Validity of observational evidence on putative risk and protective factors: appraisal of 3744 meta-analyses on 57 topics

Background The validity of observational studies and their meta-analyses is contested. Here, we aimed to appraise thousands of meta-analyses of observational studies using a pre-specified set of quantitative criteria that assess the significance, amount, consistency, and bias of the evidence. We also aimed to compare results from meta-analyses of observational studies against meta-analyses of randomized controlled trials (RCTs) and Mendelian randomization (MR) studies. Methods We retrieved from PubMed (last update, November 19, 2020) umbrella reviews including meta-analyses of observational studies assessing putative risk or protective factors, regardless of the nature of the exposure and health outcome. We extracted information on 7 quantitative criteria that reflect the level of statistical support, the amount of data, the consistency across different studies, and hints pointing to potential bias. These criteria were level of statistical significance (pre-categorized according to 10−6, 0.001, and 0.05 p-value thresholds), sample size, statistical significance for the largest study, 95% prediction intervals, between-study heterogeneity, and the results of tests for small study effects and for excess significance. Results 3744 associations (in 57 umbrella reviews) assessed by a median number of 7 (interquartile range 4 to 11) observational studies were eligible. Most associations were statistically significant at P < 0.05 (61.1%, 2289/3744). Only 2.6% of associations had P < 10−6, ≥1000 cases (or ≥20,000 participants for continuous factors), P < 0.05 in the largest study, 95% prediction interval excluding the null, and no large between-study heterogeneity, small study effects, or excess significance. Across the 57 topics, large heterogeneity was observed in the proportion of associations fulfilling various quantitative criteria. The quantitative criteria were mostly independent from one another. Across 62 associations assessed in both RCTs and in observational studies, 37.1% had effect estimates in opposite directions and 43.5% had effect estimates differing beyond chance in the two designs. Across 94 comparisons assessed in both MR and observational studies, such discrepancies occurred in 30.8% and 54.7%, respectively. Conclusions Acknowledging that no gold-standard exists to judge whether an observational association is genuine, statistically significant results are common in observational studies, but they are rarely convincing or corroborated by randomized evidence. Supplementary Information The online version contains supplementary material available at 10.1186/s12916-021-02020-6.

Results: 3744 associations (in 57 umbrella reviews) assessed by a median number of 7 (interquartile range 4 to 11) observational studies were eligible. Most associations were statistically significant at P < 0.05 (61.1%, 2289/3744). Only 2.6% of associations had P < 10 −6 , ≥1000 cases (or ≥20,000 participants for continuous factors), P < 0.05 in the largest study, 95% prediction interval excluding the null, and no large between-study heterogeneity, small study effects, or excess significance. Across the 57 topics, large heterogeneity was observed in the proportion of associations fulfilling various quantitative criteria. The quantitative criteria were mostly independent from one another. Across 62 associations assessed in both RCTs and in observational studies, 37.1% had effect estimates in opposite directions and 43.5% had effect estimates differing beyond chance in the two designs. Across 94 comparisons assessed in both MR and observational studies, such discrepancies occurred in 30.8% and 54.7%, respectively. Conclusions: Acknowledging that no gold-standard exists to judge whether an observational association is genuine, statistically significant results are common in observational studies, but they are rarely convincing or corroborated by randomized evidence.
Keywords: Umbrella review, Observation studies, Randomized clinical trials, Mendelian randomization

Background
The validity of observational studies of putative risk or protective factors is a subject of continuous debate. Critics focus on the weaknesses of the observational evidence and occasionally debates get further fueled by comparisons against other designs, in particular randomized trials. Usually debates address either single research questions or few associations [1,2]. However, now we have the opportunity to assess systematically collected and synthesized evidence from thousands of observational associations. In the last decade, numerous umbrella reviews have summarized systematically the evidence from meta-analyses of observational epidemiological studies across entire fields of research [3,4]. Umbrella reviews also typically assess the observational evidence by looking at the level of statistical support (statistical significance of results), the amount of data, the consistency across different studies, and hints pointing to potential bias. A series of seven standardized quantitative criteria (Table 1 and Additional file 1: Appendix Method 1) have been previously proposed and are commonly used [3][4][5][6].
Some of these umbrella reviews have also included systematic assessments of meta-analyses of randomized controlled trials (RCTs) and of Mendelian randomization (MR) studies (an alternative way to generate an equivalent to randomization under certain assumptions using genetic instruments) [7]. Juxtaposing observational and randomized evidence may allow to corroborate results and probe causality.
Here, we overview the evidence obtained from 3744 meta-analyses of observational studies included in umbrella reviews evaluating putative risk or protective nongenetic factors. We evaluate how these meta-analyses of observational studies perform on different quantitative criteria that address statistical significance, amount of evidence, consistency, and hints of bias. We also assess the concordance of observational epidemiological data Table 1 The seven standardized criteria

Levels of evidence Description
Convincing • Associations with a statistical significance at P < 10 −6 • More than 1000 cases included (or more than 20,000 participants for continuous outcomes) • The largest component study reporting a significant result at P < 0.05 • A 95% prediction interval that excluded the null • Absence of large heterogeneity (I2<50%) • No evidence of small study effects (P > 0. 10) • No evidence of excess significance (P > 0. 10) Highly suggestive • Associations with a statistical significance at P < 10 −6 • More than 1000 cases included (or more than 20,000 participants for continuous outcomes) • The largest component study reporting a significant result at P < 0.05.

Suggestive
• Associations with a statistical significance at P < 0.001 • More than 1000 cases included (or more than 20,000 participants for continuous outcomes).

Weak
• Associations with a statistical significance at P < 0.05 Previous umbrella reviews have used various criteria to assess the evidence from meta-analysis of observational epidemiological studies. The combination of these criteria allows to tentatively classify evidence from meta-analyses of statistically significant risks and protective factors into four levels described below. A more detailed description of the criteria can be found in Additional file 1: Appendix Method 1 against corresponding meta-analyses of RCTs and MR studies.

Data sources and searches
We systematically searched PubMed, up to November 19, 2020, for studies labeled as umbrella reviews in their title: umbrella [Title] AND review [Title]. The protocol has been registered on the Open Science Framework [8].

Study selection
All umbrella reviews including meta-analyses of observational studies assessing putative risk or protective factors were eligible. We considered all putative factors (i.e., any attributes, characteristics, or exposure of an individual [9] that may either increase or decrease the occurrence of any type of health outcomes). Umbrella reviews not assessing any putative risk or protective factors in observational settings or not using any of the seven previously proposed standardized criteria (Table 1) to assess the evidence were excluded. One author (PJ) screened all resulting articles from the literature search for inclusion criteria and consulted with a second author (JPA) when in doubt. If two or more umbrella reviews had 50% of their associations (i.e., a putative risk or protective factor with a health outcome) assessed overlapping, we retained the one with the largest number of associations.

Data extraction
At the umbrella reviews level, we abstracted data regarding study design (observational studies alone or combined with other study types); number of factors evaluated by study design, when available; methodological quality tool used (e.g., AMSTAR [10]); and method used to evaluate the evidence (i.e., the seven standardized criteria [3][4][5][6] or other method). We then extracted the following data for each metaanalysis included in each umbrella review examining the association of a putative risk or protective factor with a health outcome: exposure, outcome, study designs included (e.g., cohort or case-control studies), number of included studies, participants, metric used (e.g., odds ratio, risk ratio, hazard ratio, mean difference, standardized mean difference), and data necessary for the evaluation of the pre-specified seven standardized criteria (Table 1). Data extraction was repeated limited to data from prospective cohort studies. When cohorts were mentioned, without specification of whether these were prospective or retrospective, we kept these data and then excluded them in separate sensitivity analyses.
For umbrella reviews that also separately considered RCTs and MR studies besides the observational association studies, we extracted the effect size and corresponding 95% confidence interval, total number of participants, number of cases/events, and genetic instruments used for MR studies. We did not perform any new quality assessment and relied on the ones performed by umbrella review authors. Two authors (PJ and AA) independently extracted 20% of the included umbrella reviews, while the rest was split between them. Discrepancies were resolved through consensus.

Data synthesis and analysis
We started by reassessing the evidence for each association using the pre-specified list of criteria presented in Table 1 (more details in Additional file 1). In case of missing data, the criterion was considered as failed. The number and proportions of associations fulfilling each criterion and meeting the different levels of evidence (i.e., convincing, highly suggestive, suggestive, and weak) based on their combination (Table 1) were counted for each umbrella reviews (also labeled as topic). For each level of evidence, proportions were summarized across umbrella reviews using the restricted maximum likelihood random effects model meta-analysis and the arcsine transformation to normalize and stabilize the variance [11]. Similarly, proportions were summarized for each criterion but focusing solely on statistically significant associations (those with P < 0.05 for the random effects summary effect). The between-umbrella heterogeneity was estimated using I 2 [12].
The concordance between the 7 criteria was assessed by Cohen's kappa (κ), where a κ<0.6 represents weak agreement [13,14]. First, we estimated the different κ across all umbrella reviews, including only statistically significant associations (those with P < 0.05 for the random effects summary effect). We then estimated the different κ and their corresponding confidence intervals within each umbrella review and combined them using random effects [15].
In previously published umbrellas, when all 7 criteria are met (P < 10 −6 , ≥1000 cases (or ≥20,000 participants for continuous factors), P < 0.05 in the largest study, 95% prediction interval excluding the null [16,17], and no large between-study heterogeneity, small study effects [18][19][20], or excess significance [21][22][23]), the evidence has been called "convincing" [3][4][5][6] since there is strong statistical support, large amount of evidence, consistency, and no overt signals in the bias tests. We should acknowledge, however, that there is no gold standard of what constitutes a genuine risk or protective factor. Some convincing associations may have some other problem in their evidence that invalidates them. Conversely, other associations that are not mapped as convincing may well be true. Allowing for this uncertainty, we tried to address which criteria were the most constraining to reach a convincing level of evidence, as each criterion was separately removed from being required to have an association called convincing. This analysis was performed only on statistically significant associations for which information on all seven criteria was available. Numbers of additional associations reaching a convincing level of evidence were recorded. In addition to testing the different criteria, different statistical thresholds (P < 0.001 and <0.05) were also tested as alternatives to the original convincing level of statistical significance (P < 10 −6 ). We also recorded how evidence was impacted by restricting the assessment of associations to prospective cohorts.
For associations assessed both by meta-analyses of observational studies and by either meta-analyses of RCTs or MR studies, we compared the effect sizes and corresponding 95% confidence intervals. The estimates across different designs were paired according to outcome, exposure, comparison, and population. For RCTs, if there were more than one meta-analysis for the same topic, we retained the one with the largest number of studies included. For MR studies in case of multiple studies for one observational association, each study was compared with the corresponding meta-analysis of observational studies. We specifically examined if the direction and statistical significance of the associations were concordant with the direction and statistical significance of effects in meta-analyses of RCTs and MR studies. We considered the traditional P < 0.05 threshold of statistical significance and also the more recently adopted P < 0.005 [24].
Moreover, to investigate whether the difference between the meta-analyses estimates was beyond chance, Q tests were performed (P < 0.10) [25]. For ease of interpretation, we converted all weighted mean differences (WMDs) and standardized mean difference (SMDs) to odds ratio (OR) equivalents [26] and assumed that relative risks (RRs) and hazard ratios (HRs) were interchangeable with ORs (a reasonable assumption for mostly rare event rates and for a minority where event rates are substantial, the OR is substantially larger than the RR). We also checked how often OR estimates using the different designs differed by two-fold or more.
For factors with statistically significant results both in observational as well as RCTs or MR studies' evidence (and thus have the most consistent support), we recorded the pattern of the seven pre-specified criteria in the meta-analyses of observational epidemiological data.

Eligible umbrella reviews and meta-analyses of observational associations
The literature search yielded 449 articles of which 180 umbrella reviews were potentially eligible. Of those, 123 umbrella reviews were excluded as they had limited or inadequately reported data available, and did not use the seven standardized criteria to assess the evidence of their included associations or reported associations overlapped by over 50% with another umbrella review ( Fig.  1).
Fifty-seven umbrella reviews including 3744 associations assessed by meta-analyses of observational studies were included [5,6, (Fig. 2 and Table 2). The median number of estimates included in each metaanalysis was 7 (IQR 4 to 11) ranging from a minimum of 2 up to 309 estimates.
Assessment according to a set of 7 pre-specified quantitative criteria Overall, 99 (2.6%) associations were graded as convincing, 253 (6.7%) as highly suggestive, 440 (11.8%) as suggestive, and 1497 (40.0%) as weak and 1455 (38.9%) were not statistically significant at P < 0.05 (Fig. 2). Metaanalyses of the proportions of convincing and highly suggestive associations across the 57 topics resulted in 1.3% (95% CI [1.0-2.2%]) summary proportion for convincing and 4.6% (95% CI [2.9-6.6%]) summary proportion for highly suggestive associations, and both had very high between-topic heterogeneity (I 2 = 73.9% and I 2 = 85.7%, respectively) (  (Table 2). Moreover, the number of nonstatistically significant associations (those with P≥0.05) varied substantially between topics from 0% for the associations of depression with mortality outcomes, antipsychotics with life-threatening events, and health factors with loneliness [40,55,68] to 80.7% for risk factors of prostate cancer [41]. 41.4% (1549/3744) of the associations had at least one missing criterion (Additional file 3: Figures 6 to 7). An additional 25 and 82 associations would have reached a convincing and highly suggestive level of evidence, respectively, if missing criteria were considered to be satisfied.
We performed meta-analyses for the proportion of associations that met each of the 7 pre-specified quantitative criteria across the 57 topics, limiting to the 2289 statistically significant associations. Only 29% (95% CI [24.9-33.3%]) of the associations had P < 10 −6 . Conversely, 74 [72.6-82.5%]) of the associations with available data had no signals of smallstudy effects or excess significance, respectively. Between-topic heterogeneity for the presence of each criterion was typically high (Table 3 and Additional file 4: Figures 8 to 15).

Concordance between the 7 pre-specified quantitative criteria
There was a limited concordance between the different criteria, meaning that they provide mostly independent information (Fig. 3). Excluding the kappa coefficients for the concordance of different P-value thresholds, a weak to moderate concordance existed only between prediction intervals excluding the null and P < 10 −6 (κ=0.44) (Additional file 5: Table 1 and Additional file 6: Figures  16 to 43).
Impact of each pre-specified criterion on number of associations deemed to have convincing evidence 1457 statistically significant associations (P < 0.05) had information available on all 7 criteria. Replacing the Pvalue threshold of <10 −6 by <0.001 as a requirement for convincing evidence, convincing associations increased from 6.8 to 9.2% and increased even further to 9.7% when the threshold was set at <0.05 (Table 4). The most constraining criterion appeared to be the absence of large heterogeneity (I 2 > 50%); removing it increased the number of convincing associations to 10.9%.

Analyses limited to prospective cohort studies
We were able to isolate 1141 associations which included only cohorts or where it was possible to separate cohort studies from other designs. Out of the 1141 associations, 849 were assessed by an unspecified mix of prospective and retrospective cohorts with no means to distinguish them from one another, 126 only by prospective cohort studies, 25 only by retrospective cohort studies, and 141 by a mix of study designs but where it was possible to separate the prospective cohort studies from the other designs. Across the 1141 associations, when limited to cohort studies, convincing associations decreased slightly from 5.7% (n = 65) to 4.2% (n = 48), and highly suggestive associations decreased from 13.5% (n = 154) to 11.7% (n = 133) ( Fig. 2 and dataset available on the Open Science Framework [82]).

Comparison against RCTs and MR studies
Only 16 out of the 57 umbrella reviews also investigated evidence from RCTs, [36,37,44,45,47,52,56,69,77], MR studies [27,33,38,62,73], or both [6,71] in addition to observational studies. Of those 16, 5 had no overlapping associations between the different study designs [37,44,47,52,77] and one only provided a narrative summary of MR studies [62]. For 121 of the 882 observational associations evaluated in the 16 included umbrella reviews, evidence from 62 meta-analyses of RCTs or 60 MR studies could be juxtaposed; of note, one association was assessed both by a meta-analyses of RCTs and by a MR study. Nine observational associations were assessed by more than one MR study using different genetic instruments, thus resulting in a total of 94 comparisons. Results are presented in Fig. 2 and Additional file 7: Table 2 and Additional file 8: Table 3. When comparing meta-analyses of observational studies against meta-analyses of RCTs, half of the associations (31/62) were only statistically significant in metaanalyses of observational studies (at the P < 0.05 level), while eight were only statistically significant in metaanalyses of RCTs. Four estimates were statistically significant with point estimates in the same direction for both types of design. Conversely, for one association, the point estimates were statistically significant, but in different direction, statins significantly increased the risk of pancreatitis (OR= 1.  Table 2). When the P < 0.005 level was used, only two associations were statistically significant in both meta-analyses of observational studies and RCTs. The differences between the meta-analyses estimates of observational studies and RCTs were beyond chance for 43.5% (27/62) associations (P < 0.10 for the χ 2 Q test) and 12.5% (8/64) differed in their effect sizes by two-fold or more in the two designs (Additional file 9: Figure 44 to 45).
Of 94 comparisons between meta-analyses of observational studies and MR studies, 62.8% (59/94) were solely statistically significant in observational studies (at the P < 0.05 level). Eleven comparisons showed a statistically significant evidence in both study designs with point estimates in the same direction. However, seven comparisons resulted in discordant results with statistically significant point estimates in opposite direction. Overall 30.8% (29/94) comparisons had point estimates in opposite directions between meta-analyses of observational studies and MR studies. Between MR studies, differences in the direction of the point estimates were also noted. Fig. 2 Overview of the included associations. MR, Mendelian randomization; OBS, observational studies; RCTs, randomized controlled trials. The statistical significance threshold was at P < 0.05. *Twenty-one of which were not assessable anymore as included only one cohort study per association. † Sixteen of which were not assessable anymore as included only one cohort study per association     Table 3). When using the P < 0.005 level for claiming statistical significance, only seven out of 18 associations remained statistically significant in MR studies. When comparing the meta-analysis' effects in observational studies versus the MR studies, there were significant heterogeneity (P < 0.10 for the χ 2 Q test) between the two designs for 54.7% (54/94) comparisons and 12 (12.8%) differed by two-fold or more in their effect sizes (Additional file 9: Figures 44 to 45). Overall, only four associations assessed by observational studies and RCTs and another three comparisons assessed by observational and MR studies had consistently statistically significant results (P < 0.05) in the same direction. Of these seven associations, the seven pre-specified criteria had graded two of them as highly suggestive, two as suggestive and three as weak.

Discussion
We assessed the evidence obtained from observational studies for associations on 3744 putative risk and protective factors assessed by a median of 7 (IQR 4 to 11) estimates per meta-analysis from 57 umbrella reviews on diverse topics. Although the majority (61.1%) of the investigated associations were statistically significant at the traditional P < 0.05 level, only 2.6% and 6.7% were classified as having convincing or highly suggestive evidence, respectively, using a set of pre-specified criteria that have been used in the literature of umbrella reviews [3][4][5][6]. The proportions of associations meeting the various prespecified criteria of statistical significance, amount of evidence, consistency, and lack of hints for bias and reaching different level of evidence varied across topics. Variability was highly prominent for the proportion of probed associations that had non-statistically significant (P≥0.05) results (0-80.7%).
The seven criteria that have been previously used to assess evidence from meta-analyses of observational associations have been developed ad hoc [3][4][5][6] aiming to capture sufficient statistical support, amount of evidence, consistency, and lack of signals that may herald bias [12,20,21]. It is unknown how well they can really identify convincing/strong evidence, let alone causality. A perfect gold standard is missing for causality in observational associations. Nevertheless, we could assess here the performance of these criteria against each other. They mostly showed low concordance among themselves and thus may offer relatively independent, complementary insights into the evidence of an observational association. Most associations did not offer any signal of small-study effects and excess significance. However, these results are to be interpreted with caution since both tests are not definite proof of presence or absence of bias; given the typically small or modest number of studies in each meta-analysis the power of these tests is very limited [83]. Conversely, substantial evidence of heterogeneity was common, with most meta-analyses of observational associations presenting I 2 estimates exceeding 50%. Heterogeneity was also the most constraining criterion. When removed from the list of criteria to reach a convincing level of evidence, the number of associations increased substantially. Heterogeneity in meta-analyses of observational studies may be due to bias but also genuine difference between studies [5]. It is often hard to detangle between the two.
It is important to acknowledge the limits of our proposed criteria and of the ways that they can be combined to reach an overall grading. P-value thresholds are set arbitrarily, the random effects meta-analysis may produce inconsistent results [84], the excess significance of bias has limited power if only a few studies are statistically significant [21,22], and similarly both small-study effect and excess significance testing may be misleading when there is substantial heterogeneity [85]. Even if all 7 criteria are fulfilled, observational evidence could still remain at risk of unmeasured confounding, undetected bias, and reverse causality [6]. One illustration would be the downgrading of the evidence for associations for which we re-analyzed the data using only cohort studies.
Furthermore, we should acknowledge that different types of observational associations vary a lot in prior plausibility and thus the amount of statistical support that is required to make them convincing is likely to vary. Fields like pharmacoepidemiology might be very reluctant to adopt a P-value threshold of P < 10 −6 for signal detection of medication harms. In agnostic searches, conversely, even such P-value thresholds may not be low enough [86]. Field-specific setting of P-value thresholds has been proposed, e.g. through empirical calibration [87,88], but such calibrations are still unspecified and lack consensus for the vast majority of fields in epidemiology.
Most decision-makers have required evidence of causality for interventions, but licensing based on observational evidence alone is becoming increasingly common [89,90]. While discordant results between RCTs and observational studies were highlighted long ago [1,91,92], there is ongoing debate on whether overall there are big differences and even on whether these designs can be formally compared when the same factor/intervention is involved [93,94]. Most of the evidence that has been systematically assessed to-date pertains to situations where therapeutic interventions are assessed [2]. On average, the two designs may give similar results [2], but single comparisons may deviate substantially in the effect size estimates and in some settings even average effects seem to differ markedly across designs [95]. The observational literature that we assessed was mostly compiled to assess risk factors rather than interventions per se. Most of these risk or protective factors would not be possible to operationalize into intervention equivalents. However, when both observational and randomized evidence were available, in our overview, point estimates in different direction were quite common, 37.1% for observational studies versus RCTs and 30.8% for observational versus MR studies. Discrepancies beyond chance in the effect size estimates occurred in 43.5% for observational studies versus RCTs and 54.7% for observational studies versus MR studies.
Our study has several limitations. First, the seven standardized criteria were pre-specified based on what had been done previously in umbrella reviews. However, no consensus exists for a gold standard against which any criteria may be affirmed to truly quantify strength of the evidence and risk of bias [36] in observational studies of risk factors. Other efforts to-date have focused mostly on interventional evidence from RCTs where some observational evidence may be included (e.g., GRADE [96]) or specifically for interventional observational studies (e.g. ROBIS [97]).
Second, even though we included tens of thousands of observational studies, our assessment covers only specific fields for which umbrella reviews had been performed and these may not necessarily be fully generalizable to all observational epidemiology. Furthermore, only 16 out of 57 umbrella reviews also investigated meta-analyses of RCTs and MR studies in addition to meta-analyses of observational studies. Thus, we might not be capturing all meta-analyses of RCTs and all MR studies that reflect our included associations. MR studies are fairly recent and may even be more difficult to capture as they are often included in large genomewide associations without being clearly identified. Moreover, both false positives and false-negative claims of causality may be made with MR studies, e.g., in the presence of weak genetic instruments.
Third, we used existing umbrella reviews which themselves focus on already existing meta-analyses. We did not appraise ourselves the quality of the included metaanalyses as this was already performed by the umbrella reviews' authors but flawed meta-analyses are not uncommon [98] and results should be taken with caution. The original studies may also be affected by selection bias, missing data, inadequate follow-up, and poor study Meta-analyses for the individual criteria excluded associations with missing data. Meta-analyses for the levels of evidence were conducted across all 3744 associations regardless of their statistical significance status. The meta-analyses for the individual criteria were conducted across the 2289 statistically significant associations. Out of 2289, statistically significant associations, 182 associations did not report on the number of cases,508 on whether the largest study had P < 0.05, 153 on the 95% prediction interval, 12 on the I 2 for heterogeneity, 125 on the small study effect test, and 237 on the excess of significance bias. Data on all 7 criteria were available for 1457 statistically significant meta-analyses conduct. For example, the serum uric acid [6] and statins [36] umbrella reviews also assessed the original studies in depth and found errors (e.g., incorrect data combining different level of exposure, use of duplicated data, and inclusion of different populations) that led to downgraded associations. Such errors require in-depth re-evaluation of the primary studies and their data. If anything, the proportion of associations with convincing or highly suggestive evidence might decrease even further, if one were to downgrade evidence because of the poor quality of meta-analyses and of primary studies. Finally, some of the included meta-analyses in umbrellas of different topics may have had some overlap, but we kept them so as to have each topic represented in its totality. We estimate that approximately 5% of the metaanalyses may be duplicates across two different topics, Fig. 3 Kappa heatmap for the seven criteria across all umbrella reviews. Only statistically significant associations (with P < 0.05 for the random effects summary effect) were included in the Cohen's kappa analysis. A κ<0.6 (lighter red) represents a weak, 0.6≤κ< 0.8 a moderate (red), and κ≥0.8 (dark red) a strong strength of agreement. Conversely, a κ>−0.6 represents a weak (light blue), −0.8<κ≤−0.6 a moderate (blue), and κ≤−0.8 (dark blue) a strong disagreement. The kappa estimated within each umbrella reviews and combined using random effects meta-analyses are presented eFigure 5 and eFigure 6 These are the associations that are statistically significant (P < 0.05) and also have information on all criteria but the exact number depends on how exactly duplication/overlap is defined. Regardless, the proportion is low to affect the results materially.

Conclusion
Allowing for these caveats, overall, our bird's eye view evaluation across 3744 meta-analyses of observational evidence on risk factors suggests that strong, large-scale, consistent, and uncontested observational evidence is probably very uncommon, even though statistically significant results are very common. It is also uncommon to find consistent corroborating evidence from RCTs or MR studies. Associations from meta-analyses of observational studies can offer interesting leads but require great caution, especially when high validity is required for decision-making.
Abbreviations AMSTAR: A MeaSurement Tool to Assess systematic Reviews; HR: Hazard ratio; MR: Mendelian randomization; OR: Odds ratio; P: P-value; RCT: Randomized controlled trials; RR: Relative risks