(III) #4cronico ¿Es un riesgo estratificar a la población basándonos en «factores de riesgo»?

Uno de los elemento compartidos por las diferentes estrategias de cronicidad es la «estratificación de la población» : Segmentación en población de riesgo (según la Estrategia Valenciana, página 30), estratificación poblacional (según el proyecto estratégico 1 de la Estrategia en Euskadi)

¿Qué vamos a suponer que es Enfermedad Crónica?¿Hasta dónde va a entrar el «etiquetado»? En una brillante presentación de Iona Heath en los Seminarios de Innovación en Atención Primaria del año 2008, apuntaba el riesgo del etiquetado diagnóstico. Heath señalaba los estudios en USA y Noruega donde al utilizar ciertos criterios diagnósticos, un 76% de la población adulta noruega estaba «en riesgo», paradójicamente en uno de los países con mejor esperanza de vida del mundo. ¿Demasiada gente «pre-enferma» en países poblacionalmente sanos?

Este etiquetado anticipado supone así mismo un contacto precoz con el sistema sanitario y probablemente generando un efecto perverso, medicalizador, y contrario al deseado.

 

«With the development of increasingly sophisticated methods of biometric measurement, the definition of disease has shifted and has become increasingly dependent on number and an assessment of the deviance of an individual’s measurement from the statistical norm.  This has begun an apparently inexorable process by which an ever greater proportion of the population is classified as being in some way abnormal.  The classification of disease has become detached from the experience of suffering.  This is happening with the definitions of diseases and even more with the identification of risk factors for disease.  Two studies serve to illustrate these processes.

In 1999, Lisa Schwartz and Steven Woloshin showed that the implementation of newly recommended and broader definitions of four common conditions – diabetes, hypertension, hypercholesterolemia, and being overweight – would have the effect of labelling 32 million more Americans as suffering from at least one of these four common conditions and as a result 75% of the entire adult population of the US would be so labelled.#  The scale of these findings has been corroborated by a more recent paper by Linn Getz and colleagues who applied the thresholds recommended in the 2003 European guidelines on cardiovascular disease prevention in clinical practice to the entire adult population of the Norwegian county of Nord-Tröndelag.#   The guidelines suggested blood pressure above 140/90 mm Hg, with no age correction, and serum cholesterol of 5 mmol/L as the appropriate thresholds for intervention. The clinician is not necessarily required to start treatment at these levels but is expected to inform the patient that these measurements mean that he or she is at increased cardiovascular risk.   The Nord Tröndelag health survey collected measurements of blood pressure and cholesterol for some 62 000 adults aged 20-79 in 1995-7.  When the European guidelines are applied, half of the population are considered to be at risk by the early age of 24 years. By the age of 49, this proportion rises to 90% and as much as 76% of the total adult population are found to be at “increased risk.”  Yet the current life expectancy at birth in Norway is 78.9 years, making it one of the longest living populations ever.  Something appears to be going very wrong – it is simply not possible for three quarters of one of the longest living populations in history to be at increased risk of early death and yet, fear is sewn in every preventive health consultation which follows these guidelines and fear itself throws a shadow across life and undermines health.#