- NEW YORK - Various medical organizations are calling for the diagnostic
definitions of four major illnesses - diabetes, high blood pressure, high
cholesterol, and overweight - to be changed in order to encourage early
detection and treatment. However, researchers warn that under these new
standards, 75 percent of the U.S. adult population would be considered
- And whether these "new 'patients'
would ultimately benefit from early detection and treatment of these conditions
is unknown," write Drs. Lisa Schwartz and Steven Woloshin of the Dartmouth
Medical School in Hanover, New Hampshire. Their analysis is published in
the April issue of the journal Effective Clinical Practice.
- The authors examined data from the Third
National Health and Nutrition Examination Survey, a nationwide health survey
conducted between 1988-1994 by the US Centers for Disease Control and Prevention
in Atlanta, Georgia. They used survey data to estimate the impact of proposed
new definitions of four major chronic health conditions: diabetes, hypertension,
high blood cholesterol, and overweight.
- For example, the Expert Committee on
the Diagnosis and Classification of Diabetes Mellitus recently advocated
that the threshold for diabetes be lowered from a fasting glucose of 140
mg/dL to 126 mg/dL. Based on the CDC survey data, the Dartmouth authors
estimate that such a change would increase the number of American diabetics
by over 1.7 million.
- Likewise, changes proposed by the Joint
National Committee on Detection, Evaluation and Treatment of High Blood
Pressure would lower the definition of high blood pressure from 160/100
mm Hg to 140/90 mm Hg. This new diagnostic threshold would increase the
number of US hypertensives by 13 million patients, according to the researchers.
- Similar changes advocated by other organizations
would add 42 million Americans to the ranks of patients with high blood
cholesterol, and 29 million Americans to the list of the overweight.
- Altogether, according to the Dartmouth
team, broadening diagnostic standards would "ultimately label 75%
of the adult US population as diseased."
- While the new definitions may help physicians
diagnose some cases of disease earlier, they may also increase levels of
public anxiety. "In a nation already obsessed with weight and body
image and in which eating disorders are prevalent, labeling half the population
'overweight,' for example, may be traumatic," the authors point out.
- In his editorial commentary, Dr. H. Gilbert
Welch points out that a widening of disease definitions may lead to a situation
where "people who previously felt healthy... are being unnecessarily
informed that they are sick."
- Many patients in these stages of so-called
'early disease' may not even respond to therapy, and "some will be
treated unnecessarily," Welch explained.
- He also believes that in their zeal for
early detection, physicians may unnecessarily alarm the public (Welch cites
the '1-in-9' risk for breast cancer, for example). He also asks "if
the focus on finding early disease is distracting us from caring for the
- The current HMO culture, with its emphasis
on prevention rather than treatment, may encourage this trend, Welch explained.
"It is clearly easier for health plans to measure how well providers
comply with screening recommendations than it is to determine how good
they are at helping sick patients," he writes.
- Welch and the Dartmouth researchers agree
that the prevention of major chronic illnesses must remain an important
part of healthcare. However, Schwartz and Woloshin point out that "the
extent to which new 'patients' would ultimately benefit from early detection
and treatment of these conditions is unknown."