Until August 15, 2012, if you asked almost any American physician whether someone with a blood pressure reading of 145/95 should be treated with medication, the answer would have been a resounding yes! Medical students and residents are taught that hypertension increases the risk of heart attacks, strokes and early death. Physicians have come to believe that aggressive treatment of patients with high blood pressure will lead to better outcomes.
Everything changed on August 15, 2012, when the Cochrane Collaboration published its analysis: “Benefits of antihypertensive drugs for mild hypertension are unclear.” The Cochrane Collaboration represents the highest level of scientific scrutiny of available studies. The experts who analyze the data are independent and objective and have come to be regarded as the ultimate authority on the medical interventions they evaluate. As far as we can tell, there is no better organization for assessing the pros and cons of pharmaceutical and alternative therapies than Cochrane.
There is no doubt that this review will create extraordinary controversy and push-back from the medical community. A bedrock belief is being challenged. That’s because these experts are suggesting that most of the nearly 70 million Americans diagnosed with high blood pressure are probably being treated unnecessarily. The researchers reviewed data from nearly 9,000 patients enrolled in four randomized controlled trials. These were people who had been diagnosed with what is called stage 1 hypertension. That means their systolic blood pressure was between 140-159 and their diastolic blood pressure was between 90 and 99.
Here is what the Cochrane Collaboration found:
“Individuals with mildly elevated blood pressures, but no previous cardiovascular events, make up the majority of those considered for and receiving antihypertensive therapy. The decision to treat this population has important consequences for both the patients (e.g. adverse drug effects, lifetime of drug therapy, cost of treatment, etc.) and any third party payer (e.g. high cost of drugs, physician services, laboratory tests, etc.). In this review, existing evidence comparing the health outcomes between treated and untreated individuals are summarized. Available data from the limited number of available trials and participants showed no difference between treated and untreated individuals in heart attack, stroke, and death.”
The abstract concluded:
“Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs [randomized controlled trials]. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.”
Over the last few decades something called “disease creep” has penetrated American medicine. That implies that the definition of illness has broadened dramatically. The label “hypertensive” used to be reserved for people with systolic blood pressure (the upper number) over 150 and diastolic blood pressure (the lower number) above 99. Nowadays, anyone with blood pressure readings greater than 120/80 may be labeled hypertensive.
There are data to suggest that once someone is labeled hypertensive it affects mental attitude. And most physicians feel it is their duty to treat high blood pressure aggressively to get the numbers as close to 120/80 as possible. That almost inevitably means medication; sometimes three or four different drugs are needed to achieve that number. Not uncommonly, these medications cause a range of side effects. ACE inhibitors can cause an unpleasant (and sometimes disastrous) cough. To read more about complications of this cough visit these links:
Link 1
Link 2
Link 3
Other antihypertensive medications can cause fatigue or dizziness and affect sexual function. It is important to know when to treat with drugs and when to encourage lifestyle changes (weight loss for example and relaxation techniques) to control mild hypertension.
To read more about the new Cochrane Collaboration conclusions we encourage you to read the reports by Jeanne Lenzer in the BMJ and Slate. She has done an excellent job reviewing the findings and making them understandable.
If you would like to learn more about ways to control high blood pressure with nondrug approaches we suggest you check out our Guide to Blood Pressure Treatment as well as the in-depth chapter in our book, Best Choices From The People’s Pharmacy.
No one should EVER stop taking a medication without consulting his physician. Those with definite hypertension, (like the fellow in the picture with a blood pressure reading of 189/101) must be treated aggressively with medication. Hypertension does cause heart attacks, strokes and kidney damage and leads to premature death.
We do encourage those with mild hypertension to make sure their physicians read the review in the BMJ and then take time to review the Cochrane Collaboration report. Shouldn’t physicians practice what they preach, ie “evidence based medicine?” The Cochrane Collaboration has reviewed the evidence and has challenged the status quo with hypertension heresy.
We hope the medical community will be open to considering the new data analysis. And we hope there will be more serious consideration of nondrug approaches such as losing weight, deep breathing, exercising and learning how to relax and shed some of the stress that can contribute to higher blood pressure readings. Health coaches can assist in this process. So can family and friends. Perhaps it is time to look beyond medications for mild hypertension.

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  1. pointyView
    Reply

    This is an interesting post. More studies should be done to determine if some persons are biologically normal and fit with higher bp. The study would probably be attacked by the medical community and drug industry. I have long suspected a stronger link to profit than health concerns. If 1 million people fall within a hypothetical range of point E and point O why not just move the range a little downward and upward to points D and P to increase revenue volume by 20%.. sell more pills… sell more Dr. office visits.

  2. sb
    Reply

    Your doctor can see huh? I had double bypass surgery 6 years ago due to build up of cholesterol plaques in 2 coronary arteries after 2 heart attacks in one day. Apparently, I should have been dead. I had high LDL cholesterol levels and low HDL levels so it turned out.
    There were NO symptoms until the heart attacks (and even they were atypical!) and I not overweight.
    I had a stream of cardiologists come in and look at me. Each of them could not believe that I would have had the problems I did, except for one possibility … that I had diabetes. So each of them asked “How do you manage your diabetes?” I responded “I don’t have diabetes!” They’d dive into the chart and a look of puzzlement would fill their face “Oh, you’re right, you don’t!” It was the same for each of them!
    So, bottom line here is, your doctor cannot tell that you don’t have coronary artery disease with cholesterol plaques simply by looking at you. Even X-Ray vision alone won’t help him come to that conclusion!

  3. MT
    Reply

    I have been prescribed BP meds including Diovan for a few years now and it recently almost killed me. I’m a very active person who regularly gets dehydrated without realizing how severely. What I didn’t know was that it’s not a big deal if your kidneys can signal your arteries to constrict and raise your BP. Diovan blocked the response and my BP dropped very rapidly to 80/40 and just about killed me.
    I was Triaged right at blackout and recovered within minutes when they stimulated my HR up from 40 BPM’s and flooded me with 4 liters of IV. I’ll take my chances with a heart attack before I’ll risk Hypoxia again just because I worked out for too long…

  4. mike deason
    Reply

    Am I the only one to realize that drug companies have a drug for everything but cannot cure a damn thing!!!!!

  5. JVT
    Reply

    Very interested in your post.
    What is controlled breathing program? I was recently hospitalized with pneumonia and sent home with BP med.
    Energy was not improving at all and I came to suspect BP med. Stopped med and within one day I was full of energy and feeling like old self.
    Am thinking breathing program may help my lungs heal.
    Thank you for your help :)

  6. JLLW
    Reply

    I am a very active woman 81 years of age. As a rule I take no medications of any sort except for occasional ibuprofen. Five years ago my physician prescribed meds to control HBP which had no effect (but honestly no particular side effects, either). Adding a gradual increase of moderate walking, up to 3 miles, two or three times a week and eliminating added sodium and red meat was, however effective.
    Then a year ago I had a colectomy requiring a 10 day stay in hospital. The staff on all levels were amazed to learn of an American (!) who took NO meds, During that stay my (resting :-)) BP was highly erratic and often off the charts (Systolic as high as 190, At my request, I received no medications except for a few days of Oxy on a PCA program and none since. My physician (the chief hospitalist) was well aware of my aversion to meds and did not express concern re BP readings I recently changed physicians and the new MD observed my BP to be 145/77) and suggested meds again, refusing to retest for white coat effect. (I switched to a more sympathetic MD within the practice) I have resumed the exercise program and more recently a controlled breathing program (3x daily) and the last readings have been consistently BELOW 120!! MY advice _ change doctors!

  7. DL
    Reply

    I am 72 good health good weight. Eat and exercise non drinker for over 40 yrs. Last few yrs. have had spikes in my blood pressure. Always had perfect pressure in the past. Medications cause very bad side effects. The hypertension doctor is baffled. I have also tried natural cures to no avail. It was thought to be white coat bp. The problem is it goes up at night also. I have worn bp monitor for 24 hrs. We are at a loss to find a solution.

  8. Larry
    Reply

    I went to a doctor for treatment of a leg infection. When I arrived, I was asked to sit in the waiting room. The nurse came and invited me into the intake area where there was a chair, a table, and a balance scales. She asked me to sit in the chair to remove my shoes, then she had me stand up and step up on the scale where she took my weight. Then she had me sit down and immediately took my blood pressure. As one might imagine, it was elevated but just into the bottom of the “pre-high blood pressure” range.
    Nevertheless, the doctor made sure to note the elevated pressure reading, warn me of the damage high blood pressure can do, and offer to prescribe 5 mg tablets of a very strong drug (lisinopril) designed to force the body to lower blood pressure. When I mentioned diet modification, he brushed it away by saying I didn’t have time to get my pressure down. I could always try to lower it with diet/exercise but in the mean-time I should be sure to take the drug.
    As a regular listener to The People’s Pharmacy, I searched this website and found many stories about the drug. I was alarmed to note the warnings not to discontinue the drug (despite published research showing no immediate spike in blood pressure following abstinance).

  9. je
    Reply

    I am 64 and take 100 metoprolol er and 40 lisinopril for three days now. It’s a new pill because the others did not work. My blood pressure is from 146 to 156 over 83 to 88 while on the pills. When I walk trying to exercise it feels like its going too high and I just sit down. Is the pills not working or too soon to tell? At night when I get up the pulse rate goes high fast then calms down. I am a little scared.

  10. SalW
    Reply

    My husband, age 75, is at our geriatrist’s office right now for new meds to control his erratic blood pressure. Suffering from severe back pain, he has had seven spinal steroid injections (barely missing by only one day the compound that caused fungal meningitis) in the past 17 months. At that time he was on 100 mg Metoprolol twice a day and 100 mg of Losartan Potassium once daily. When his BP went to 200/100 before the last injection (he had taken his BP meds), he was told to see our doctor for a new med to control it. The doctor then added 5 mg of Amlodipine to his BP meds.
    Fast forward to minimally invasive back surgery two weeks ago. Same problem with high BP just before surgery (and after his now three BP meds). Surgery was very successful, but his BP has been all over the place. We ended up at the ER a week ago when his BP went to 245/110 at 9:00 p.m. and was given 10 mg of Clonidine to bring it down three hours later and was told to take it any time his BP went over 180.
    You have written about the danger of combining a beta blocker with Amlodipine and also about the ineffectiveness of taking beta blockers long term. He had a heart attack 24 years ago but with no heart damage, and he has been on Metoprolol about ten years. He no longer sees his cardiologist but needed clearance before his surgery. A much younger cardiologist, after viewing his echocardiogram, said he needed to cut back on Metoprolol to 50 mg/50 mg. The CT scan of his heart was fine. His diastolic pressure now often goes below 60. This morning his diastolic was 53 before BP meds but then went up to 170/70 after BP meds (no food, no coffee)
    I question why blood pressure can go up drastically after taking BP meds. Is he being over medicated for hypertension? Our 62-year-old doctor isn’t open to results of any studies we present him and certainly does not like it when I make suggestions. I am not a doctor, but I can read–especially your very informative newsletters. Thanks!!

  11. BobK
    Reply

    A retired doctor friend of mine has done a lot of research on the subject of hypertension. His conclusions were that there really isn’t any valid data from long term trials that supports the fears of organ or vessel damage due to high blood pressure. He also stated that if there is damage it is automatically repaired by the body.
    My friend also admitted that these new conditions (hypertension, pre-diabetes, elevated cholesterol, etc.) are being used by the medical industry to increase the number of visits to the doctor’s office. In other words when the doctor says “…come back in 3 months so we can track this condition…………..) this puts a fear in the patient’s mind that something is wrong and of course you need to track it more often than on a yearly basis.
    I have often asked the question that if high blood pressure causes damage to organs and blood vessels then why doesn’t athletics have an unusually high rate of these problems given that their BP raises significantly during physical exercise. One primary care physician said that it is because exercise is done for a short period of time. I’m not sure I buy into that answer since pressure can do physical damage immediately to a vessel or organ.
    Bottom line is that I would like to see trial data that links hypertensive blood pressure to organ and blood vessel damage and more importantly what is the damage rate that is seen. All too often we are given statements like “..was an increase in…” or “…..had a higher rate of incidence…..” or some other meaningless answer. If some condition increases from 0.1% to 0.2% I don’t much care. However, if some condition increases from 10% to 30% then it is something that I should take more seriously.
    PEOPLE’S PHARMACY RESPONSE: The hypertension your doctor friend is referring to is mild or moderately high blood pressure. Really high blood pressure is a significant danger, but it isn’t clear that treating moderate hypertension prolongs life. That’s what this Cochrane review shows.
    Athletes may have their blood pressure and more notably heart rate increase during exercise, but if they have been exercising regularly both will drop after exercise and stay lower than they would have been if the person were sedentary.
    Do heed our warning not to discontinue blood pressure medicine without checking with your doctor. It is not safe to stop some blood pressure medicines suddenly.

  12. gw
    Reply

    Your article is very enlightening as I have been seeing a ‘pill pusher’ for nearly 10 years now. Whoever mentioned that your mind locks (buys in) into the theory that you are going downhill fast and need to grab all the ropes the Dr throws your way is right on the money.
    I am an aging triathlete in my late 40’s and I have done more cardio than most will do in a lifetime yet I still have a condition known as pre-hypertension. It is my belief, in my own case, that is is wholly brought on by the stress,fear, and anxiety of life and just trying to stay in the game. Consider how many health related commercials one takes in just trying to watch a sporting event on tv. I have several college mates in the pharmaceutical field and they earn a lot of money doing what they do.
    Exercise and eating right didn’t help my numbers at the doctor’s office (home #’s are what I go by now). I have selected a spiritual approach to my body now and more importantly my mind. Once something is locked in your mind for a time, it becomes engrained, and you are susceptible to ‘self fulfilling prophecy’. I’ve experienced death in my life of various friends, some in their 20’s and know now that life is not promised no matter how healthy or what meds we take.
    My advice- enjoy each day, eat to live, drink lots of water, and be as active as you possibly can. Celebrate when you are at a celebration- it may be your last one…and lastly, just be thankful for what you have…. so many more have much less. Be blessed!

  13. Salman
    Reply

    I am worry about my bp because I am 20 year old and my bp always stay on 135 90 like this.
    but today its was on 183 to 113 what should I do? I am much worry about this pls explain me
    PEOPLE’S PHARMACY RESPONSE: Blood pressure this high deserves medical attention.

  14. Torrence
    Reply

    OK, so I’m told to take my BP at home, but the problem is I get excited when I even think of getting my pressure taken. How do you overcome that? My BP went through the roof at the hospital Friday [just the other day] when I was to get a heart catheterization, but after the test was all done my pressure dropped to 136/82. Still on a pill! Any ideas?

  15. Mj
    Reply

    So confused. The Medical Professionals make it seem so cut and dry. To them 120/80 is your number. My question is who came up what that and how much did they get paid to come up with that number.
    Everyone is different and EVERYONE”S blood pressure fluctuates though out the day, depending on what they are doing. Not to mention the different variables, that these people have put in place, it contradicts itself for example: a bp of 122/74 has a pulse pressure of 48 vs a BP of 140/100 has a pulse pressure of 40.
    It would be told that the pulse pressure of 40 is more desirable.
    The desirable pulse pressure example is a person with hypertension so is that ok? So confused.
    I think blood pressure is not a disease it a business.

  16. Dr. MEB
    Reply

    When a patient’ s BP is elevated In the office, I ask them to check their BP at home twice a day for five days and call the results to my office. I also have a chance to mention salt intake, weight, exercise. I make a decision about changes in their meds based on that information rather than one or two office numbers.
    Many doctors work for large clinics managed by “suits” who are dedicated to maximizing profits. The “suits” dictate the length of time one can spend with a patient and have shortened appointment times to a less than adequate time for reasonable care. The business of running a medical practice is so complicated by insurance plans, coding patient’s visits for billing, managing staff etc that it is very difficult to have a successful practice without abandoning any hope for a family life. As long as the insurance companies and the “suits” are running medicine, we are all in trouble.
    I work for the VA and I think we give better care than most private groups. We have 30 minutes for every office visit. We can see a patient as often as we feel is needed. We are not rewarded financially for doing procedures. We aren’t perfect–we’ve got plenty of bureaucratic nonsense that is frustrating. But we’ve got the best patients in the country.
    PEOPLE’S PHARMACY RESPONSE: Thank you for this perspective from the other side of the stethoscope!

  17. SDM
    Reply

    As a physician with mild hypertension your article and the BMJ article interested me. On initial read I thought I should stop my anti hypertensive medication. However, this cochrane review has many flaws that your readers should be aware of. My primary concern is that these patients were not treated for longer than five years. The effects of hypertension are more long term than that. Some of the patients included in the study were only treated for only 1 year. It scares me to read people on here saying they stopped their medicines and feel fine. The high blood pressure is slowly causing damage that cannot be felt or seen, which is why it is called a silent killer. Although the mortality benefits were not seen in this study, that is possibly because the patients were not studied for a long enough period of time. There is a reason they titled the study with the word “unclear”.
    Furthermore, cochrane is not the gold standard source of evidence based medicine. Their reviews are often riddled with the flaws of any meta-analysis. Taking 4 bad studies and combining them does not make one good study but rather just one big bad study. Additionally, the 4 included studies all had different inclusion and exclusion criteria and goals. Therefore, cochrane’s combination of these different studies may not be valid. This all needs further evaluation and study before any changes to treatment recommendations are made. Practicing evidence based medicine today would indicate the need for medications for hypertension, including mild hypertension based on prior long term studies.
    And for the conspirators out there, I am an ER doctor who never treats essential hypertension. As I explain to my patients who come in with hypertension and no other symptoms, this is a long term disease problem that your primary care doctor needs to treat. In the ER I don’t fret much about high blood pressure, I’m much more concerned about low blood pressure that is associated with emergency medical diseases.

  18. Beth R.
    Reply

    I do believe in evidence based medicine, but I am concerned that the Cochrane collaborative review failed to take into consideration the number of people who have “mild” HTN for decades (as most RCCTs collect data over months or years rather than decades). As a cardiologist with particular interests in HF and geriatric cardiology I have seen more than my fair share of older patients who were told that they had “borderline HTN” for literally decades. Untreated or under-treated, many of these folks have developed one type or another of heart failure, not to mention mild to moderate chronic kidney dz.

  19. J.T.
    Reply

    Recently my doctor noticed higher BP readings. I experience “white coat” like many others. I also have bipolar disorder. I was told I may have to take BP meds.
    I elected to try diet/exercise/relaxation. I purchased a BP cuff (manual and electronic) and charted my BP. My readings were 114/72, 120/80 consistently. I also took pressure readings when I woke up. When stressed my BP would go up to 149/89.
    In the doctor’s office the same. But at home, across several months, I get normal readings. My doctor elected to try Losartan. I was hesitant and went online. I was shocked to find out that most BP meds are contraindicated for use with lithium.
    Something told me not to start taking it. I’m glad I didn’t. I contacted my doctor and he was impressed that I had made the effort to be my own advocate. I was speechless. My doctor really tries hard to spend time with me. And we talked on the phone for almost 20 minutes about the risks of lithium and BP meds.
    He then said he would do more research to find out what medication would be suitable for someone like me. And that he was learning a lot by talking to me. He kept saying it was such a pleasure to have a patient so willing to assist him in ensuring the best treatment protocol.
    For now at least, I am controlling the BP with diet, exercise, and stress-reduction techniques. I know hypertension is dangerous. And I do not take the matter lightly. I have learned how to take my own BP, and it has to be done consistently, using the same methodology, across several time periods, and in a resting, relaxed position. It normally sit still for four minutes before taking a reading. I take it on both arms too.

  20. SEC
    Reply

    My bp was always through the roof in the doctors office!! They never believed that at home it was within normal range. They did a week long bp monitoring, which was uncomfortable, but confirmed “white coat syndrome” !! Don’t be alarmed if your dr. doesn’t believe in “such a thing”.

  21. smcc
    Reply

    Id
    Chronic cough is a persistent side effect in a small proportion of patients on Lisinopril and other ACE inhibitor drugs. In your position, having donated a kidney to your sister and with a family history of high BP, I think you should tell your doctor about the side effects and ask whether there is an alternative drug, such as an ARB (angiotension receptor blocker) which also has kidney-protective action.

  22. LG
    Reply

    As a physician/psychiatrist I have been quite concerned about “illness creep” for a long time. At first I thought it was mostly a mental health phenomenon, but over the last 10-15 years it is clear that the entire medical field is at risk. Last week I had my first annual physical in 40 years, and fell right into this “mild hypertension” quagmire. It was my first visit with this doctor, and being a physician myself, he released me on my own “recognizance” to monitor at home. I can’t imagine how vulnerable one must feel going to a doctor’s office these days without having gone first to medical school. It is imperative to become as informed as possible about any medical concern.

  23. RAV
    Reply

    I started taking a BP med many years ago, even though my BP and kidneys were good. My doctor wanted to protect my kidneys, just in case there might be a problem. Diabetics are more prone to have kidney problems. I had only mild side effects with the BP med. In 2007 I started having higher BP numbers, like 135/75, so my BP dosages were doubled. I started having dizziness as a side effect.
    For 5 years I have had dizziness, and recently it is much worse. Sometimes I fall down or stagger with dizziness. I stopped my BP med for two weeks last year and my dizziness was so much better, I could walk normally. What a relief, but my BP increased into the 140’s. While using a full dosage of the BP med my BP is like 120/58. Why is that second number so low? Is that dangerous?
    My doctor says it is not dangerous. If I use a half dosage my BP is like 135/65. Is it better to have a 135/65 and very little dizziness, or is it better to have a 120/58 and lots of dizziness? I have never had any kidney problems, so I do not need a BP med for my kidneys. The recent research makes me skeptical about my higher BP dosage.

  24. flury
    Reply

    it is just like cholesterol…. decades ago you were medicated if it was near 300…
    now over 150 is reason to pop pills….
    My mother at 65 was told to take BP and cholesterol meds… instead she took 1 mile walk daily and watched her diet… Numbers fell… she takes no meds and is 70 this year..
    Get off the couch, buy some beans skip the meds.

  25. RAV
    Reply

    I am 72, and have been a type 1 diabetic for 66 years. Many years ago my doctor had me start using a BP med, to protect my kidneys. A side effect of BP meds offers kidney protection for diabetics. My BP and kidneys were fine when I started using the med. I had no side effects from the med, but in early 2007 my BP increased to approximately 130/75, so my doctor doubled my BP med dosage. I started having terrible dizziness.
    My BP had improved but the dizziness grew worse. I am presently having BPs like 120/58. Why is the second number so low? Is that dangerous? My doctor says that is not dangerous. If I take half the dosage I am like 135/65. At half dosage I have much less dizziness and can function normally. With full dosages I get so dizzy that I fall down sometimes. I have never had kidney problems!! Is it better to go on like this with lower BPs, or is it better to use a lower dosage and have BPs like 135/65? My doctor insists that I continue the high dosage.

  26. smcc
    Reply

    My father was recorded as having high blood pressure when he left HM Forces at the end of World War II. I assume that at that time the levels required for the diagnosis of hypertension were considerably higher than today.
    His BP was checked on a number of occasions over the years and was always said to be high, but he always refused treatment. He was always physically active being a cross-country runner and soccer player. He died suddenly, 10 years ago, at the age of 82, still regularly walking several miles and performing 200 press ups every day.
    Perhaps if his hypertension had been treated he might still be alive today, but would he have wanted to do so?

  27. MP
    Reply

    A note on “white coat hypertension”. Often a higher pressure in the doctor’s office is due to incorrect technique. The scenario is this; you walk into the exam room and are told to get on the scale (stressful for many), then you are told to sit on the exam table with your feet dangling and your blood pressure is immediately taken often with the person taking it talking to you or asking questions. Any wonder your blood pressure is higher than when you take it at home?
    Proper protocol is to sit for a few minutes with your feet on the floor and no distractions. My docs and their personnel get a little peeved when I call them on this. I am an RN. I have doubted new pre-hypertension numbers since they first came out.
    Why haven’t more doctors questioned them?

  28. ld
    Reply

    I donated a kidney to my diabetic sister 15 years ago. My bp goes through the ceiling in the Dr. office, but I monitor it at home & it is very good. My new doc decided that in order to protect my remaining kidney, and because my mother had high bp, that I should go on lisinopril – 5mg. I took it for 3 months & felt like I couldn’t get out of bed, nagging cough, rash on my face & chest. I cut the pills in half & have fewer side effects. After seeing this article, I’d like to stop the med completely, but I am concerned about my only kidney! Comments?

  29. Karen
    Reply

    Went to the Slate version of the story, to find the author talking out of both sides off her mouth, at the end, page 2:
    “we shouldn’t subject patients to possible harm unless and until we have reasonably good evidence that it’s worth doing.”
    OK, but we’ve done exactly this by changing the entire American food supply to be corn based at the root, and modified in just about every way possible in addition.
    >But we do know this: Emphasizing far more effective—and evidence-based—approaches, such as exercising, quitting smoking, and following a Mediterranean diet, seems to be a very good idea. And besides, they work.
    “besides, they work” is only true as far as it goes. When they don’t work well enough, or the patient isn’t able to work them hard enough (some of us simply choose not to be triathletes, even if that “would work” to control BP), what’s a girl to do?

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