How labels get in the way of trusting ourselves - Entry 15, 2008

One day in 2000 I became overweight. No, the reading on my scale didn’t change, but the definition used by the World Health Organization did (1). Instead of being in the “normal” category (Body Mass Index up to 25.8), I slid just over the boundary (2). Or, more correctly, the boundary slid just below me. In the language of epidemiology, I instantly became “at risk” for several diseases and health events. I wasn’t any different—I already knew I should lose a few pounds—but the label said I was.

Of course, it is natural in science (and life) to classify things as good or bad, problematic or not. Plus, defining criteria for “at risk” helps us allocate our resources and attention; it helps us know who to worry about, and when we should pay attention ourselves. But it seems our society over-emphasizes the absolute medical label, like “I am hypertensive” or “I am pre-diabetic” and de-emphasizes how much influence we each have on our own wellbeing. When we get a scary disease name, like hypercholesterolemia (elevated cholesterol), we have a tendency to think we require professional help.

Yes, we have to draw the line somewhere, but have we over-simplified messages about risk? If you are near the edges, should a label make the difference? Body weight really isn’t a pass-fail situation. Shouldn’t I pay attention to extra pounds and a healthy diet regardless of my risk label? Or for other things: if I have a cholesterol level of 201 versus 199, a systolic blood pressure of 141 versus 139, or a fasting blood sugar of 101 versus 99, does the exact cut-off change my well being?

Instead, EITHER number—in the vicinity of a “problem” level—warrants one’s attention and consideration of personal behaviors. For all of these metrics and a vast majority of people, small changes in diet, exercise, sleep, and other habits have incredible power to change the numbers in a positive direction, perhaps making a drug unnecessary.

More and more, medical science continues to broaden its definition of risk and disease, leading to more and sooner treatments. Just last week, the American Academy of Pediatrics recommended screening children as young as 2 for cholesterol and beginning cholesterol-lowering medications as young as age 8. While acknowledging that the current trends for young children to develop diabetes and cardiovascular problems reflect our societal patterns of poor diet, inactivity and prevalence of childhood obesity, their solution is to classify diseases at a younger age and prescribe medicine. (Note: the report does list healthy lifestyle as an intervention, but the news to the public clearly emphasized prescribing Statin drugs at age 8 (3).)

If the purpose of this test for children was simply to inform families, rather than activate an early sequence of labels and treatments, perhaps this would be reason to celebrate. But it is hard not to worry about the unknown side effects of decades of medication use, not to mention the effects of labeling small children (who may feel fine) by telling them they have to take a pill because they are “sick.” How might a child think of himself or his skills differently? Does this promote a culture where we all understand how to take care of ourselves? Or does it assign responsibility to outside experts to tell us if we are OK, and the exclusive power to make us better when we are not OK?

Labels have consequences in both directions.
In the medical system, labels can be tickets of admission. In many cases, a doctor must assign a diagnosis to get paid; a patient must have a diagnosis to have certain treatments approved for payment. From a financial perspective, a more severe diagnosis will result in more insurance reimbursement to the physician or hospital. Labels can provide an incentive to get something we want, or permission to avoid something we don’t like. (“I can’t do that because I have X.”)

Simultaneously, labels can be future barriers to the same medical system. In some instances, an insurance plan will restrict coverage for existing conditions. Also, disability and life insurance may be more expensive when we have a previous disease label. Both positively and negatively, a label may change our access in the future.

So, if you have a cholesterol value that is “borderline,” who decides if you get a label now? If you want to try diet and exercise to get below a “high” designation, what happens to the label? Do you know what labels are in your records, assigned by the doctor for billing purposes?

Giving power to others.
One problem with giving permission to others to label us is that they may not have the same goals we do. A sad example of accepting labels that have caused damage in recent years is in the financial realm. In the past 20 years, lending institutions have relaxed their criteria drastically to label a person “financially healthy”, or “qualified”, for increasing amounts of credit. By lending more money, the companies earned more fees and interest (for awhile anyway). This led to the public accumulation of record levels of debt, and assumption of unreasonable home mortgage debt that threatens the economy today.

Interviews of individuals facing foreclosure often include statements like, “I guess I knew it was out of my reach, but they said I ‘qualified,’ so I did it.” This isn’t all together different than the power the medical sector wields when they label us. The expanding definitions of sick and at-risk are sometimes as fuzzy as the definitions that allowed home-buyers to believe they were financially healthy and qualified. In both cases, people have a tendency to rely on the label assigned by outside experts more than the truth, which we often know. Expertise would be more valuable if we used it to decide for ourselves, rather than getting “the answer,” which may not be appropriate for us.

Now, some legislators suggest bailing out individuals who over-borrowed, assigning virtually all the blame to unscrupulous lenders. This logic seems oddly similar to lawsuits against McDonald’s for its role in making us obese, or against tobacco companies for giving us cancer. One has to wonder how so many of us got into the position of assigning responsibility (and blame) for our personal health and financial health to someone else.

In reality, as an adult it’s my job to recognize when I carry extra pounds (or debt), and my job to decide how best to handle these situations, regardless of what category someone puts me in. If someone tells me I am skinny, when I am not, I still have the extra pounds. If someone tells me I am obese, when I am not, I have to decide if I want to take diet pills. The labels may actually get in the way of simply relying on my own judgment and deciding what is best for me.

Why this matters.
In medicine and finances, information, metrics, and expertise can help us understand our current health and risk status. But the labels we apply to our situation—and what we decide to do about it—really should be our choice. Usually, there is a continuum behind the cutoff. And even if the label qualifies us for something we want (services or help), there are always other ramifications. Rarely is there only one option available to us in how to respond to, or change, the situation. Yet, too often we passively accept both a label and a prescribed response, rather than taking charge of both.

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References

1. World Health Organization. Global Database on Body Mass Index: BMI Classification. World Health Organization; 2008 Jul 18. (accessed July 18, 2008).

2. National Center for Health Statistics. Plan and Operation of the Third National Health and Nutrition Survey, 1988-1994. Vital Health Statistics. 1994; 1:32.

3. Blankenhorn, D. Pediatric Market Opened to Statins. ZDNet Healthcare; 2008 Jul 7. (accessed July 18, 2008).