Selling Sickness is the title of a book I mentioned in “You are ill — because we say you are” (2010/10/04). My full review of the book has now been published. I was reminded of it by this recent news item:
“Percentage of U.S. adults with hypertension holds steady at 30% — But CDC report shows more people have their high blood pressure under control”.
“Hypertension” means higher than “normal” or “natural”; but how is the normal or natural level determined?
In the United States, the appropriate levels for blood pressure, serum cholesterol, and a number of other physiological variables are defined by advisory panels at the Food and Drug Administration or the Centers for Disease Control and Prevention or other such agency. Those advisory panels typically comprise a majority of researchers who consult for drug companies and who are thereby inclined to the view that treating such conditions is a good thing. As a result, the levels of blood pressure, serum cholesterol, weight (body-mass-index), etc., defined as appropriate or desirable are periodically revised, always in the direction of favoring expanded treatment.
As I pointed out in the post mentioned above, certain physiological changes with age are perfectly natural, including increased blood pressure; yet a large proportion of seniors are taking medications to treat “hypertension”. This recent news item prompts a rhetorical question:
“How likely is it that 30% of the US population could have blood pressure that is higher than appropriate?”
Not content to leave this as a rhetorical question, I decided to look at what the guidelines precisely are. Once again a surprise. I find myself increasingly astonished at the lack of logic, the absence of plain common sense, in official statements about matters of medical science. Concerning blood pressure, the authoritative documents agree that it rises steadily with age, certainly beginning in the teens. At the same time, “hypertension” is defined by a single number irrespective of age!
Various sources agree on how blood pressure typically changes with age between 15 and 64. I found only one source for ages 65-80:
Now, a commonsense definition of “hypertension” — pressure “too high” — would then be some percentage above the known, observed, natural range at any given age; or perhaps for any individual an increase of pressure with age at a significantly higher rate than average, or perhaps a sudden jump.
Instead, the definition of hypertension propagated by official agencies is a single number irrespective of age and equal to the average at age around 65!
“Your blood pressure changes throughout the day. It is usually lowest when you’re asleep, and it rises when you awaken. It also can rise when you are excited, nervous, or active. So it varies throughout the day. A systolic blood pressure of 140 mmHg or higher, or a diastolic blood pressure of 90 mmHg or higher, is considered high blood pressure, or hypertension. Hypertension is the medical term for high blood pressure. . . . High blood pressure currently affects more than 72 million Americans. That’s 1 in every 3 adults” — NIH Senior Health.
So at what time of day should one regard 140 mm systolic as hypertension? When one is active, excited, or nervous, or when one is relaxed and inactive? When measured in a doctor’s office, where it’s known to be typically higher than when measured at home?
Advice from the U.S. Department of Health and Human Services via the National Heart, Lung, and Blood Institute states:
“A blood pressure level of 140/90 mmHg or higher is considered high. About two-thirds of people over age 65 have high blood pressure. If your blood pressure is between 120/80 mmHg and 139/89 mmHg, then you have prehypertension. This means that you don’t have high blood pressure now but are likely to develop it in the future. You can take steps to prevent high blood pressure by adopting a healthy lifestyle.
Those who do not have high blood pressure at age 55 face a 90 percent chance of developing it during their lifetimes. So high blood pressure is a condition that most people have at some point in their lives” [emphases added].
Well of course they do, since the normal range at age 55 is about 117-143.
The Centers for Disease Control and Prevention (CDC) also enlightens us about how the proportion of people with “elevated blood pressure” changes with age:
So CDC, just like Big Pharma, is in the business of selling sickness, of persuading us that perfectly normal characteristics of human life are ailments to be treated. And as so often, African Americans seem to be categorized as inherently more diseased than others — or is it possible that there’s a correlation here with the higher proportion of African Americans who excel at various athletic pursuits?
Unfortunately this is not a willful conspiracy, it is the result of good intentions coupled with ignorance and incompetence within an enormously complicated bureaucratic system. Deliberate wrongdoing might be much easier to correct. The problem is this: They all take correlation as proving causation. Because the incidence of strokes goes up with age, and blood pressure goes up with age, why, therefore of course the higher blood pressure is causing the strokes! Makes obvious sense, doesn’t it?
Only if you don’t think about it. First, correlation NEVER proves causation, no matter how plausible the connection might seem. Second, the fact that blood pressure increases starting in the teens is powerful evidence that this is interconnected with other physiological processes, and it may well be that these increases are desirable, that they play an important function, as the rest of the organism also ages.
The variation of blood pressure with stress and with time of day demonstrates its interaction with other aspects of physiology. Since these changes are observed in healthy people, it’s plausible that they are appropriate changes. Blood pressure in older people also responds to external temperature, decreasing when it’s warmer and increasing when it’s colder (Alperovitch et al., Archives of Internal Medicine, 169  75-80). By what stretch of some imagination could it make sense to try to force everyone’s blood pressure to below the same fixed value, no matter their age?
But that’s what we do. So it’s hardly surprising that older people in particular are over-medicated, to the extent that “Nearly 40% of the participants used at least one potentially inappropriate medication” — in quite a large a study of older people (>9000 individuals), not in nursing homes, living in France (Lechevallier-Michel et al.,. European Journal of Clinical Pharmacology, 60  813-9). I doubt that the proportion would be less in the United States.
These circumstances also explain why “Disease-specific causes of death, especially vascular diseases, could be overestimated in this age group [senior citizens]” (Alperovitch et al., European Journal of Epidemiology, 24  669-75). When someone taking medications for hypertension, high cholesterol, and other “ailments” dies, the death is likely to be attributed to one or more of those “ailments”, not to side effects of the drugs that have been consumed steadily for many years.
This is a little -discussed but crucial aspect of drug “side” effects: the length of time during which a drug is supposed to be taken. Something that shows up in only 1% of cases in a clinical trial lasting 6 months might well show up in a lot of cases when the drug is then being taken lifelong, as is the case with substances “treating” high cholesterol or high blood pressure or seeking to “thin” blood to prevent clots or strokes.
So, for example, not much more than a year after Gardasil vaccine was approved to guard women against cervical cancer, there had been several deaths attributable to it as well as nearly 400 “serious” adverse events (CDC mongers fear and hawks deadly vaccine, 2008/03/13).
Unabashed, an advisory panel to the Food and Drug Administration urged that Gardasil and its competing knock-off Cervarix be administered to boys to prevent genital warts (Gardasil and Cervarix: Vaccination insanity, 2009/09/21). The push for this continues:
“Merck & Co’s Gardasil vaccine is approved for boys, safe and it would be cost-effective, CDC researchers and vaccine experts told a meeting of the Advisory Committee on Immunization Practices Thursday” (HPV shots for boys debated by experts — Gay men would be among groups protected from various cancers by vaccine, CDC says). “HPV infection is best known as the primary cause of cervical cancer, but it can also lead to cancers of the anus, penis, head and neck. Vaccinating men and boys could prevent some of these cancers.”
Perhaps this continuing push comes because the earlier considerations judged that the possible prevention of genital warts in boys did not justify the high cost ($360) of the vaccination. That high cost did not prevent its inclusion in a federally funded program, though, “the Vaccines for Children Program, a government-funded system that provides vaccines to children eligible for the state-federal Medicaid health insurance plan and other uninsured children”. The new push cites a concern to safeguard gay men in particular:
”cases of anal cancers are increasing in the United States, especially among women, and men who have sex with men. ‘Estimates from various studies indicate that the incidence of anal cancer in men who have sex with men may be as high as 37 cases per 100,000 men’”.
The campaign seems to be working: “36 percent of pediatricians and 24 percent of family medicine physicians are administering the vaccine to males”.
Once again, I’m not pointing fingers at any conspiracy, any willful wrongdoing. These people think they are doing good — just like Tom Lehrer’s “the old drug peddler, doing well by doing good”. The problem is, they think correlations prove causation, even when the correlation is “as high as” 37 cases in 100,000. This incompetence in statistics is matched by ignorance of the problem of drug “side” effects, even though a decade ago already it was reported that there are in the United States “106,000 deaths/year from non-error, adverse effects of medications” (Starfield, JAMA 284  483-5).
Anecdotes don’t count as evidence, of course, but they are mighty impressive subjectively. In my bridge group of senior citizens, several have mentioned loss of feeling in their feet. Each one I’ve asked, “Do you take statins?” All have said “Yes”.
An older friend of mine, now dead, was very slight of build, and always found it difficult to persuade his doctors that he should be taking a lower than average dose of most medications. After a bad fall, he suffered a cerebral hemorrhage from which he never recovered. The doctor who supervised his admission to hospital said he should never have been taking the blood-thinning Plavix that his physician had prescribed for him, let alone at the dose he had been using (and he had been using only half of what had been prescribed).