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Syndrome X & Big Pharma

DRUG BUST by Alan Cassels

Sometimes, you see someone and you can’t help think, “Now there goes a walking time bomb.” The person is overweight and wheezing, his doctor probably calls him a ”borderline diabetic” and he’s likely taking prescription drugs for blood pressure and high cholesterol.

These people, along with my friend Richard who fits this description almost perfectly, have disease written all over them, in letters large enough for anyone to read. You don’t have to go to medical school to see that people like Richard are probably at higher risk for a heart attack or stroke and exercise and a better diet should be the first prescription on their road back to better health. But our medical culture seems dissatisfied treating that which is obvious and instead goes for the not so obvious: a complicated set of criteria, a medicalized label and even more rigorous screening for disease.

This is the phenomenon in play around a relatively new condition said to affect a third of the population. Statistics supplied by the US National Health Statistics for 2009 said that approximately 34 percent of adults in the US meet the criteria for “metabolic syndrome” which is a cluster of above-normal measurements of blood sugar, blood pressure, cholesterol and Body Mass Index (BMI). Having this particular cluster of bad things wrong with you, a phenomenon also known as Syndrome X, means you might be a candidate for a heart attack or stroke.

My question is are people like Richard, who could be the poster child for Syndrome X, any better off now that they have a new label?

That’s hard to say, but one thing is for sure: getting the label involves lots and lots more screening and that screening typically ends in more drugs. Medical screening is all about doing something to discover diseases in healthy people before those diseases can go on to hurt them. Most of us would submit to screening if we were confident it could detect something early enough to save our life. But how valuable is it to have a medical screening program that “finds” disease in a third of the entire population?

It’s worth being reminded the combined factors of age and weight means most of us are sliding towards metabolic problems naturally. Which is to say, as we get older, our blood pressure rises, we usually become heavier and these factors typically cause some level of ‘insulin resistance,’ which is the precursor to diabetes. It’s not to say this is good, but for many of us, it’s natural.

But do they actually “screen” people for Syndrome X? Doctors already routinely test for blood cholesterol, sugar and pressure, as well as nag us about our weight. Some groups recommend it, but there is a problem right from the start: there are contradictory and varying definitions of Syndrome X. The International Diabetes Federation defines it as someone who is obese with raised triglycerides, reduced HDL cholesterol, high blood pressure and high blood sugars (what is called increased fasting blood sugar.) The World Health Organization says if you’ve got “impaired glucose tolerance” (diabetes symptoms) along with two of the following: high blood pressure, high cholesterol, obesity or microalbuminemia (protein in your urine indicating kidney problems) then you have the disease. Other definitions also abound.

What does the evidence say? A review by the Mayo Clinic in 2006 said the way Syndrome X was diagnosed was “arbitrary and not evidence based” and another review in 2008 in the Lancet said that measuring metabolic syndrome was a lousy way to determine a person’s risk of future cardiovascular disease. The authors of that review noted there are better and more accurate ways to predict cardiovascular disease and diabetes and that fasting blood sugar measurement is a cheaper and easier test and a better predictor of future diabetes than a diagnosis of metabolic syndrome. Other organizations such as the American Diabetes Association and the European Association for the Study of Diabetes have warned that clinicians should avoid using the term “metabolic syndrome,” reasoning if you have risk factors for cardiovascular disease, doctors should treat those risk factors individually. Their 2005 joint statement on the issue wondered “whether medical science is doing any good by drawing attention to and labelling millions of people with a presumed disease that does not stand on firm ground.”

Who is behind pushing this diagnosis?

We know that Syndrome X easily fits the “more is better” ideology underlying the medical screening paradigm, which is of great benefit to pharmaceutical or medical lab investors. One commentator, Joanna Breitstein, writing in PharmExec magazine in 2004 noted drug companies eager to sell metabolic syndrome drugs have sponsored initiatives that emphasize the connection between insulin resistance and cardiovascular disease and said that “metabolic syndrome promises to as big as or bigger than the emergence of a market for cholesterol lowering drugs.”

There have been a number of drugs specifically developed to treat metabolic syndrome including the drug rimonabant, launched in Europe in 2006 and subsequently withdrawn because of the severe depression it caused. Other proof the drug industry is interested in Syndrome X hits close to home; a clinic specializing in metabolic syndrome opened in 2006 at St. Paul’s Hospital in Vancouver, thanks in part to a $1.6-million grant from AstraZeneca. The University of Montreal began “Metabolic Syndrome Awareness Days” in 2006 to raise awareness and screen people for metabolic syndrome. Overseas, there’s activity as well. In 2007, Novartis Turkey began a campaign to educate doctors and the public about metabolic syndrome and screening and in 2008 Japan started a nationwide metabolic syndrome screening program.

People and organizations pushing Syndrome X (including the American Heart Association and the WHO) say that such a diagnosis can be a helpful reminder for doctors. They reason if they find one symptom of metabolic syndrome in a patient, they may be twigged to pursue more. Hmm. Others have said people might like having a label such as Syndrome X – it’s something they can hang onto and perhaps offers an easy escape from personal responsibility.

There’s a simple fact behind all of this: many of the symptoms of metabolic syndrome are caused largely by both genetic and lifestyle factors. You can’t do much about your genes, but we know the quantity and quality of food you eat and the amount of exercise you get are all important factors.

The gurus on screening at the United States Preventative Services Task Force (USPSTF) recommend screening of all adults for obesity, hypertension, diabetes and cholesterol. Groups like the American Diabetes Association, American Cancer Society and American Heart Association endorse preventive screenings on a regular basis, as well as sponsoring initiatives to encourage workplace screening for “risks leading to heart disease, cancer, diabetes, stroke and metabolic syndrome.”

It seems to me that, above all, Syndrome X is a gateway diagnosis that may lead to more and more prescriptions yet whether it leads to more and more disease prevention is certainly not clear.

By all means, if you are worried about your health, go and get your blood pressure, glucose or lipid (cholesterol) levels screened and find out if you have Syndrome X. It likely won’t change your life, but it will likely lead to more prescriptions.

Helping people work towards a healthier lifestyle is probably the best thing our doctors can do and I would think energy spent doing that could be far more useful than slapping on a scientific label to a problem that just leads to more drugs.

In a final irony about screening people for this condition the physician, Dr. Gerald Reaven, who coined the term “Syndrome X” in 1988 and proposed insulin resistance as its underlying cause, later recanted. Just as the syndrome was gaining speed among the drug companies and medical authorities, he published a paper in 2006 saying that physicians should stop giving this diagnosis to patients.

Alan Cassels is a drug policy researcher at the University of Victoria and is currently working on a book on medical screening. Have you been screened for something and have a story to tell? Let him know at cassels@uvic.ca. Read his other writings at www.alancassels.com

One comment

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