Overdosed America (34 page)

This is just a sampling of some of the research that doesn’t get pushed out into the public’s awareness by commercial sponsors. Where might you find additional information about bone health to guide your decisions? Almost half of Americans turn to the Internet for health information. If you go to the
website sponsored by Merck
, the manufacturer of Fosamax, you will be advised to “know your T score” and told that “If your T score is less than -1.0, talk to your doctor about treatment options.” (Remember, on a statistical basis, half of women in their early fifties have a T score of -1.0 or less, but treating these women with drugs does not decrease, and may actually increase, their risk of fractures.) The information you find on the
National Osteoporosis Society
website won’t be free of commercial influence, either. This tax-exempt nonprofit institution receives a large amount of drug company support, as indicated in its annual report.

Popular search engines quickly bring up numerous sites with information about BMD testing, many with no apparent ties to the drug industry.
A 2004 article published in the
International Journal of Technology Assessment
in Health Care
shows just how difficult it is to get unbiased information from the Internet. Researchers from the British Columbia Office of Health Technology Assessment identified the consumer health websites most frequently selected by widely used search engines. They then compared the information about bone mineral density testing presented on those sites with the information presented on the websites of noncommercially funded health technology assessment organizations.

The difference in the “information” could not have been greater. Consumer health sites, primarily commercially sponsored, present a consistent message: BMD is a simple, painless test that predicts the risk of fracture from osteoporosis—sounds like apple pie and motherhood. The message on the health technology assessment organizations’ websites was equally consistent: BMD measurements are not good predictors of fracture risk.

One website with good information about osteoporosis (and many other medical issues as well) is offered by the
Center for Medical Consumers
.
Our Bodies, Ourselves
is an excellent reference book on women’s health issues.

In the final analysis, the “disease” of age-related osteoporosis is not a disease at all, but the quintessential example of successful “disease mongering.” The drug industry has succeeded in planting the fear that bones will suddenly and without warning “snap” in women who had naively believed they were healthy. This is very far from the reality of osteoporotic fractures, and in the end it harms women’s health by diverting attention away from the constructive, evidence-based, inexpensive, do-it-yourself ways to prevent fractures and maintain overall health. All postmenopausal women should be exercising routinely, eating a healthy diet, taking calcium and vitamin D supplements, and decreasing their risk of falls. Bone density tests are hardly needed to make these recommendations.

If a fraction of the resources spent on the exaggerated risk of osteoporosis were invested in these other ways to improve women’s health, hip fractures could be greatly reduced and overall health greatly improved. Unfortunately, the mainstream women’s health movement seems to have been hijacked by commercial interests, acting more like a wolf in sheep’s clothing or, more specifically, the biomedical-commercial model of health dressed in a healer’s garb, and quite convincingly pretending to care.

The first thing most middle-aged and older people conjure up when they think about the greatest risk to their health is the “number one killer”: heart disease. And the next thing they think about is their cholesterol level. Everyone knows that high cholesterol is the greatest risk factor for coronary heart disease, right?
The National Cholesterol Education Program
has been remarkably successful in achieving its goal of raising “awareness and understanding about high blood cholesterol as a risk factor for CHD [coronary heart disease] and the benefits of lowering cholesterol levels as a means of preventing CHD.” So successful, in fact, that about twice as many people
discuss cholesterol with their doctors
during physical exams (67 percent) as are counseled about the
importance of routine exercise
(34 percent) or as
are advised (if smokers) to quit smoking
(37 percent). Even the most obvious counseling,
advising obese people to lose weight
, occurs at only 42 percent of obese people’s yearly checkups.

Heart disease is the number one killer only because eventually, if nothing else kills us, our hearts will give out. Of much greater importance is what robs us of the prime years of our lives. On that score,
cancer is far worse
; it deprives Americans of twice as many years below the age of 75 as heart disease does. Nonetheless, CHD is still a major health problem that deserves major attention.

The good news is that the death rate from coronary heart disease has dropped quite dramatically since its peak in 1968. Several factors have contributed to this improvement: After the first Surgeon General’s report on the dangers of smoking was issued in 1964, the
percentage of adult smokers in the United States declined
steadily, from 42 percent in 1965 to 25 percent in 1990. (
Smoking is responsible for as much as 30 percent
of all deaths from coronary heart disease in the United States each year.) Beginning in 1970,
Americans’ per capita consumption
of beef, eggs, and whole milk began to decline, leading to a decrease in the percentage of calories derived from saturated fats and cholesterol.
And good progress was made
during the 1970s and 1980s in reducing the number of Americans with uncontrolled high blood pressure.
Largely as a result of these lifestyle changes
and improved blood pressure control, the death rate from heart disease in the United States went down by half between 1970 and 1990.

In the second half of the 1980s, the
“revolution” in prevention and treatment of heart disease
began with the introduction of clot-busting drugs and angioplasty to open up blocked arteries in people who were having heart attacks. The number of angioplasty procedures in the United States tripled in the 1990s, accelerated by the introduction in 1995 of wire mesh stents to keep narrowed coronary arteries from becoming completely blocked. Despite the advent of stents, the
number of coronary artery bypass surgeries
increased by about a third during the 1990s. In 1987 the
FDA approved the first cholesterol-lowering statin drug
, Mevacor. Sales of statins climbed steadily, so that in 2002 they took over as the best-selling class of drug in the United States.

What effect did all of these breakthroughs have on the death rate from coronary heart disease? Instead of a dramatic improvement, the
rate of decline in the death rate actually slowed during the 1990s
(from an average decline of 3.1 percent per year between 1970 and 1990 to 2.8 percent per year between 1990 and 2000). Why didn’t the death rate decline at an even faster rate after all these great breakthroughs in prevention and treatment?

The advances, it appears, diverted attention from the lifestyle changes that had been working so well over the previous two decades. The declining percentage of
Americans who smoked
abruptly leveled off in 1990, with no further decline through 2002. The
decline in per capita beef and egg consumption stalled
in the 1990s and actually went up slightly in 2000. The
decline in whole milk consumption leveled off
, while the increase in the consumption of lower-fat milk peaked in 1990. There was little improvement in the number of Americans engaging in regular exercise. The percentage of
obese Americans nearly doubled
between 1990 and 2002 (11.6 percent versus 22.1 percent). The number of Americans with type 2 diabetes, which significantly increases the risk of heart disease, increased proportionately. Likewise, the progress made in reducing the number of people with uncontrolled
high blood pressure
in the 1970s and 1980s stalled in the early 1990s—the total number of people with high blood pressure actually increased, probably as a result of the increasing prevalence of obesity combined with inadequate exercise.

The problem is that all the current medical recommendations, public education campaigns, drug advertisements, and news of breakthroughs in the prevention of heart disease give the benefits of a healthy lifestyle just enough lip service to preempt criticism that these issues are being ignored. The end result is that doctors and patients are being distracted from what the research really shows: physical fitness, smoking cessation, and a healthy diet trump nearly every medical intervention as the best way to keep coronary heart disease at bay.

An article published in JAMA in 1999, for example, shows how much more of a health risk poor fitness is than elevated cholesterol levels.
The study collected data on 25,000 executive and professional men
at the time they underwent “executive physical exams.” Ten years later, the findings of the exams were correlated with the deaths that occurred from cardiovascular disease (heart attack, stroke, and blood clots) and from all causes to determine which factors contributed the most. It turns out that being among the 20 percent least physically fit (as determined by the results of a treadmill test) is a far greater health risk than is an elevated total cholesterol level (above 240 mg/dL). For the normal-weight men, low fitness accounted for three times as many deaths from cardiovascular disease as did elevated cholesterol. For the overweight and obese men, low fitness accounted for one and a half times as many cardiovascular deaths as did elevated cholesterol. Even more important was the overall risk of death: The normal-weight men with elevated cholesterol levels had no additional risk, but the unfit men had a 60 percent higher risk of death. For the overweight men, elevated cholesterol levels increased the rate of death from all causes by 30 percent, but low fitness increased the death rate by more than twice as much, 70 percent. In absolute terms, poor physical fitness was associated with seven extra deaths per thousand normal and overweight men each year. For comparison, among the very high-risk men in the WOSCOPS study (LDL cholesterol averaged more than 190 mg/dL), not taking a statin was associated with only two extra deaths per thousand men each year.

Don’t despair if you have let yourself get out of shape. The evidence shows that it’s not too late to change your sedentary ways. A study published in JAMA followed
almost 10,000 men who underwent exercise testing
to establish a baseline level of fitness. They were retested five years later to see if their level of fitness had changed, and then followed for another five years after that. The men who had been among the least fit on the first test but who then improved on the second test cut their risk of dying of cardiovascular disease over the subsequent five years in half, compared with the men who remained among the least fit at both exams. In absolute terms, there were five fewer deaths each year for each 1000 men who became fit.

There is also good evidence showing that
physical fitness plays a major role in protecting women
from heart disease. In the early 1970s, 3000 women underwent physical exams, blood tests, and exercise testing on a treadmill. The findings were somewhat of a surprise. The typical reason for performing stress tests is to see if the EKG pattern changes in ways that suggest that the heart is not getting enough blood during maximum exercise. It turned out, however, that these changes did not predict an increased risk of premature death. The women who were among the least fit, on the other hand, had far more risk of dying of CHD and more than twice the overall risk of death during 20 years of follow-up than did the most fit women.

Does exercise help people who already have heart disease?
Post–heart attack patients
randomized to participate in an exercise program had a statistically significant (27 percent) lower death rate than those in the control group. (Most of the
randomized studies of statin treatment
in post–heart attack patients do not show this much benefit.) It is likely that for secondary prevention of heart disease, statins and exercise together result in lower mortality rates than either alone, but such a study has not yet been done. It would be a risky proposition for a drug company when sales were going so well, especially when the current evidence suggested that the benefits of exercise would outshine the benefits of taking a statin drug.

Exercise isn’t everything when it comes to reducing the risk of coronary heart disease. Diet and other lifestyle changes can also make a big difference, as shown by the randomized studies of primary and secondary prevention of heart disease done in Oslo and Lyon reviewed in the last chapter.

The American Heart Association was so impressed with the findings of the
Lyon Diet Heart Study
that it issued an “AHA Science Advisory” in July 2000, calling the results an “unprecedented reduction in coronary recurrence rates,” and noting that, “it clearly points to other important risk factor modifications [besides cholesterol levels] as major influences in the development of coronary heart disease.” The American Heart Association’s Advisory concluded with the statement that “it would be short-sighted to not recognize the enormous public health benefit that this diet could confer.”

The expert panel of the
National Cholesterol Education Project
, on the other hand, was not even impressed enough to mention the American Heart Association’s Advisory in its 2001 cholesterol guidelines. The guidelines were strikingly understated with regard to the spectacular results of the Lyon Diet Heart Study, saying simply “compared to the control group, subjects consuming the Mediterranean diet had fewer coronary events.” There was no mention that the patients in the Lyon Diet Heart Study derived more than two and a half times more benefit from eating a Mediterranean diet than did similar patients taking cholesterol-lowering statin drugs.