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Tuesday, November 09, 2010

The Soul of a New Disease

The Soul of a New Machine Disease
I read this article today in the morning WSJ.  (BTW - I really like this publication because its well sourced and for the most part accurate.  Of course the downside is it is about "evil capitalism" of which big Pharma is a large, unsavory part.)  Its about hypertension - no, not the kind than can break your starship's hyperdrive - the kind that means you have high blood pressure.

You probably know what blood pressure is - its the thing they measure when they put that contraption around your arm at the doctors office and pump up the air until your arm feels like its going to fall off.  You can think of blood pressure like the pressure in your garden hose - except its inside your arteries instead of the hose.  If the water pressure gets too high the hose can fail - rupturing, leaking or ballooning out.  These types of hose failure correspond to arterial diseases caused by hypertension like strokes and aneurysms.

Up until about 10-15 years ago or so 120/80 was considered the gold standard of "normal" blood pressure.  However, that's been changing during the last decade.  These days 120/80 is now considered prehypertensive.  This means that if this is your blood pressure then its likely your blood pressure will start to increase over time - especially if you have risk factors: smoking, obesity, etc.

But I don't like how these sorts of measurements change - there's some troubling aspects to it.

First of all reading these accounts of what's going on with hypertension is like reading this articles namesake: "The Soul of a New Machine" - a book about how a new computer was born, including all the trials and tribulations.  Some one creating something out of nothing...

Second, and even more subjectively, if my blood pressure was always 120/80, even in childhood as a non-obese, highly active athlete, was I still prehypertensive? 

On the other hand you can argue that its just medical science getting better and better at making you healthy, or is it?

Let's see what the article claims.  First off there's this: "About a third of U.S. adults have hypertension, which leads to one in six deaths in the U.S.  But at least the same number, and possibly as many as 37%, are prehypertensive."  What this is saying is that 1/3 of adults in the US have hypertension and another 1/3 or more have prehypertension, i.e., are likely to develop hypertension.  The 1 in 6 deaths figure is designed scare you and to show us we're all on the highway to hell - 1/3 ok, 1/3 in the queue for hypertension, 1/3 about to croak - implying 1/2 of the 1/3 of hypertension suffers will die (of course, in truth everyone will die - but more on that later).

A quick check of the CDC 2007 statistics on death in the US (found here, page 5) cast some doubt on these numbers.  You will see about 1/4 of all deaths are heart related and about 1/12 or so are strokes.  Further down on page 22 you will see that more 1/2 of all deaths occur after age 70 and that your probability of dying is remains under 10% until age 70 (page 26).

Page #9

Interestingly on page 9 you see that cardiovascular and stroke deaths are steadily decreasing and have been since 1958.  The only types of death increasing are Alzhiemers, Parkinsons, kidney failure, and hypertension.  But hypertension deaths are about 100 times less likely the heart disease or stroke.  (Note that this chart is logarithmic and hence increase by times 10 (10x) for each major tick on the left.)

Hypertension is its own cause of death, at least according to the CDC.  Yet somehow its entwined with heart disease and stroke in the original article and study.  How one type of actual death leads to another is unclear here.  Particularly since hypertension death has been its own category for some time.  I think this study need more study (see "Does my Medication Really Work").

The article claims that lifestyle changes are key for treating hypertension.  This is no surprise based on this and other articles I have written here.  Yet no one at the federal government bothers to include exercise or nutrition in their guidelines for treating people of all ages: vitamins are not even part of food stamps.

The other issue here is that most people die in their elder years and often suffer from multiple diseases - yet there is only one check box on the death certificate for "cause of death".

Digging a bit deeper we find a WSJ blog article that discusses this in more detail (written by Katherine Hobson).  Now we start to see what's going on...

Hypertension was designated as its own separate "disease" classification in 2003 - its unclear exactly what that means in this context, but no matter.  Later on, about 2006, it was shown that specific existing heart drugs can be used to treat the hypertension. This history goes back much further than 2006 - all the way to here (1999).

And then we get to the money shot:

"In August of this year, an article in the British Medical Journal noted that in the wake of the new classification, prehypertension is emerging as a potential goldmine for drug companies, and pointed out that many physicians who were members of the committee have disclosed financial relationships to industry.

One of the committee members named in the article is George Bakris, director of the Hypertension Center at the University of Chicago, who has disclosed consulting arrangements with several drug companies. Bakris, for his part, tells the Health Blog that the committee’s decision had nothing to do with drug-company interests, and was meant to educate and empower patients.

I suspect this is just in time, too.  The big pharma gravy train of cholesterol drugs is winding down.  Drugs are patented for specific things and the patents on treating cholesterol with drugs are running out.  So its probably no surprise that a new, related use appears conveniently on the horizon just in time to save big Pharma from financial ruin.

But hold on one minute.  Everyone dies.  And everyone gets to die of exactly one cause as we saw in the link to death certificates.

So lets consider this point.  Everyone dies and gets to die of one thing.  Hence I will argue there will always be one or two major causes of death because bureaucrats like forms with a small number of choices that are easy to fill out - similarly for the CDC that analyzes the data.  So we can always write articles about "the major cause of death".

Your heart and pulmonary system works continuously throughout your life - wouldn't you expect something like this to fail first?  Sure bad behavior and risk factors can cause early failure - but that's also true of anything else, like a car.  Drive your car down along the rocky creek-bed for a few miles and it too will fail prematurely.

Then there's the profit motive.  No one makes any money getting people to move around and eat right.  You make money selling people drugs that they can take for a long time that have some marginal benefit that do not produce nasty or fatal side effects.

I will also posit a new motive: the societal bandwagon phenomena.  With such emphasis on "heart disease" and its friends like cholesterol (or like global warming) pretty soon everything looks like the same kind of problem because research and funding follow the government money and produce results to, not surprisingly, produce even more studies and more funding.  Its the same as the police treating everyone like a drug dealing criminal (hands on the steering wheel) even if you're not - so much of the same thing year in and out colors the perspective.

There is clear and undisputed evidence that proper nutrition and exercise get you the most bang for the buck - but as I said, no one makes money from that.

Bottom line - hold on to your wallet because the drum beat of hypertension as the new big "killer" will start to wind up.

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