Too much medicine? Or too little?

While the commercial world seems awash in a flood of corporate greed, the biomedical research community is increasingly apprehensive about perceived “conflicts of interest,” with multiple attestations now required for submission of manuscripts and feature articles on the topic in major medical journals of Europe and North America [1–3]. While no one would argue against the need for scientific integrity, much of the current concern seems misdirected and even wrong-headed. A case in point is recent commentary on the purported problem of “medicalizing” risk factors, particularly those for the complex chronic diseases that increasingly plague Western societies [4–6]. Some have gone so far as to imply that this represents a sinister plot by unscrupulous drug companies to create nonexistent diseases which can then be targeted for expensive, but unnecessary, therapies [2]. Osteoporosis has been singled out as a prime example of this phenomenon. One recent attack cited informal alliances of pharmaceutical firms and consumer advocacy groups “ostensibly engaged in raising public awareness about underdiagnosed and undertreated problems” while promoting “a view of their particular condition as widespread, serious, and treatable” [2]. Is this complaint accurate? Is osteoporosis really no more serious than male pattern baldness? What are the facts? By any definition, osteoporosis is a common disorder that affects both sexes and all races, albeit to different degrees. Despite the claim that drug companies attempted to inflate the size of the medical problem by sponsoring meetings where the disease was being defined [2], the World Health Organization (WHO) Working Party settled on a more conservative BMD cutoff level (2.5 SD below the young normal mean) to define osteoporosis than had been accepted until then [7]. Thus, the WHO definition did not increase the size of the affected population but reduced it: in concrete terms, an estimated 45% of postmenopausal white women in the United States met the previous BMD criterion of t 2.0 at hip, spine, or forearm, but only 30% met the WHO definition [8]. According to the WHO definition, about 17% of postmenopausal white women and 4% of white men 50 years of age in the United States have osteoporosis at the femoral neck alone [9]. Although there remains some uncertainty about appropriate normal values for men and non-white women, it seems inescapable that, wherever the cutoff is placed, millions of women and men are affected. Unfortunately, relatively few people with osteoporosis are diagnosed before the onset of osteoporosisrelated fractures, and most of them are never treated for osteoporosis either before or after the fractures have occurred [10–14]. In brief, there can be little doubt that osteoporosis is both underdiagnosed and undertreated. It is also indisputable that osteoporosis contributes to the occurrence of most fractures among older individuals [15,16]. These fractures are linked to an increased risk of death [17–20], and all of them can be disabling with respect to specific activities of daily living [21]. Hip fractures are most serious in both respects [22]. Hip fractures alone lead to nearly 140,000 nursing home admissions annually in the United States [23], and this must surely be considered serious given that many elderly women would rather die than go into a nursing home. Direct medical expenditures for treating osteoporotic fractures exceeded $13 billion in 1995 ($17.5 billion in 2002 dollars) [23], which is greater than the combined cost of managing breast and gynecological malignancies [24]. Even governmental agencies agree that these costs could rise threeto eight-fold over a 50-year span because the number of fractures rises inexorably as the elderly population increases [25]. Any serious reduction in * Corresponding author. Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Fax: 1-507-284-1516. Bone 32 (2003) 327–331 www.elsevier.com/locate/bone