Many diseases represent an arbitrary number

By | May 5, 2019

A wag once said: “There is no such thing as a healthy person, just one who has not had enough tests.”

As we make every minor deviation from the average into a disease, that jest is becoming uncomfortably close to the way our current medical system behaves.

Part of the problem is that many diseases represent an arbitrary cut-off of a number. Thus, hypertension is defined as a blood pressure above a specific threshold. We all have blood pressures, and these pressures vary from minute to minute. Clearly, everyone with any medical background would accept that a BP of 220/150 was a very bad thing and should be treated.

But how about 142/90? To demonstrate how arbitrary any number is, consider that the diagnosis of hypertension starts at 140/90 according to the European guidelines, and 130/80 according to the U.S. guidelines. The U.S. definition was recently changed to a lower cut-off, overnight classifying tens of millions of people as having a disease. Using this definition, almost half of all adults would now carry a diagnosis of hypertension.

Before the discovery of insulin, pregnant women with diabetes all died. Once insulin was introduced, diabetes became a treatable condition, and doctors went looking for it. Since blood sugars also range widely, and reflect when and what we last ate, arbitrary thresholds were set to define gestational diabetes, or diabetes developing during pregnancy. The numbers used were changed in 2008, not because of new knowledge but by consensus among experts. As is virtually always the case, the numbers were set to label many more women as having the disease — and therefore creating many more customers for the physicians treating them and the pharmaceutical industry.

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Then there are diseases that are only laboratory numbers. Thus chronic kidney disease is defined by a serum creatinine above an arbitrary number. The number picked does not take into account that kidney function slowly deteriorates with normal aging. Almost half of older adults are thus labeled as having chronic kidney disease even though most of them will never have any symptoms from their kidneys in their lifetime nor benefit from any treatment.

Proponents of these expanded definitions may well have the best of intentions, but over-diagnosis is not harmless. In many cases, people newly labeled with a disease are put on medications that are of minimal benefit and may do harm. They may become uninsurable or may have to pay higher premiums for life and health insurance.

The expert panels that promulgate these definitions almost invariably make changes that expand the pool of patients. They rarely look at the downside of over-treatment, and they tend to be dominated by academics with multiple financial ties to the pharmaceutical industry.

Your best defense against being labeled with one of these diseases by definition is to suggest that your doctor give you 6 to 12 months of lifestyle changes before giving you either a label or medication. Perhaps the desire to escape being labeled as hypertensive or pre-diabetic may be just what you need to motivate you to lose that 10 pounds you have always said you would and to start walking at lunchtime.

Edward Hoffer is an internal medicine physician and author of Prescription for Bankruptcy: A doctor’s perspective on America’s failing health care system and how we can fix it. He blogs at What’s wrong with health care in America?

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