A note on approach. This essay is an audit of specific decisions taken by specific committees on specific dates. When laboratory categories and disease labels appear (hypertension, diabetes, cholesterol, osteopenia, “vitamin D deficiency,” “autoimmune”), they appear in the establishment sense: what the committee voted the category to mean and how the pharmaceutical response followed. Terms such as “disease,” “patient,” and “diagnosis” are used in the register the profession uses. Whether the underlying biological framework these categories rest on is itself sound is the subject of other essays. The point here is narrower, and in a sense more damaging to the profession’s self-account: even inside its own framework, the thresholds that separate health from illness are set by votes, not by biology, and the voters are paid by the companies that sell the treatment.
The Overnight Sick
Thirty-one million Americans became sick between one Sunday and the following Monday in November 2017.
Nothing happened to their bodies. Twenty-one members of a joint task force convened by the American College of Cardiology and the American Heart Association voted to redefine high blood pressure. The threshold moved from 140/90 mmHg to 130/80 mmHg. The vote was announced at the AHA’s annual scientific sessions in Anaheim. In the interval between one press conference and the next, approximately 31 million additional Americans became hypertension patients.¹
What changed was the number on the wall of the exam room.
The pattern is not unique to blood pressure. Between 1994 and 2018, guideline committees performed the same operation on twelve of the most common conditions in adult medicine. Each time, the mechanism was identical: a specialist panel, most of its members holding financial ties to the companies that manufacture the drugs used to treat the condition being redefined, moved a threshold. Each move converted millions of people who felt fine into patients requiring lifelong monitoring, testing, and, increasingly, pharmaceutical management.
What follows is an audit of the twelve.
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1. Hypertension: 140/90 → 130/80
Year: 2017. Committee: ACC/AHA joint task force (21 members). Patients created: approximately 31 million Americans overnight.²
The threshold move was justified by SPRINT, a trial that used automated office blood pressure measurement. Automated readings run systematically lower than the standard clinical technique most doctors use, meaning a “130” in SPRINT corresponds to something higher on a typical office cuff. The guideline did not correct for this. The trial was also stopped early for benefit, a pattern that tends to inflate effect sizes.³
Following the vote, approximately 46% of the American adult population meets the definition of hypertension.⁴ Antihypertensive drug sales continue their long upward march. The guideline document technically recommends lifestyle change first for the newly captured 130-139 range. In practice, a seven-minute consultation with a positive diagnostic label ends in a prescription.
2. BMI Obesity Cut-off: 27.8 → 25
Year: 1998. Committee: NIH National Heart, Lung, and Blood Institute expert panel. Patients created: approximately 29 million Americans became “overweight” overnight.
Before the 1998 revision, the overweight threshold was a BMI of 27.8 for men and 27.3 for women. The NHLBI panel harmonized both to 25, aligning US thresholds with WHO categories. The morning of the announcement, roughly 55% of American adults woke up in a heavier weight category than the one they had gone to bed in.⁵
CBS News reported the change in plain terms: “29 million more Americans are overweight than previously thought.”⁶ A woman told the network’s correspondent, “I could never be what they say I need to be.”⁷
The reclassified population became the addressable market for what has since become one of the fastest-growing pharmaceutical categories in history. FDA-approved weight-loss drugs are indicated at BMI ≥30, or ≥27 with a comorbidity. These thresholds are calibrated to the 1998 categories. Bariatric surgery kicks in at ≥40, or ≥35 with a comorbidity. Every downward revision of the underlying category expands the eligible population upstream.
The current commercial payoff of the 1998 vote is the GLP-1 boom. Semaglutide (marketed as Ozempic for diabetes and Wegovy for weight loss) and tirzepatide (Mounjaro for diabetes, Zepbound for weight loss) are the largest-selling drugs in pharmaceutical history. Semaglutide alone generated approximately $29 billion in 2024 revenue for Novo Nordisk. Tirzepatide reached approximately $36 billion in 2025 for Eli Lilly, surpassing the peak sales of any oncology or immunology drug ever brought to market.⁸ Their FDA labels prescribe eligibility at BMI ≥30, or ≥27 with a comorbidity. The 1998 thresholds are the entry gate to a $100-billion-a-year drug class. When the NHLBI panel voted in 1998, that class did not exist. When it did exist, the panel’s numbers determined who could buy it.
3. Chronic Kidney Disease: New Staging System (2002)
Year: 2002. Committee: National Kidney Foundation K/DOQI Work Group. Patients created: approximately 26 million Americans reclassified as having “chronic kidney disease.”⁹
Before 2002, kidney disease was a clinical diagnosis: it was present when a patient had symptoms or when kidney function was unambiguously reduced. The K/DOQI Work Group replaced that with a five-stage classification based on estimated glomerular filtration rate, or eGFR (a calculated approximation of kidney filtering capacity, worked out from a routine creatinine blood test).¹⁰ Stages 1 and 2 required evidence of kidney damage (protein in the urine, abnormal imaging, or biopsy findings) plus a normal eGFR. Stages 3, 4, and 5 required only an eGFR below 60, with no other finding needed. An asymptomatic 70-year-old whose eGFR read 55 became a Stage 3 CKD patient.
The problem with the eGFR cut-point is that kidney filtering capacity declines with age in almost everyone. Applying a fixed threshold across the population converted the natural decline of aging into a disease category. Richard Glassock, one of nephrology’s senior figures, called the KDOQI classification’s application to individual patient management its central limitation, noting that most people captured in Stage 3 will never progress to renal failure.¹¹
The pharmaceutical response followed: erythropoiesis-stimulating agents, phosphate binders, vitamin D analogs, and the newer SGLT2 inhibitors indicated for CKD have all been marketed into the population the classification created.
4. Cholesterol: The Ratchet (1988 → 1993 → 2001 → 2013 → 2018)
Committee sequence: National Cholesterol Education Program (NCEP), then successive ACC/AHA guidelines.
The first NCEP report in 1988 set total cholesterol above 240 mg/dL as “high” and below 200 as “desirable.”¹² Subsequent revisions in 1993 and 2001 progressively lowered treatment eligibility and target values. The 2001 ATP III guidelines tripled the number of Americans with cholesterol classified as abnormal.¹³
A BMJ investigation by Jeanne Lenzer found that most panelists on the 2001 guidelines held current or recent financial ties to statin manufacturers.¹⁴ The 2013 ACC/AHA guidelines then shifted the target from LDL numbers to a “10-year risk calculator” that dramatically expanded statin eligibility. The 2018 update pushed LDL targets down further, to below 70 mg/dL for many patients, and below 55 mg/dL for very high-risk patients. These lower targets are reachable in most people only by adding newer drugs, including PCSK9 inhibitors and ezetimibe, on top of high-intensity statins.
The absolute risk reduction for statins in primary prevention (in people without existing heart disease) is approximately 1-2% over five years. The relative risk reduction, which is the number quoted in patient conversations, is 30-40%.¹⁵ Each guideline revision expanded the population exposed to that arithmetic. None expanded the underlying benefit.
5. Diabetes: 140 → 126
Year: 1997. Committee: International Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, sponsored by the American Diabetes Association. Patients created: approximately 1.6 million Americans became diabetic overnight; millions more within years as testing followed the new threshold.¹⁶
Before 1997, the fasting plasma glucose threshold for diabetes was 140 mg/dL. The Expert Committee lowered it to 126. Anyone whose fasting glucose sat between 126 and 140, previously normal, was now diabetic. H. Gilbert Welch, in Overdiagnosed, calculated that the change turned roughly 1.6 million Americans into diabetes patients on the day the recommendation was issued.¹⁷
The stated justification was that retinopathy incidence rose noticeably at a fasting glucose of about 126, so catching people earlier would reduce complications. The problem with the justification: the new patients captured between 126 and 140 have milder metabolic disturbance and, correspondingly, a lower absolute risk of the complications the treatment is meant to prevent. Their numbers needed to treat balloon accordingly.
Metformin prescriptions grew. Continuous glucose monitors, HbA1c tests, and diabetes-education services grew with them.
6. Osteopenia: The Category That Did Not Exist (1994)
Year: 1994. Committee: WHO Study Group on Assessment of Fracture Risk (WHO Technical Report Series 843), chaired by John Kanis. Patients created: almost every postmenopausal woman becomes a candidate for a bone-density diagnosis.
This entry is the archetype. It deserves the attention.
Before 1994, osteoporosis was diagnosed clinically. A person had it when they had a fragility fracture from minor trauma. The WHO Study Group changed that. It defined osteoporosis by a laboratory measurement: bone mineral density on a DEXA scan, expressed as a T-score, calculated by comparing the patient’s bone density to the mean of a young adult reference population.¹⁸ A T-score at or below −2.5 was “osteoporosis.” Between −1.0 and −2.5, a new category the Study Group invented: “osteopenia.”
Three features of this construction deserve attention.
The reference population is a young adult. The T-score does not compare a sixty-year-old woman to other sixty-year-old women; it compares her to the average bone density of a healthy thirty-year-old. Bone density declines with age in every population ever studied. Anchoring the comparison to peak young-adult density guarantees that the majority of older women will fall short of it. It is mathematically identical to defining “short” as “shorter than the tallest 5% of the population,” a threshold that will always find shortness.
The cut-points were chosen for epidemiological convenience, not clinical significance. Kanis and colleagues acknowledged in later publications that the −2.5 threshold was set to capture roughly 30% of postmenopausal white women, a prevalence figure that made the category useful for study design and drug trials. The −1.0 boundary of osteopenia has even less justification. It captures another 30-40% of the same population, ensuring that most women who present for DEXA scanning receive some form of bone-related diagnosis.¹⁹
Osteopenia is not a disease. Bone density between −1.0 and −2.5 T-score is a statistical position on a normal distribution, not a clinical entity. The Study Group’s own report did not claim otherwise. What happened over the following decade is that “osteopenia” migrated from a research categorization into a clinical diagnosis reported to patients, discussed in exam rooms, and treated with drugs.
The commercial sequel was immediate. Merck launched Fosamax (alendronate) in 1995, the year after the WHO report. The company signed financing agreements with the two dominant DEXA manufacturers, Lunar and Hologic, to subsidize scanner acquisition by physician offices. In 1995 there were roughly 750 bone-measuring devices in the United States. By 1999 there were between 8,000 and 10,000, according to Merck’s own figures.²⁰ The company also funded the Bone Measurement Institute, which lobbied Congress in 1997 to pass the Bone Mass Measurement Act, making DEXA screening a Medicare-reimbursable procedure. Bone-scanning claims to Medicare leapt to 1.5 million by 1999. Internal Merck documents obtained through later litigation reveal company excitement about the new diagnostic category and the market it was building.²¹
The mechanism of the drug that followed compounds the problem. Bisphosphonates work by killing osteoclasts, the cells that break down old bone. They increase mineral density on the scan. They do not build new bone. Bone that has not been resorbed for years becomes older, more brittle, and structurally compromised. Predictable results: osteonecrosis of the jaw (the jawbone dies and crumbles) and atypical femur fractures, in which the thigh bone snaps in unusual locations under minimal load.²²
A category was invented. A drug was launched to treat it. The category ensured a patient population. The drug produced the disease it claimed to prevent. This is the play in its cleanest form.
7. Pre-diabetes: A Category Invented, Then Widened (2003)
Year: 2003. Committee: American Diabetes Association Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Patients created: tens of millions.
The 1997 committee that lowered the diabetes threshold also defined a new intermediate category, impaired fasting glucose, spanning 110 to 125 mg/dL. In 2003, the ADA lowered the lower bound of that category from 110 to 100. Anyone with a fasting glucose between 100 and 125 was now “pre-diabetic.”²³
The CDC currently estimates that approximately one in three American adults has pre-diabetes. Most will never develop diabetes. Pre-diabetes is not a disease. It is a laboratory position. It exists as a category because it captures a population large enough to justify a public health infrastructure: screening programs, lifestyle-intervention services, HbA1c monitoring, and, increasingly, prescriptions for metformin used off-label for a condition the drug is not FDA-approved to treat.
The invention of pre-diabetes provided a novel resource to the medical-industrial complex: patients who feel completely well and require nothing, whom the system can nevertheless bill for monitoring and intervention.
8. Vitamin D “Insufficiency”: 30 ng/mL as the New Floor
Year: 2011. Committee: Endocrine Society Clinical Practice Guideline task force, chaired by Michael Holick. Patients created: by the guideline’s own calculations, most of the world population.
The Endocrine Society’s 2011 guideline defined “deficiency” as a serum 25-hydroxyvitamin D level below 20 ng/mL and “insufficiency” as 21-29 ng/mL, recommending that levels above 30 be maintained.²⁴ The Institute of Medicine, examining the same evidence in the same year, concluded that 20 ng/mL was adequate for bone health in 97.5% of the population.²⁵ Two committees, same year, same data, different thresholds. One created a global “deficiency epidemic.” The other did not.
Michael Holick, the guideline’s chair, has received research funding from the Indoor Tanning Association and its offshoot the UV Foundation, consulting income from Quest Diagnostics (the largest commercial vitamin D testing laboratory), and payments from supplement manufacturers.²⁶ The higher threshold produced a corresponding boom in testing and supplementation. Cholecalciferol (the compound sold as vitamin D3) supplement sales rose several-fold in the years following the guideline. Chronic supplementation depletes cofactors including magnesium and vitamin K2, generating a downstream cascade of further supplementation.
The relevant question is whether raising a laboratory number by supplementation produces any clinical benefit. It has been answered largely in the negative by the VITAL trial and subsequent meta-analyses, which have failed to find cardiovascular, cancer, or fracture benefit at the population level.²⁷ The threshold remains where the 2011 guideline placed it.
9. TSH Normal Range: 5.0 → 3.0
Year: 2002. Committee: American Association of Clinical Endocrinologists. Patients created: the diagnostic pool for hypothyroidism approximately quadrupled.
Before 2002, the standard laboratory reference range for TSH (thyroid-stimulating hormone) was approximately 0.5 to 5.0 mIU/L. In January 2002, AACE narrowed the range to 0.3 to 3.0. A patient whose TSH was 4.0 the day before the announcement, unambiguously normal, was now above the upper bound of the new range and a candidate for thyroid hormone replacement.²⁸
Stefan Grebe and colleagues at the Mayo Clinic examined the practical effect. Analyzing TSH measurements from 75,882 patients with no known thyroid disease, they calculated that lowering the upper limit from 5 to 3 mIU/L would quadruple the number of patients classified as having elevated TSH, from about 5% of the cohort to about 20%.²⁹
Levothyroxine (Synthroid) is now the third most-prescribed medication in the United States, with over 80 million prescriptions annually. Approximately 23 million Americans take it every morning.³⁰ Between 10% and 28% of those patients report persistent symptoms despite biochemically “normal” TSH. The laboratory number does not correspond to how patients actually feel.³¹
10. PSA Cut-off: 4.0 and the Attempt to Lower It Further
Year: 1994 (FDA approval for screening) and subsequent efforts to lower the trigger. Committee: FDA advisory panel over the objections of its own members; subsequent advocacy by prominent urologists.
The 4.0 ng/mL threshold that triggers a prostate biopsy was, according to New York Times reporting, chosen “just sort of arbitrarily.”³² William Catalona’s influential 1991 New England Journal of Medicine paper established the cut-off without reporting false-positive rates. The FDA approved PSA for screening in 1994 despite significant advisory-panel concerns, with one panel member warning: “Like Pontius Pilate, you cannot wash the guilt off your hands.”³³
Catalona subsequently advocated lowering the biopsy threshold from 4.0 to 2.5 ng/mL, a change that would have swept several million additional men into the biopsy cascade. This proposed move did not become universal guideline, but many urologists adopted the lower trigger in practice.³⁴
Richard Ablin, who first identified the prostate-specific antigen in 1970, called the use of PSA for population screening a “profit-driven public health disaster” in a 2010 New York Times op-ed.³⁵ Annual PSA screening of approximately 30 million American men triggers about one million prostate biopsies. At least three-quarters of those biopsies find no cancer. Radical prostatectomy peaked at 2,600 post-surgery deaths in 1992, in men who died from surgery for cancers that would never have threatened their lives.³⁶
The lifetime risk of dying from prostate cancer is approximately 3%. The lifetime risk of being diagnosed with it, given contemporary screening, is roughly 16%.³⁷ The gap between diagnosis and death is the overdiagnosis window the arbitrary threshold created.
11. LDL Sub-Fraction Targets: Below 70, Below 55
Year sequence: 2004 (below 70 for high-risk), 2018 (below 55 for very-high-risk). Committee: NCEP ATP III update (2004), then ACC/AHA/multi-society guidelines (2018).
The 2001 ATP III guidelines set an LDL target of below 100 mg/dL for coronary heart disease patients. A 2004 update lowered the target to “optional” below 70 for very-high-risk patients, a change that expanded the market for higher statin doses and combination therapy.³⁸ The 2018 ACC/AHA cholesterol guideline pushed the target lower still, endorsing LDL below 55 mg/dL for very-high-risk patients with established atherosclerotic disease.³⁹
Reaching these targets in most patients requires more than statins. It requires the addition of ezetimibe and PCSK9 inhibitors (evolocumab, alirocumab: biologic drugs that block a liver protein, produced by biotechnology methods, costing thousands of dollars annually). It now also increasingly requires inclisiran, a newer drug administered by injection twice yearly. The threshold moves down; the products required to reach it move in.
The evidence for population-wide benefit at these lower targets does not hold up on close examination. Uffe Ravnskov’s analysis of the TNT trial documented that the difference in all-cause mortality between low-dose and high-dose atorvastatin was 5.6% versus 5.7%, with fewer cardiovascular deaths in the high-dose group offset by more deaths from other causes.⁴⁰ The lower LDL target sold more drug. It did not extend more lives.
12. ADHD: Successive DSM Broadenings (1980 → 1994 → 2013)
Committee sequence: APA DSM-III (1980), DSM-IV (1994), DSM-5 (2013).
Attention deficit hyperactivity disorder as a diagnostic category was established in DSM-III (1980), reconfigured in DSM-IV (1994) to formalize three subtypes including the “predominantly inattentive” presentation (which captured children who were quiet, distractible, and daydreamy, behaviors previously not classified as disordered), and reconfigured again in DSM-5 (2013), which raised the age of symptom onset from 7 to 12, reduced the number of required symptoms for adults, and removed the previous exclusion of ADHD diagnosis in the presence of autism spectrum disorder.
The 1998 NIH Consensus Conference on ADHD acknowledged plainly: “We don’t have an independent, valid test for ADHD; there are no data to indicate that ADHD is due to a brain malfunction; existing studies come to conflicting conclusions as to whether use of psychostimulants increases or decreases the risk of abuse, and finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains speculative.”⁴¹
Each DSM revision captured additional populations. Stimulant prescriptions followed. Methylphenidate (Ritalin) is classified by the DEA as Schedule II, the same restrictive category as morphine and cocaine, reflecting the potential for dependence. The 2007 follow-up of the MTA study, the largest trial ever conducted, found that by three years, medication use was “a significant marker not of beneficial outcome, but of deterioration.”⁴² By eight years, there were no differences between medicated and unmedicated children in school grades, arrests, or psychiatric hospitalizations.
Joseph Biederman, the Harvard psychiatrist who established childhood bipolar disorder as a diagnostic category, received $1.6 million from pharmaceutical companies between 2000 and 2007. In a 2009 deposition he described his approach: “The conditions that we see in front of us are reconceptualized.”⁴³
The Play
Twelve committees. Twelve threshold moves. Twelve populations reclassified from health to illness without a single change in the underlying biology of a single person.
The mechanism is identical in every case. A specialist panel meets, its members holding financial relationships with the companies that manufacture the drugs used to treat the condition being redefined. The panel lowers the threshold. Millions become patients. Prescriptions and revenue rise together. No population-level improvement in longevity, function, or quality of life follows.
The public assumes that the numbers on the wall of the exam room (the systolic blood pressure that requires a prescription, the LDL that requires a statin, the T-score that requires a bisphosphonate, the TSH that requires levothyroxine) are discovered facts about the human body. They are not. They are the outputs of votes taken in committee rooms by people with a financial interest in the vote’s direction. This is not the paranoid interpretation. It is the documented one, verifiable through Endocrine Society disclosures, ACC/AHA conflict-of-interest statements, and the payment records that the industry itself files with CMS Open Payments.
Every committee named in this essay is a matter of public record. Every threshold move has been published in a specific journal on a specific date. Every industry payment disclosure is filed and accessible. A reader inclined to verify any of the twelve entries can do so without leaving their desk. The instrument that expanded the population of the sick was built in the open. Its blueprints remain there.
The threshold-moving described here is one mechanism inside a larger structure. The same industry that funds the committees also designs the trials that produce the evidence the committees cite, controls the analyses of that evidence, and decides which findings reach publication. For readers who want the book-length account, that is The Architecture of Deception, from which several of the twelve entries above were drawn.
How to Explain It to a Six-Year-Old
Imagine your teacher decides that being “tall” means being taller than the tallest kid in the whole school. Only one kid gets to be tall.
Now she changes her mind. She says “tall” means taller than most kids. Suddenly, half the class is tall.
Then she changes her mind again. She says “tall” means taller than the shortest kid in the class. Now almost everyone is tall.
Nobody in the class actually grew. Nobody got taller in the night. The only thing that changed was where the teacher decided to draw the line.
That is what happened with high blood pressure, and diabetes, and cholesterol, and bones, and thyroid, and prostate, and everything else in this list. The doctors did not find new sickness. The committees just moved the line, and millions of people who felt fine when they went to bed woke up sick.
The people who moved the line were paid by the companies that sell the pills.
In Print
The Unbekoming library is available in paperback, printed to order through Lulu and shipped worldwide. The shelf begins with the paradigm question underneath everything else — No Virus, the isolation problem, the collapse of virology’s foundational claims, and a disease-by-disease reappraisal — and moves through the suppressed compounds mainstream medicine set aside: The DMSO Book, Chlorine Dioxide: The Forbidden Remedy, The Iodine Book, and The Hydrogen Peroxide Book. Two more recover what’s still on the kitchen shelf: Baking Soda and The Castor Oil Book. Two more recover the minerals modern soil, water, and processing quietly stripped from the diet: The Magnesium Handbook and The Boron Book. Sitting alongside these is No Contagion, co-authored with Jamie Andrews — the case against germ theory itself, catalogued through 258 failed contagion experiments.
The critique books cover what medicine, dentistry, psychiatry, and veterinary practice have become. The Unvaccinated treats the completely unvaccinated as a comparison group across twenty chapters and five appendices. Medicalized Motherhood follows a woman through 123 documented interventions from teenage pill to postpartum discharge. Drilling for Profit treats cavities, gum disease, and crooked teeth as the dietary problem they are. What Your Vet Can’t Tell You applies the same critique to pets. Escape from Psychiatry documents the fabrication of the DSM and the specific damage of every major psychiatric drug class. The Vitamin K Injection covers what happens in the first hours of a newborn’s life.
The full shelf is at lulu.com/spotlight/unbekoming. A physical book reaches the person a Substack post never will — the skeptical relative, the friend who won’t click a link but might open a book, the visitor whose eye lands on a coffee table. Buy one to keep, and one to give away.
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Catalona WJ, Smith DS, Ornstein DK. Prostate Cancer Detection in Men with Serum PSA Concentrations of 2.6 to 4.0 ng/mL and Benign Prostate Examination. JAMA. 1997;277(18):1452-1455.
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I've been writing about this for decades. But to see the whole enchilada in one place..... Devastating! You've done it again, Unbekoming!
While living in Belgium for 40 years my blood pressure was measured about 4 times. 'bloodwork' was done twice, both times before surgery. I had never seen the doodah on your finger that supposedly measures oxygen. When I came here I was astonished of how many unnecessary tests were done. In Belgium you see the doctor - there is no sign-in paper, questionnaire and 2 or 3 nurses who ask you what you filled out on the questionnaire again. You tell the doc what is wrong, and are asked relevant questions. the numbers there are still a few years behind - I will still ask when the doc here tells me this or that is too high or low, and he laughs and says, they consider that bad over there? Jeez! You are fine, don't worry.
Exactly like you explain to the 6 year old what happened. I absolutely love that part of your articles! It is a meme in words.