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You might have heard the frightening news last year suggesting half of all Americans had some form of diabetes. A survey in the journal JAMA was covered extensively, including by NBC, WebMD and the Los Angeles Times.
But as the HealthNewsReview blog later pointed out, almost none of the media coverage raised questions about the expanding definition of diabetes or the controversial new “pre-diabetes”, claimed to afflict close to 90 million Americans.
Part of the expanding empires of disease, the creation of new “pre-conditions” is turning millions of people into patients across the globe. We now have pre-osteoporosis, pre-hypertension and pre-dementia – and, like pre-diabetes, all of them are controversial.
An article in The BMJ (British Medical Journal) in 2014 asked bluntly “whether it is worth having the category of pre-diabetes at all”. It suggested the term go into cold storage until it was clear that the millions of people being labelled with it would actually benefit.
“Rather than turning healthy people into patients with pre-diabetes,” argued two distinguished professors in The BMJ, “we should use available resources to change the food, education, health and economic policies that have driven this epidemic.”
Diagnosis creep
As I explain in an editorial on this problem of “diagnosis creep” in the journal Australian Prescriber today, there is an urgent need for much greater scepticism about the expanding empires of disease – and we’re not just talking about pre-diseases.
A dramatically expanded definition of “chronic kidney disease” gives a label to around one in ten adults, and almost half of the elderly, many of whom will never suffer any kidney disease, chronic or otherwise.
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New diagnostic criteria will almost triple the numbers of pregnant women who are labelled as having gestational diabetes – without good evidence that the newly labelled women or their babies will benefit.
And thresholds that define attention-deficit hyperactivity disorder (ADHD) continue to fall, which means even more children and now adults will be diagnosed.
Early diagnosis is a double-edged sword
Medicine is transforming more and more formerly healthy people into patients and building ever bigger potential markets for the industries that sell treatments.
Some of the newly labelled patients will benefit – early detection can mean deadly disease is stopped in its tracks.
But early diagnosis is a double-edged sword. For other people with mild problems or at very low risk of future illness, a diagnosis can bring more harm than good. It can cause a cascade of overtesting and overtreatment and waste precious resources better spent on those in greatest need.
A few years ago, colleagues and I analysed changes made by expert panels of doctors to the definitions of 14 common conditions, including high-blood pressure, depression, arthritis and Alzheimer’s disease. Our study was published in the international journal PLOS Medicine and was covered on The Conversation.
In summary, most conditions were expanded – including high blood pressure, Alzheimer’s disease, high cholesterol, depression, rheumatoid arthritis, multiple sclerosis and myocardial infarction or heart attack. Pre-diseases were created, thresholds for diagnosis were lowered, or the processes used to diagnose were changed so that people would be diagnosed and labelled earlier.
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No panel rigorously investigated and reported on the potential downside of their decision to expand – the danger that some people might be caught unnecessarily by the newly widened definitions.
No panels reported on the possibility that the new patients created by the new definitions might be “overdiagnosed” – they might be labelled with a disease that would never harm them, or be given a diagnosis and treatment that would do them more harm than good.