How credible are the new blood-pressure guidelines?

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Dear Cecil: Recently it was announced that medical experts had lowered the numbers of what acceptable blood pressures are, so now nearly half of all adults are considered to have high blood pressure. Is this a drug-company ploy to get even more people on medications? Pressured in Michigan


Illustration by Slug Signorino

Cecil replies:

Funny, isn’t it? What with the fast food, the sedentary lifestyles, and the increasingly hair-raising national politics, we Americans shouldn’t really need help getting diagnosed with high blood pressure — doing just fine, thanks. Yet along come these goalpost-moving guidelines: where previously hypertension meant 140 over 90 and up, the new threshold is 130/80 — meaning that, yep, quite literally overnight, a full 46 percent of Americans now have HBP.

The change came via a report in November from the American Heart Association and the American College of Cardiology, part of a regular, federally sanctioned process to guide medical practices across the country. Redefining a worrisome medical condition to include 14 percent more patients sounds drastic, but how big a deal is is it really? I’d submit to you that what we’re looking at is a little more nuanced than the breathless news coverage would suggest — though you’re certainly not wrong, Pressured, to cast a skeptical eye.

The shady stuff we’ll get to in a minute, but first the official line on the matter — why, in theory at least, the new guidelines aren’t simply a big drug-company ploy. According to defenders, the idea isn’t to get more folks on medication but to keep more folks off it, by motivating them into blood-pressure-lowering lifestyle changes before meds become necessary. Anyway, hypertension drugs work best on those with systolic blood pressures of 140 and above, so the newly designated HBP sufferers, the 130-to-139 crowd, aren’t even the target market; according to one estimate, the new numbers will mean only a 1.9 percent increase nationwide in the prescription of blood-pressure meds. (Which admittedly shakes out to about 4 million people — not nothing.) So the half-the-country’s-got-HBP framing is maybe a little hyperbolic — one could reasonably argue the AHA et al just want to get you to quit smoking, while it’s the headline writers who are trying to give you a heart attack.

If the guidelines are broadly unobjectionable, you honestly can’t say the same about the medico-corporate milieu whence they emerged, which has taken deserved heat. The last time blood-pressure guidelines underwent major revision, back in 2003, the change prompted a Seattle Times investigation focusing on the links between the new rules and the pharmaceutical companies uncomfortably close to their creation. The 2003 report created a new condition called “prehypertension” (eliminated in the 2017 update), it recommended the wider use of hypertension drugs — and, conveniently enough, nine of the eleven authors of the report, the Times found, had ties to Big Pharma.

That’s a conflict of interest basically baked into this particular system. Groups like the American Heart Organization and the American Cancer Society are what’s called patient advocacy organizations, or PAOs, and over time have come to be heavy hitters on the American medical scene: authoring guidelines, influencing policy and regulatory decisions, sponsoring research, etc. Who can disagree with patient advocacy? Unfortunately, that kind of work ain’t cheap, and many PAOs receive substantial funding from for-profit companies, including pharma manufacturers and medical-device makers.

A 2017 sample of PAOs found that 67 percent received at least some cash from for-profit companies, and 12 percent got more than half their budget that way. This study was part of a series of JAMA Internal Medicine articles on the growing problem of industry influence on things like medical guidelines; it was noted elsewhere, for instance, that the industry-funded National Osteoporosis Foundation “continues to promote the idea of a widespread ‘disease’” while “others point to concern about the condition’s overdiagnosis and overtreatment.”

The problem was described a bit more heatedly in a 2009 article in the New York Review of Books by Marcia Angell — longtime editor at a little pamphlet out of the northeast called the New England Journal of Medicine — about the infiltration of industry money into things like “expert panels” on health issues. Angell cited as an example the National Cholesterol Education Panel, which in 2004 recommended lowering acceptable levels of “bad” cholesterol, and eight of whose nine members proved to have financial ties to cholesterol-drug makers. Angell’s conclusion? “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.”

So there you have it. The specific guidelines you’re asking about seem harmless enough, Pressured — most of us, anyway, could stand to exercise a little more. (We’ll note that one big doctors’ organization, the American Academy of Family Physicians, decided not to endorse the new hypertension guidelines — citing, among other issues, potential conflicts of interest on the authors’ part.) But going forward, you’d be wise to take this sort of medical-pronouncement-from-on-high with a grain of salt — or, depending on your dietary restrictions, the low-sodium flavor enhancer of your choice.

Cecil Adams

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