The Medicalizing of America
Part I: The Numbers Game
Medicalize: "To identify or categorize (a condition or behavior) as being a disorder requiring medical treatment or intervention," American Heritage Dictionary.
Responses to virtually all questions, medical and otherwise fall into two categories: 1. Those having a finite number of answers, including yes, no, or in-between, for example "are you hungry?" or "are you sick?" and 2. Questions having a range of answers or values. Biologic and other scientific measurements fall into this latter category and include such things as weight, age, height, blood pressure, blood chemical values, such as glucose, cholesterol, PSA, etc. Where we get into trouble is in deciding, particularly in medicine, what is indeed normal and what is not. No matter where we place the dividing line or cutoff point, we are faced with an irresolvable medical dilemma.
If we make the cutoff between normal and abnormal too low, we include too many normal in the abnormal group (called false positives, a Type I error); if the cutoff is too high, we include an excess of abnormal in the normal group (false negatives, Type II error). In the first instance we call too many well people sick, and in the latter, too many sick people well. (We are assuming the spectrum of low to high corresponds to the range of normal to abnormal; sometimes this range is reversed.)
Over the years, various cutoff points for normal values have been based on generally accepted statistical and common sense clinical grounds. For example we have "normal" values for fasting and non-fasting blood sugars, upon which the diagnosis of diabetes is based; the "normal" level for blood pressure, defining the condition, hypertension; cutoff points for weight, defining obesity; and "normal" levels of blood lipids (HDL,LDL and total cholesterol) which for some even define the presence of heart disease (sic!). In what appears as a fatally misguided hope of extending treatment benefits to as many citizens as possible, various professional societies as well as Government Agencies have indeed changed our definitions of disease with unforeseen consequences. Specifically, in the present climate of change driven by a perceived need to keep us healthy and long-lived, these cutoff points have been lowered progressively and so drastically as virtually to create a nation of patients.
In a revealing article in Effective Clinical Practice (March/April 1999) Lisa M. Schwartz and Steven Woloshin conclude that the number of people with at least one of four major medical conditions (actually risk factors) has increased dramatically in the past decade because of changes in the definition of abnormality. Using data abstracted from over 20,700 patients included in this Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) conducted by the National Center for Health Statistics, the authors calculated the prevalence of diabetes, hypertension, elevated cholesterol, and being overweight under the old and the new definitions and calculated the net change (i.e., number of new cases). Here are the results reported in the above article.
Old Definition: Blood sugar > 140 mg/dl
People under old definition: 11.7 million
New Definition: Blood sugar > 126 mg/dl
People added under new definition: 1.7 million
Percent increase: 15%
The definition was changed in 1997 by the American Diabetes Association and WHO Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
High blood pressure is reported as two numbers, systolic or peak pressure and diastolic pressure when heart is at rest) in mm Hg.
Old Definition: cutoff Blood Pressure > 160/100
People under old definition: 38.7 million
New Definition: Blood Pressure > 140/90
People added under new definition: 13.5 million
Percent Increase: 35%
The definition was changed in 1997 by U.S. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Prehypertension, a new category created in 2003: blood pressure from 120/80 to 138/89 includes 45 million additional people! If one includes this category, we have a grand total of 97.2 million total numbers of hypertensives and prehypertensives (whatever that is).
High (Total) Cholesterol:
Old Definition: Cholesterol > 240 mg/dl total cholesterol
People under old definition: 49.5 million
New Definition: Cholesterol > 200 mg/dl total cholesterol
People added under new definition: 42.6 million
Percent increase: 86%
The definition was changed in 1998 by U.S. Air Force/Texas Coronary Atherosclerosis Prevention Study.
Body Mass Index (BMI) is defined as the ratio of weight (in kg) to height (in meters) squared and is an inexact measure of body fat, though it supposedly establishes cutoff points of normal weight, overweight, and obesity.
Old definition: BMI > 28 (men), BMI > 27 (women)
People under old definition: 70.6 million
New definition: BMI > 25
People added under new definition: 30.5 million
Percent Increase: 43%
The definition was changed in 1998 by U.S. National Heart, Lung and Blood Institute.
"The new definitions ultimately label 75 percent of the adult U.S. population as diseased," conclude the two researchers. They add cautiously that "...the extent to which new 'patients' would ultimately benefit from early detection and treatment of these conditions is unknown. Whether they would experience important physical or psychological harm is an open question."
We seem to live in an equal opportunity consumer culture tyrannized by the fear of growing "epidemics" going by the leading risk brand names, High Blood Pressure, Obesity, Diabetes, and High Cholesterol. Just read the papers, peruse the Internet, or turn on your TV to learn what the Government watchdogs, the consensus insurgency, and the other image makers have to say about our disastrous state of health.
Several related questions arise when we consider the implications of these new definitions of disease (actually disease risk-markers). First how did these official and semi-official watchdogs achieve their status of "guideline-makers,"who appoints them and why, and how powerful an influence do they wield in terms of medical practice? Finally, one has to wonder what is the rationale for adding over 86 million new "patients" (not counting 45 million "prehypertensives") to our already staggering over-the-top healthcare cost.
Coming soon, these and other issues will be examined in our next newsletter.
Martin F. Sturman, MD, FACP
Copyright 2005, Mathemedics, Inc.
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