I recently read an interesting book titled, Overdiagnosed: Making People Sick in Pursuit of Health. In the book, Dr. Welch talks about the dangers of over-diagnosis and how it is “biggest problem posed by modern medicine.” Over-diagnosis is defined as the diagnoses that will never cause symptoms or death and generally occurs because doctors seek early diagnoses – “either as part of an organized screening effort or during routine exams.” According to Welch, over-diagnosis of asymptomatic disorders leads to over treatment of mild abnormalities which skews the risk/benefit analysis of the treatment in favor of “no” treatment. He vividly describes an anecdote of an elderly patient who was diagnosed with mild diabetes based on revised and more stringent metrics and due to the aggressive treatment guidelines was started on blood sugar lowering medication that acutely lowered his blood sugar while driving, causing him to faint and suffering an accident. He goes on to make similar arguments with a host of conditions ranging from hypertension to hypercholesterolemia. As a practicing physician, I mostly agree with Dr Welch’s assessment about the risk/benefit analysis of over-treatment and even some of the unhealthy obsession with “abnormals” in health care. However, in my opinion, the fault is often not always with the over-diagnosis but with the over-treatment. We as physicians are far too quick to treat “abnormals” with pharmaceutical interventions when in fact behavioral and lifestyle modification is a superior alternative.
For the first time in recorded human history, non-communicable diseases (NCDs) are the leading cause of morbidity and mortality in Western societies. They kill nearly 38 million people each year. Cardiovascular diseases, diabetes, and cancers account for nearly 30 million of those deaths. Furthermore, many NCDs can mostly be attributed to modifiable lifestyle risk factors such as smoking cessation, alcohol use, physical inactivity, and a poor diet. In a 2013 Global Burden of Disease analysis, behavioral risk factors were found to account for ~40% of the attributable disability-adjusted life-years (DALYs) worldwide. If you take the example of diabetes and consider glucose intolerance, pre-diabetes, diabetes, and insulin dependent diabetes as spectrum of abnormality (chart above). Then according to the chart, the lower you are on that spectrum, the less you stand to gain from treatment. However, treatment does not equal pharmaceutical intervention. I would re-label the y-axis as pharmaceutical treatment benefit. Therefore, the lower you are on that spectrum, the less you benefit from pharmaceutical interventions. Glucose intolerant, pre-diabetic, and over weight diabetics can and should be treated exclusively with intensive lifestyle modifications regimens that have shown to reverse these conditions. It is not the over-diagnosis that is causing the harm but the over-treatment with pharmaceuticals.
Despite the clear benefits of lifestyle modification and even the adverse consequences of early pharmaceutical treatment, the amount of revenue being generated by drugs treating chronic diseases is astronomical and ever increasing. Spending on prescription drugs increased by 13.1% in 2014 and the vast majority of that spending is on chronic disease treatment. Furthermore, the number of diabetics in the United States continues to increase. According to the American Diabetes Association (ADA), approximately 29 million Americans have diabetes and 86 million Americans age 20 and older have pre-diabetes. Approximately a third of pre-diabetics will progress to diabetes unless aggressive lifestyle and behavioral modifications are not undertaken. All of the forces that have created the current paradigm of over-treatment including the medical-industrial complex, the deterioration of the physician – patient relationship, and lack of social services available to patients are all powerful obstacles to fixing the problem. The entire medical-industrial complex is actually incentivized to “over-pharmaceuticalize.” If we are to overcome the overwhelming financial and health burden of non-communicable diseases, we must be vigilant in diagnosing pre-symptomatic patients. However, systems need to be place that ensure that these pre-symptomatic individuals are treated with lifestyle management techniques that have shown to effectively stymie the progression of these individuals into full blown diabetics.