The hidden big business behind your doctor's diagnosis

The Seattle Times

(KRT)

SEATTLE - You walk into your doctor's office for a physical exam and step on the scale. Last year, the doctor said you were overweight. Now he says you are obese - at the same weight.

A nurse takes your blood pressure. You have hypertension - with the same previously healthy reading you've had for years.

The doctor scans your wrist bone. You have a condition called "osteopenia" - with the same bone density that was fine last time you were measured.

You mention you are not enjoying sex as much as you used to. Diagnosis: a new kind of sexual dysfunction.

You leave the office with a head full of worry and a fistful of new prescriptions, joining more than 40 percent of Americans who take one or more prescribed drugs daily in the effort to stave off more serious trouble.

You are suddenly sick, simply because the definitions of disease have changed. And behind those changes, a Seattle Times examination has found, are the companies that make all those newly prescribed pills.

The Seattle Times found that:

-Pharmaceutical firms have commandeered the process by which diseases are defined. Many decision makers at the World Health Organization, the U.S. National Institutes of Health and some of America's most prestigious medical societies take money from the drug companies and then promote the industry's agenda.

-Some diseases have been radically redefined without a strong basis in medical evidence.

-The drug industry has bolstered its position by marketing directly to the health-conscious consumer, leading younger and healthier people to consider themselves at risk and to start taking medications.

Every time the boundary of a disease is expanded - the hypertension threshold is lowered by 10 blood-pressure points, the guideline for obesity is lowered by 5 pounds - the market for drugs expands by millions of consumers and billions of dollars.

The result? Skyrocketing sales of prescription drugs. Soaring health-care costs. Escalating patient anxiety. Worst of all, millions of people taking drugs that may carry a greater risk than the underlying condition. The treatment, in fact, may make them sick or even kill them.

Dartmouth Medical School researchers estimate that during the 1990s, tens of millions more Americans were classified as having hypertension, high cholesterol, diabetes or obesity simply because the definitions of those diseases were changed.

Today, three of every four Americans technically have at least one of those diseases. But millions of them are not truly sick and may never be, even without medication. The Dartmouth researchers said it was unknown whether those people would benefit from early detection and treatment, while it is "an open question" whether branding them diseased and feeding them drugs may be causing significant physical or psychological harm.

The medical profession's term for these people is "the worried well." They are otherwise healthy people who have risk factors, such as high blood pressure or high cholesterol, but may never suffer a heart attack or stroke.

Dr. Alfred Berg, chairman of family medicine at the University of Washington and a past chairman of a federal task force that fights drug-industry influence on disease and treatment guidelines, said the best advice for many people at risk of so-called "lifestyle diseases" is to simply change their lifestyles.

"Diet and exercise and righteous living - but nobody wants to hear that," Berg said.

Instead, he says, a "commercial prevention" industry has emerged, focused on selling drugs to people who don't really need them but who can pay for them.

"We have a system that nobody but Big Pharma is happy with," says Dr. John Kitzhaber of The Foundation for Medical Excellence in Portland, who was Oregon's governor from 1995 to 2003.

But the drug companies can't do it alone. They need, and receive, support from much of the world's medical establishment.

Treatment guidelines established by international and national health organizations instruct physicians on diagnosis and treatment of disease and are meant to be scientifically pristine. But many of those groups lack any process for preventing or disclosing conflicts of interest.

The Seattle Times found that for a broad spectrum of diseases, the experts writing the treatment guidelines had drug-company ties ranging from research contracts to consultancies to stock ownership.

Berg's group, the U.S. Preventive Services Task Force, flatly prohibits any conflicts of interest, either in money or previous research. As a result, it is consistently more conservative in its recommendations than other medical guideline-writing groups and pushes fewer drugs.

Dr. H. Gilbert Welch, a Dartmouth medical professor and editor of Effective Clinical Practice, a journal of the American College of Physicians, agrees that his profession shares the blame for what he sees as an overdose of preventive medicine.

The problem begins, he said, with the expanding definitions of disease.

"You can't tell me that three-quarters of my population is sick before I start," he said. "That just doesn't pass the laugh test.

"Our business is in a hard place right now," Welch said. "A lot of docs know it's not right."

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WHAT YOU SHOULD KNOW

In general:

-Ask your doctor about the actual health risks for someone with your weight, age, sex, race and overall health.

-Ask how the treatment might translate into longer life or better quality of life for someone with your characteristics.

-Inquire about the details of the treatment: How does it work? What will it do for you specifically? What evidence is there that it will work better for you than other treatments available? What other areas of the body might it affect?

-If a drug is recommended, ask: How long you will have to take it? What protections does it offer, and what proof exists that it is worth your trying?

-Ask about the good and bad effects the drug has had on other people who have taken it.

-Ask your doctor and pharmacist how the drug will interact with other drugs you're taking.

Dr. Marcia Angell, former editor in chief of The New England Journal of Medicine, offered this advice in her recent book, "The Truth About the Drug Companies":

-Older drugs tend to have better safety records, so ask whether taking an older drug at a higher dose would be comparable to taking a new one for the same condition.

-Ask your doctors about their relationships with drug companies, whether they are paid to enroll patients in drug trials, or consult for drug companies whose products they prescribe. Such relationships should be viewed with caution.

-Ignore drug advertising, which increases the cost of drugs.

In searching for health information, use sites accredited by HON - Health On the Net Foundation. The nongovernmental Swiss foundation was founded to link people with "authoritative, trustworthy Web-based medical information." It links only to those sites that adhere to its code of conduct: http://www.hon.ch.

Drug safety: The FDA provides information about drug recalls and problems with safety: www.fda.gov/medwatch/index.html

Guidelines: The U.S. Preventive Services Task Force writes guidelines for treating various diseases. Its members are independent scientists, with no financial ties to drug companies. To search for guidelines: www.ahrq.gov/clinic/

HYPERTENSION: The first question to ask your doctor is: "How sick am I?" Because there is a range of risk associated with hypertension, ask for specifics on what risks are associated with your blood-pressure reading for people of your age, sex, race and overall health.

OBESITY: The first question to ask is: How much body fat is too much? Medical experts disagree about the point at which body fat presents a dangerous health risk and the best ways to reduce risk.

OSTEOPOROSIS: The use of portable X-ray machines to measure bone-mineral density in the wrist, finger and heel has proliferated in the past decade. But the method still considered the "gold-standard" is called central DEXA, an enhanced form of X-ray that measures bone density in the lower spine and hip - the areas where doctors are most concerned with preventing fractures. Because bone density varies at different spots in the body, devices that measure bone density at the heel, wrist or finger are not considered as accurate in predicting fractures.

Central DEXA can't predict you'll fracture a bone, but it can help assess your risk of having a fracture in the future based on your age, gender, race and overall health.

Bone health: For an overview on bone health, go to an advertising-free Web site run by Dr. Susan Ott, a bone specialist at the University of Washington: http://courses.washington.edu/bonephys/

DEEP-VEIN THROMBOSIS: When presented with a treatment plan, ask specific questions about the evidence behind it. Get a picture of the actual risks for your age, sex, race and overall health.

Inquire about the details of the treatment: What will it do for you specifically? What evidence is there that it will work better for you than other treatments available? Why is it better than no treatment at all?

FEMALE SEXUAL DYSFUNCTION: While experts agree that some women suffer from very real sexual problems, they disagree over whether those problems constitute a disease. Treatment guidelines have been published, along with new proposed definitions of various disorders, but they're controversial and still evolving.

While some doctors advocate psychotherapy and counseling as the main treatment, others have prescribed drugs that were approved for other uses. The use of those medications in women is largely untested, so the risks and benefits are hard to weigh.

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GLOSSARY

Disease: a collection of symptoms that constitutes a recognizable medical problem or condition. Diseases are increasingly defined by such surrogate measures as blood pressure or bone density, which can paint an inexact picture of risk.

FDA: Food and Drug Administration, the federal agency that regulates drug approval and drug safety.

Guideline: a set of recommendations from a group of experts that lays out findings about a disease and how to treat it.

NIH: National Institutes of Health, the primary federal agency for conducting and supporting medical research. An arm of the Department of Health and Human Services, the NIH consists of 27 institutes and centers that focus on various diseases.

WHO: World Health Organization, an agency of the United Nations that coordinates global response to epidemics and provides a common language for disease used by doctors and health systems around the world. The WHO routinely invites experts to meetings where they reach consensus on various medical conditions and how they should be treated. Those findings are considered the most authoritative in the world and influence the global practice of medicine.

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ON THE WEB: To read the 5-part series, "Suddenly sick," go to www.seattletimes.com/suddenlysick

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(Duff Wilson reported and wrote this story while working for The Seattle Times. He now reports for The New York Times.)

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(c) 2005, The Seattle Times. Distributed by Knight Ridder/Tribune News Service.