua=0] Is there a causal effect of A on U? Yes, path
is open and directed
10. True False Pr[Zu] = Pr[Zu|U=u] Exchangeability; if they’re not
exchangeable, can’t be causal; Does U have causal effect
on Z? No, open but undirected

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2. The table below shows average country level milk intake and coronary heart disease (CHD) mortality rates
for 4 European countries in the year 1977. [Milk intake was measured from food disappearance data for
each country. CHD mortality rates are a measure of the number of deaths from CHD per 100,000 men
ages 55-64 years in a country during a given year]

Country Milk, g/100 kcal CHD mortality rate

West Germany 69 463
France 74 198
United Kingdom 136 710
Finland 254 1031
Artaud-Wild et al. Circulation 1993;88:2771

a. Plot the association

b. Describe the association using direction/shape and magnitude. For magnitude, focus on the lowest
and highest exposure levels and estimate i. an absolute difference and ii. a relative difference. Show
calculations and describe the association in words.
The association is positive and non-monotonic.

Milk consumption increases from 69 g/100kcal (West Germany) to 254 g/100kcal (Finland) with
an absolute difference of 185 g/kcal of milk consumption (254-69=185). CHD mortality rate
corresponding with these values increases from 493 CHD deaths per 100,000 men (West
Germany) to 1031 CHD deaths per 100,000 men (Finland) with an absolute difference of 538
CHD deaths per 100,000 men (1031-493).

The relative difference between milk consumption in these countries was an increase in
magnitude by about 3.68 times (254/69). For CHD, relative increase was by a factor of 2.23
(1031/493).

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c. Draw a DAG representing each of the following potential explanations using only the information
provided in each. Make sure to include both milk intake and CHD in each scenario. Include any
additional variables as needed and make sure to label all variable names. For each scenario, list all
paths from milk intake to CHD in the DAG and for each path state i. whether you expect or not an
association and ii. whether you expect or not a causal effect. Do this only for any paths between milk
intake and CHD.

i. People with CHD symptoms are encouraged by their doctors to increase whole grain cereal intake.
In these countries, when people eat whole grain cereal for breakfast, they typically add milk to it as
a habit acquired from childhood.

There is one path from milk to CHD: M to W to C.

i. There should be an association between milk intake and CHD because the path is open
and directed.
ii. There is no causal effect from milk to CHD because the arrows are not head to tail. CHD
causes milk intake to increase but the reverse is not true.

Another possible DAG; in this case, no association because the path between milk and CHD is
closed (collider) and no causal effect

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ii. Milk intake increases overall intake of saturated fat. Saturated fat increases “bad” serum
cholesterol which gets deposited under the inner walls of the coronary arteries making them
narrower and restricting the blood flow to the heart, which means CHD. On the other hand, the
presence of certain gene variant makes people more likely to have high bad serum cholesterol
levels, regardless of their diet. The same gene variant makes people more likely to develop CHD
directly through inflammation of the coronary artery walls.

There are two paths from milk to CHD:

1. Milk to saturated fat intake to bad serum cholesterol to narrowing arteries to CHD.
i. There is an association between milk and CHD because this is an open, directed
path.
ii. There is causation between milk and CHD because the arrows go head to tail
and the path is open and directed. Indirect effect

2. Milk to saturated fat intake to bad serum cholesterol to the gene variant to arterial
inflammation to CHD
i. There is no association between milk and CHD because this path is closed.
ii. There is no causation because the path is undirected (not all arrows flow head to
tail) and B is a collider.

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iii. At the country level, milk intake is inversely related to intake of omega-3 fatty acids from fish, for
unknown reasons. Omega-3 fatty acids decrease inflammation of the inner walls of the
coronary arteries and prevent the arteries from becoming narrower.

There is one path from milk intake to CHD: milk intake to unknown to omega 3 intake to arterial
inflammation to artery width to CHD
i. There is an association between milk and CHD because this is an open path.
ii. There is no causation because the path from milk to CHD is not directed.

We know U goes TO milk because in the question, it specifies “for unknown reasons”
implying that the unknown reasons cause both the connection between fatty acid intake
and milk intake.

d. Provide one reason why this study may be subject to the “ecologic fallacy”.
This study reports findings about milk intake, CHD, and other factors at the country level. This means
that the trends between milk intake and CHD found by this study may not hold true for all the individuals
within these countries.

Another note: all measures taken at the same time, so milk consumption at the time may not
reflect its influence on CHD. If milk leads to CHD, it would take time. Ie the people drinking the
milk at this time may not be the same people who developed CHD because of it.

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EXTRA CREDIT

All questions below refer to the paper by Villamor et al. Association between maternal body mass index in early
pregnancy and incidence of cerebral palsy. JAMA 2017;317:925-36.

From the list of answers provided for each question, highlight in bold the correct answer. Highlight only one
option for each question. Highlighting more than one option will invalidate the question.

Consider the DAG in panel A of the Figure (page 931). Assume it represents a complete causal system
where all known variables and connectors have been drawn. Based only on the information as presented
on the DAG, highlight true or false for each expectation below:

1. True False Maternal age is a common cause of early pregnancy BMI and preterm delivery

2. True False Maternal height causes early pregnancy BMI

3. True False Child’s sex causes cerebral palsy through preterm delivery

4. True False There is an open path from early pregnancy BMI to parity

5. True False Country of origin has an indirect effect on cerebral palsy through one path only

6. True False Maternal age !"child’s sex

7. True False Cerebral palsy mediates the effect of early pregnancy BMI on C2

8. True False Preterm delivery is a collider on one path from BMI to cerebral palsy

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