There’s an increasing vogue in medicine to treat essentially healthy people. Perhaps the most obvious example of this is people with ‘raised’ cholesterol. You could be healthy, fit and active, of healthy weight, a non-smoker, eating a healthy diet, but that won’t necessarily mean you won’t wind up on a drug to reduce your cholesterol.
The threshold for cholesterol at or over which doctors consider treatment is 5.0 mmol/l (about 190 mg/dl). Here you can read that average cholesterol levels in the UK are 5.7 mmol/l (220 mg/dl). Cholesterol is an essential body constituent, is present in the membranes of all cells in the body and is the essential building block of ‘steroid’ hormones such as cortisol, oestrogen and testosterone. As well as vitamin D. So, let’s get this straight – according to many doctors and scientists, having levels of an essential body constituent at normal levels is putting people at mortal danger of disease, and is something that requires treating.
Don’t forget too, that treating essentially healthy people with statins does not save lives.
But the desire that some have for medicating health people does not end with treating normal levels of cholesterol. It’s now extending into conditions being termed things like ‘pre-diabetes’ and ‘pre-osteoporosis’. Calls are coming from certain factions in the medical community for individuals deemed to be at risk of developing conditions to be treated in an effort to prevent the actual condition. The theory is that it will help to treat individuals ‘at risk of being at risk’.
This week’s British Medical Journal contains an article by Ray Moynihan  and accompanying editorial  which addresses some of the issues and politics surrounding ‘pre-hypertension’ (blood pressure at the high end of normal that is not so high as to be classified as raised). While many doctors concede that this is not a condition in itself, there are plenty of people who would like to see this ‘pre-condition’ more widely recognised and treated. On what basis? Because treatment might reduce the risk of developing high blood pressure (hypertension) – a condition which itself it associated with enhanced risk of health issues such as stroke and kidney disease.
Evidence supporting this concept comes, at least in part, in the form of study published in 2006 which found the anti-hypertensive drub candesartan taken for two years helped to reduce the risk of people developing hypertension. However, as Ray Moynihan’s piece points out, 7 of the 11 authors of this study declared multiple ties to drug companies and one was actually an employee of Astra-Zeneca (who make candesartan). What this study does not tell us, however, is if treating pre-hypertension actually helps anyone in terms of risk of disease or death.
The drug company ties are concerning because the pharmaceutical industry stands to do very well out of the selling and treatment of pre-conditions. It’s been estimated that one in three adults has ‘pre-hypertension’, which amounts to more than 50 million people in the US alone.
However, not everyone, as Ray Moynihan points out, is so enthusiastic about the concept of pre-hypertension and the concept of treating it. In his piece, Moynihan quotes Curt Furberg, professor of public health at Wake-Forest University in the US as saying “It’s a way of increasing markets for pharmaceutical companies.” In the 1990s Professor Furberg sat on the committee responsible for writing the guidelines for the treatment of hypertension in the US. His desire was for members of the committee to declare their financial conflicts of interest. When this was not made mandatory, Professor Furberg resigned. The guidelines were published in 2003, and it transpired that 11 of the 12 committee members had multiple ties to the drug industry.
Moynihan ends his piece with the following paragraph:
“Until now the definition of what constitutes a condition, or pre-condition, and the guidelines for treating it, have been left largely to senior members of the medical profession and their esteemed societies, often meeting in drug company sponsored forums like the coming Vienna conference. But for people like Professor Furberg, the profession has become too close to industry. He wonders whether it may be time for society at large to take more of a role in deciding who should be classified as sick. Clearly, preventing the devastating effects of heart attack, strokes, and hip fractures is in everyone’s interest, but whether medicalising billions of healthy people with a predisease label is the best way to go requires vigorous debate among a much wider group of voices. How to constitute more independent and broadly representative panels that can deliberate well outside the long shadows of the drug industry, may be a question worth pondering.”
In her editorial, Fiona Godlee, editor of the BMJ writes:
“So is it time for society at large to take more of a role in deciding who should be classified as sick? Unless the profession can regain its independence from commercial influence, my answer is yes.”
I think it is a genuine shame that the medical profession has such close commercial links with the medical industry. On the plus side, though, there is not doubt that these unhealthy ties are getting increasing exposure, and I applaud Ray Moynihan and the BMJ for their part in this. There was a time, perhaps not so long ago, where clear conflicts of interest such as those detailed here would remain undisclosed or unheard of.
1. Moynihan R. Who benefits from treating hypertension? BMJ 2010;341:c4442
2. Godlee F. Are we at risk of being at risk? BMJ 2010;341:c4766