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 [1] and accompanying editorial [2] 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.
References:
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
And one could argue that dietitians have equally become too close to the food industry in much the same way.
The more I immerse myself in informative health blogs and books, the more I am disappointed by the medical industrial machine. I recently went back to college after many years in jobs I disliked. I was/am seriously considering applying to med school, but sometimes I wonder if I want to be a part of such a flawed system. How depressing.
John, an excellent topic for your blog, thanks!
Linking to Roy Moynihans’ homepage from the link you include he looks to be a chap with some interesting opinions. Have you come accross his journal submissions before? Have you, or are you galvanised to, read any of his books? His title “Selling Sickness” fires curiosity in me.
It is interesting that this and other BMJ editorials are worthy of wider attention to a wider audience because they may just indicate a growing awareness and willingness amongst the medical fraternity to examine the symptoms of a maladapted National Health Service whose health and long term prospects of sustainability is being de-stabilised by the ever increasing imperative of the corporate agenda to influence practice and (prescriptive) behaviour of GPs.
And I’m in accord with Jamie that dieticians have largely adopted an orthodoxy that suits the convenience and agenda of the (process and retail) food industries. (ie. the orthodoxy that low-fat; high carbohydrate diets are unquestionably healthy.)
Also, notwithstanding that there are some excellent Dieticians and Nutritionists, Nutritionism and Nutritionists themselbves have largely permitted themselves to be co-opted to the agenda of the food industry machine, partly via their creative view of the role of food in ill-health/health, but also because simply dispensing advice to a client about what to eat does not make for a sufficiently viable business, so they have adopted an additional practice of prescribing supplements supplied in jars and blister packs, the sale of which is a valueable added income stream.
But the supplement manufacturing indistry is largely trending to be absorbed (via aquisitions and mergers, if you like) and fall under the controlling influence of prominent pharmaceuticals companies.
One highly successful supplement brand and vendor, Nutri Centre, passed into the hands of the UKs most prominent retailer, Tesco back in 2001. Tesco exchanged £2.9m in 2001 for for a 50.1% controlling stake, then subsequently converted to 100% ownership of Nutri Centre in 2007. Nutri Centre is in effect a ‘private label’ of Tesco that completes a neat three-sided economic (for profit) synergy that the paying customer need never know. The unknowing customer has fallen victim to information asymmetry.
Behind the deceptions there are subtle market distortions that result in the aspiration of a profitable return for industry at the cost of collateral damage to a consumers’ purse, or possibly worse, their health. Private labels, for eg., disguise the decline of diversity in markets.
Something to ponder on is that decline of divercity of supply or providers in markets could in itself be as destabilising to an economy as decline in species diversity almost certainly is to an ecology.
Something else to ponder on is if government policy and incentives (an issue you’ve raised before) directed at GPs stifles the diversity of ways GPs might otherwise elect to treat or advise a patient and that this in itself may be a hindrance to the possibilities of finding, testing, and evaluating alternative methods.
I think the salient point to register is that hard pressed GPs are apperently falling victim to the seductive promotion of ‘pre-conditions’ in much the same way that many consumers fall victim to the seductive virtues of value and convenience, such as two-for-one offers on ready meals, the like, and other naff foods. By not being fully informed each easily falls victim to information asymmetry.
For reasons I can’t briefly explain creating new markets has become an economic imperative. New markets do not have to be purposeful or virtuous, and increasingly they are not, as prescribing for ‘pre-hypertension’ illustrates.
Volunteers who ate a predominately raw diet comprised mostly of fresh vegetables and fruit whilst camping in an enclosure each had significant and rapid improvements in the commonly utilised markers for health such as Blood Pressure and cholesterol. But note, Ms Gartons’ explanation may not be entirely correct and may need to be taken with a pinch of salt.
The diet reduced the volunteers dependency upon energy dense foods from refined carbohyrtes such as sugar, grain, flour and derivative items. It also may have qualitatively altered the spectrum of fats that featured in the diets perhaps reducing consumption of industrially refined vegetable oils.
The beneficial effects of the diet could have been due in part to a reduction in certain polyunsaturated fatty acids, general reduction in the energy density of the food, from an increased dietary intake of (soluble) fibre, from Ms Gartons suggestions, or for one or several reasons in various permutations. Ms Gartons’ explanation, for whatever reason, remained within the conservative security of prevailing orthodoxy.
The ‘Going Ape’ experiment did have its’ limitations. The volunteers wre occupied for most of their waking hours simply chewing, digesting, or tripping to the lavatory, a factor that would limit ones’ ability to do other things like go to work and earn a living, but nonetheless perhaps there’s something that GPs, pateients, and society in general could learn from the experiment and apply within the constraints of modern lifestyles.
For one, if folks simply adopted the notion that there exists an exceedingly strong relationship between diet and health then GPs and people in general might not so readily fall victim to informmation asymmetry and ultimately to the very irrationality and asymmetry of capital itself.
I read your blog with increasing disgust at the pharmaceutical industry’s methods of selling their often needless products. You could argue that the entire population is ‘suffering’ from some kind of pre-condition, if you’re going to dish out pills just in case something might occur. Got a nasty bruise? Might end up as DVT, take a pill. Indigestion? Could be a pre-condition for ulcer or heart attack, take several more pills. How stupid does Big Pharma think we are? And why do some doctors seem quite happy to jump on the bandwagon?
Per Jamie’s comment (#1 above) about dieticians, the lead corporate sponsor of the American Dieticians Association is COCA COLA.
What a great form of hush money!!
Good work, COCA COLA.
Bad choice, ADA.
We were genetically pre wired ( as becoming modern humans dispersed globally from savannah)to walk, run and climb….13 miles per day ( “Going Ape”). No longer working to cultivate and gather our own food, we have evolved the various webs to get it. It is sub standard and breeds inflammation ( which statins treat, not cholesterol its epiphenomena).
Drink Hibiscus tea and leave pre-disease management to educated individuals who may work in partnership with Public Health enterprizes, not the sickness industry professionals.
to Feona…I don’t think some doctors have a choice…it is the ‘accepted method’ of getting levels down to the ‘predetermined level’ and therefore get paid for ‘helping’ the patient. If they don’t offer the drugs they don’t get paid…