Well Blog: Why Lost Pounds Come Back

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Jen Davis for The New York Times

In this week’s New York Times Magazine, I explore new research that helps explain why most dieters who lose weight end up gaining it all back.

If anything, the emerging science of weight loss teaches us that perhaps we should rethink our biases about people who are overweight. It is true that people who are overweight, including myself, get that way because they eat too many calories relative to what their bodies need. But a number of biological and genetic factors can play a role in determining exactly how much food is too much for any given individual. Clearly, weight loss is an intense struggle, one in which we are not fighting simply hunger or cravings for sweets, but our own bodies.

To learn more, read the full article, “The Fat Trap,” and then join me in a discussion below. I’ll be taking reader questions, but also want to hear your own stories of weight loss and gain, and whether the science reported here reflects your own experiences.

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Personal Health: A Valuable Medical Tell-All Can Be Found in Urine

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I was tempted to ask her who is likely to know or care, except perhaps a stranger in a public restroom. Surely there are worse offenses.

As one of the four routes by which substances normally exit the body (the others being feces, breath and sweat), urine has a uniquely valuable role in medicine: It holds clues not just to what people eat and drink, but also to how well their bodies are functioning. The search for these telltale signs is why doctors routinely request urine samples from patients, whether they seem healthy or are obviously sick.

The color, clarity and other physical characteristics of urine, as well as substances dissolved in it, can provide clues to a wide range of problems, including infections, inherited metabolic disorders, kidney disease, bladder cancer, diabetes, substance abuse, exposure to toxins, inadequate or excessive fluid intake and, as many competing athletes know all too well, the use of performance-enhancing drugs.

Recently, in an eight-year European study, the sodium content of 24-hour urine samples from 3,681 adults was used to estimate the effect of daily sodium intake on the development of high blood pressure and illness and death from heart disease. The authors’ conclusion that too little dietary sodium was riskier than too much has been widely challenged, and until further notice most Americans would be wise to reduce significantly how much salt and other dietary sources of sodium they regularly consume.

Color and Odor

Urine can acquire off-odors from consumption of a few foods like asparagus (a genetic factor in some people is most likely responsible) and beverages like coffee, or as a consequence of health problems like a urinary tract infection or diabetes (a sweet smell from excess sugar). But the characteristic of urine most likely to be noted by a lay person is color.

If you are well hydrated, normal urine is clear and pale yellow, a color imparted by the pigment urochrome. Dehydration — which can be the consequence of drinking too little, sweating too much or suffering from repeated bouts of vomiting or diarrhea — results in dark urine with a smell of ammonia; it should be treated as a warning to drink more water or other plain fluids.

But consistently dark-colored urine can be a sign of hepatitis, a liver disease that requires prompt medical attention.

Less seriously, many foods and certain medications can impart an unusual and, to the unsuspecting, sometimes alarming color. For example, beets, which contain a betalain pigment that turns hands and cooking water red, can turn urine a color that may resemble blood. Likewise, blackberries and rhubarb can result in red or pink urine.

Tea-colored urine can follow the consumption of fava beans and sometimes rhubarb. The beta carotene in carrots, carrot juice and high doses of vitamin C can cause orange-colored urine, and B vitamins and asparagus may turn urine a greenish color.

Among medications that can affect urine color are the laxative senna, which can bring a red or reddish brown tinge; chlorpromazine (Thorazine) and thioridazine (Mellaril), which may add redness; indomethacin (Indocin), cimetidine (Tagamet) and promethazine (Phenergan), which can color urine blue or green; warfarin (Coumadin), phenazopyridine (Pyridium) and rifampin, which can add orange; and chloroquine (Aralen), metronidazole (Flagyl), nitrofurantoin (Furadantin) and primaquine, which can make urine brown. Of course, sometimes blood does appear in urine — for example, as a result of a urinary tract infection, a kidney or bladder stone, an enlarged prostate, or a jarring accident that injures the bladder or urethra. Or blood-tinged urine may follow strenuous exercise like a long run or triathlon.

If there is no obvious explanation for blood in the urine or if it persists, a visit to the doctor is mandatory to check for kidney disease or cancer. If no other explanation for red-tinged urine is uncovered, a test for toxic levels of lead and mercury should be done.

If urine is excreted very rapidly, it may appear foamy. But consistently foamy urine can be a sign that protein is being lost, a symptom of kidney disease, and that a medical exam is needed.

Cloudy urine is typically a result of a bladder or urinary tract infection, which is typically accompanied by a frequent urge to urinate and a burning sensation or pain when urinating.

Other Important Factors

The volume of urine produced can be an important indicator of hydration. Normally, a healthy person produces about 100 milliliters (about 3.4 ounces) of urine an hour, or about one cup in 2 ? hours. If the hourly output exceeds 300 milliliters, it could be a sign of excessive fluid intake; if the volume drops below 30 milliliters, it is probably a sign of dehydration.

Consuming lots of salty foods or carbohydrates can temporarily reduce urine output, because salt, sugar and starch hold more water in the body than, say, protein. And consuming foods or beverages that are diuretics — including caffeine-containing drinks (like coffee, tea and many soft drinks), alcoholic drinks (especially beer), and foods with a high water content, like watermelon or asparagus — can temporarily result in higher-than-average urine output.

The urine of two-legged and four-legged athletes is now commonly tested for signs that performance-enhancing drugs were responsible for an unfair competitive advantage. Sometimes athletes who take medication for legitimate medical problems get caught in the net.

When you provide a urine sample as part of a routine medical checkup, it is likely to be tested for the presence of sugar (an indicator of diabetes) and protein (a sign of kidney disease), and perhaps for bile acids (an indicator of liver disease) or white blood cells (the result of an infection).

If symptoms of a urinary tract infection are present, the culprit organism — often the bacterium E. coli, a common resident of the lower digestive tract — can be isolated from urine and, if necessary, tested for antibiotic sensitivity.

Young girls who take bubble baths and sexually active women (especially those who are new or returning participants to the game of love) are especially prone to urinary tract infections. Doctors have a not-so-amusing name for this common plague of women in the throes of a new sexual relationship: They call it honeymoon cystitis.

In a healthy person, however, urine is sterile and contains neither infectious microorganisms nor white blood cells trying to fight them. Thus, in producing a urine sample for analysis, it is critically important that it be what doctors call a “clean-catch” specimen.

This entails first depositing some urine in the toilet before collecting the amount needed for testing. And be sure to cover the sample immediately to reduce the risk of contamination.

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Well Blog: New Year's Recipes for Health

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December 19, 2011

Antonio Lambert, a self-taught ex-convict turned mental health educator, has relapsed into crime and drug use before. But now, he says, “I know when it’s time to reach out for help.”

December 8, 2011

Extreme cleaners get to work during the holidays, making sure floors and toilets shine as brightly as holiday lights.

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Eat: No Meat, No Dairy, No Problem

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Yunhee Kim; food stylist: Maggie Ruggiero. Prop stylist: Megan Hedgpeth.

Among your other resolutions — do more good? make more money? — you’ve probably made the annual pledge to eat better, although this concept may be more often reduced simply to “lose some weight.” The weight-loss obsession is both a national need and a neurotic urge (those last five pounds really don’t matter, either cosmetically or medically). But most of us do need to eat “better.”

If defining this betterness has become increasingly more difficult (half the diet books that spilled over my desk in December focused on going gluten-free), the core of the answer is known to everyone: eat more plants. And if the diet that most starkly represents this — veganism — is no longer considered bizarre or unreasonably spartan, neither is it exactly mainstream. (For the record, vegans don’t simply avoid meat; they eschew all animal products, including dairy, eggs and even honey.)

Many vegan dishes, however, are already beloved: we eat fruit salad, peanut butter and jelly, beans and rice, eggplant in garlic sauce. The problem faced by many of us — brought up as we were with plates whose center was filled with a piece of an animal — is in imagining less-traditional vegan dishes that are creative, filling, interesting and not especially challenging to either put together or enjoy.

My point here is to make semi-veganism work for you. Once a week, let bean burgers stand in for hamburgers, leave the meat out of your pasta sauce, make a risotto the likes of which you’ve probably never had — and you may just find yourself eating “better.”

These recipes serve about four, and in all, the addition of salt and pepper is taken for granted. This is not a gimmick or even a diet. It’s a path, and the smart resolution might be to get on it.

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Vital Signs: Beer and Martinis: Just as Effective as Wine for Longevity?

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Many studies have found an association between the moderate consumption of alcohol and increased longevity, and some have found evidence that wine has a more beneficial effect than other alcoholic drinks.

Now an analysis in the January issue of The Journal of Studies on Alcohol and Drugs suggests that martinis and beer may be just as effective at extending life. Wine may have appeared to be better only because the people who choose it are generally healthier.

Researchers studied 802 men and women ages 55 to 65: 281 low-wine drinkers who consumed less than one-third of their alcohol as wine, 176 high-wine drinkers who consumed two-thirds or more as wine, and 345 abstainers. The drinkers had one to two drinks per day, and researchers followed them for 20 years.

Wine drinkers lived longer than abstainers, and high-wine drinkers longer than low-wine drinkers. But compared with high-wine drinkers, low-wine drinkers were more likely to be older men, to be less active physically, to smoke and to be of lower socioeconomic status. After controlling for these factors, the difference between the two groups of moderate drinkers disappeared.

The lead author, Charles Holahan, a psychologist at the University of Texas, said there may be benefits for older moderate drinkers no matter what kind of alcohol they consume. Still, he added, “The study does not encourage initiating wine consumption as a pathway to better health.”

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Really?: The Claim: Listening to Music Can Relieve Pain

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Christoph Niemann

THE FACTS

Can the right sonata soothe the pain of a medical operation?

A growing number of doctors have been using music in clinical settings, believing that it might have analgesic effects on patients — or at least take their minds off an otherwise painful procedure.

Scientists only now are seeking to determine whether the notion is more romance than reality.

In the most recent study, published in December in The Journal of Pain, 153 people were subjected to increasingly painful shocks on their hands as they listened to music. All the while, they were encouraged to engage in the songs and to identify certain notes and tones. By measuring pupil dilation and brain activity, scientists at the University of Utah found that as the subjects became focused on the melodies, they experienced more and more relief from the pain. The biggest effect was seen on the participants who were initially most anxious.

A Swedish study published in 2009 reported similarly encouraging findings: Children who were given “music therapy” after minor surgery required smaller amounts of morphine than those who were not.

But a meta-analysis of data on more than 3,600 patients in 51 studies, published in the Cochrane Database, found that the magnitude of the effect was not very large, so the potential usefulness in clinical practice — for now, at least — was “unclear.”

THE BOTTOM LINE

Listening to music during or after a medical procedure may relieve pain, but more research is needed to determine whether the effect is significant.

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Hospital Treatment for Anorexia Is Questioned

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The strategy, called “start low, advance slow,” often results in further weight or fluid loss during the first day or two of hospitalization. Now some researchers and health providers, both in the United States and abroad, are challenging the start-low approach, suggesting that many patients could be fed more aggressively as long as they are closely monitored for medical complications.

Scientific evidence in support of the start-low method has been scarce. In a study published online in The Journal of Adolescent Health in August, researchers at the University of California, San Francisco, sought to evaluate it more closely, examining weight gain in hospitalized teenagers on a recommended refeeding protocol, in what they believe is the first study of its kind.

The study, which involved 35 young people, found that 83 percent on the start-low regimen, who were fed 1,200 calories a day with increases of 200 calories every other day, lost weight. Over all, patients did not regain the newly lost weight until the sixth day in the hospital, on average.

“It’s very upsetting to parents,” said Andrea K. Garber, an associate professor of pediatrics at University of California, San Francisco and the lead author of the study. “The irony is that the goal of hospitalization is to get the kids renourished, and we’re spending the first eight days without any weight gain.”

While it is not unusual for a patient with anorexia to lose weight after hospitalization, most practitioners attribute it to fluid loss, mostly water.

“There is a body of evidence that our older, more cautious feeding strategies are older and more cautious than they need to be,” said Dr. David S. Rosen, a professor of pediatrics, internal medicine and psychiatry at the University of Michigan Medical School, who leads the American Academy of Pediatrics Committee on Adolescence.

Still, he and other doctors are urging caution before making any radical changes in treatment, saying more research needs to be done. Twenty percent of the patients in the U.C.S.F. study had low blood phosphorus levels, indicating an electrolyte imbalance and a high risk of developing a potentially lethal condition called refeeding syndrome, Dr. Rosen noted.

“We’ve proven that with the regular approach, we don’t make as much progress as we’d like,” he said. “But do we know that feeding people more aggressively is a safe thing to do? The answer is, not really.”

Though medical practices are far from uniform and treatment is individualized depending on the patient’s circumstances, a typical regimen starts young patients with meals and snacks totaling around 1,200 calories a day.

Newer regimens being evaluated — and already introduced in some inpatient programs — start patients with 1,900 calories a day. Within a week and a half, a patient may be consuming 3,000 or more calories a day. The danger is that these patients may experience refeeding syndrome, which can lead to numerous complications including cardiac arrhythmia and death, when trying to return to normal diets too quickly. These patients also may have developed digestive disorders like constipation, diarrhea and reflux disease. They may vomit involuntarily because the stomach and digestive capacity is diminished.

And there are the psychological concerns. Starvation affects cognitive ability, experts say, and often counseling cannot be effective until weight is restored. Until then, patients with eating disorders are prone to continuing aversions to food.

“Think about the psychological trauma of being in a hospital and having to eat all this food,” said Marjorie Nolan, a registered dietitian in Manhattan who specializes in eating disorders and a spokeswoman for the Academy of Nutrition and Dietetics. “These adolescents are so young they can’t process the information, and here they’ve gained five pounds in a week and their biggest fear is happening: They’re getting fat. Which we know isn’t true, but that’s how they see it.”

Ms. Nolan said one of her patients, who is now 18, was fed aggressively at age 15, and it set her recovery back in the long term.

“They got the weight back on her, which medically stabilized her to a degree, which was necessary, but it was so aggressive that now, several years later, she’s still traumatized by it,” Ms. Nolan said.

One 27-year-old woman from the New York City area who was hospitalized twice, at age 18 and again at 20, said aggressive refeeding can be psychologically overwhelming and even physically painful.

“Your stomach shrinks when you don’t eat, so it feels like Thanksgiving, every day, when you are in the hospital getting large quantities of food,” said the woman, who asked that her name be withheld to maintain her privacy. “It’s physically difficult to walk around afterward, and it’s hard to keep it all down.” After having consumed so little for so long, she said, “you eat a carrot, and you feel it.”

She said she regained a lot of weight during her first hospitalization but was so upset by the rapid gain that she promptly lost the weight as soon as she was discharged. Two years later, she was hospitalized again but remained in the hospital for a longer stay of six weeks.

Current guidelines from the American Academy of Pediatrics recommend slow refeeding of malnourished children and teenagers to prevent refeeding syndrome; the Society for Adolescent Health and Medicine also recommends “gradual increase of calorie intake.”

Yet in an editorial accompanying the new study from U.C.S.F., Dr. Debra Katzman, head of the division of adolescent medicine at the Hospital for Sick Children in Toronto, said that overzealous application of the conservative refeeding guidelines had resulted in death in some cases.

In the United States, pressure to keep hospital stays short has made rapid weight gain even more urgent, because the goal is to restore as much weight as possible before discharge, she said in an interview.

Experts agree that much more research is needed to develop clear, evidence-based guidelines for treatment.

“We don’t know the best way to treat these kids, even when they wind up in the hospital,” Dr. Rosen said. “It’s a balancing act. What you want to do is find the sweet spot between feeding people as aggressively as you can but not causing refeeding syndrome, which is a lethal, scary, dangerous disease.”

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Greeks Reeling From Health Care Cutbacks

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Four days earlier, she had run out of insulin and, without insurance and unable to pay for more, she had gone from drugstore to drugstore, pleading for at least enough for a few days. It took her three hours to find a pharmacist who was willing to help.

“I tried a lot of them,” she said, gazing at the floor.

Greece used to have an extensive public health care system that pretty much ensured that everybody was covered for everything. But in the last two years, the nation’s creditors have pushed hard for dramatic cost savings to cut back the deficit. These measures are taking a brutal toll on the system and on the country’s growing numbers of poor and unemployed who cannot afford the new fees and co-payments instituted at public hospitals as part of the far-reaching austerity drive.

At public hospitals, doctors report shortages of all kinds of supplies, from toilet paper to catheters to syringes. Computerized equipment has gone unrepaired and is no longer in use. Nurses are handling four times the patients they should, and wait times for operations — even cancer surgeries — have grown longer.

Access to drugs has also been affected, as some drug manufacturers, owed tens of millions of dollars, are no longer willing to supply Greek hospitals. At the same time pharmacists, afraid that the government might not reimburse them, are asking for cash payments, even from those with insurance.

Many experts say that Greece’s public health system was bloated and corrupt and in dire need of reform. But they say also that the cuts have been so deep and have come so fast, that they have hit like a tsunami.

In just two years, the government has cut spending on health care to $17 billion from $19.5 billion — a 13 percent decrease. And under its agreement with its creditors, Greece must find even more health care savings next year — as much as $915 million, government officials said.

At the same time, public health facilities have seen a 25 to 30 percent increase in patients because so many Greeks can no longer afford to visit private clinics.

Dr. Olatz Ugarte, an anesthesiologist at the Saint Savvas Cancer Hospital in Athens, said that breast cancer patients often have to wait three months now to have tumors removed. “Waiting that long can be life or death for these patients,” she said.

In a recent letter to the medical journal The Lancet, a team of English researchers warned that a “Greek tragedy” could be in the making, pointing to rising suicide and H.I.V. rates and deterioration of services at hospitals under financial pressure. “In an effort to finance debts,” the researchers said, “ordinary people are paying the ultimate price: losing access to care and preventive services, facing higher risks of H.I.V. and sexually transmitted diseases, and in the worst case losing their lives.”

At the Perama clinic, which is run by the international nonprofit Doctors of the World, doctors say they are seeing many families that cannot afford bus fare, let alone the new $6.50 fee at public clinics.

Technically, those Greeks who cannot pay are entitled to free care. But the bureaucracy can be overwhelming. Ms. Ragamb, a former hairdresser whose unemployment benefits and health insurance ran out six months ago, said she was still waiting to get the right papers.

The story did not surprise Dr. Liana Mailli, the pediatrician who was seeing Ms. Ragamb’s son, Elias. The 3-year-old got a diagnosis of diabetes only a few months ago, after he fell into a coma. Dr. Mailli has heard of such bureaucratic troubles from many patients. Even more often, she said, parents have fallen behind in paying their health insurance contributions, or their employers do not pay and so they are no longer covered.

One development that Dr. Mailli said she found particularly disturbing was that a growing number of children had not had their basic vaccinations.

If nothing is done, she said, polio, diphtheria and whooping cough could all return to Greece. “This is such a serious thing,” she said. “But these vaccines are expensive.”

At the start of its debt crisis, Greece was spending about 6 percent of its G.D.P. on health care — about average for Europe. But the system was far from efficient. It includes many small hospitals and a reliance on expensive brand name drugs.

Moreover, there was widespread corruption. Experts say doctors often had lucrative deals with drug manufacturers that led them to vastly overprescribe, and many expected cash payments on the side for timely and attentive care.

Since the debt crisis began in 2009, the government has frozen hiring, cut salaries and focused on tracking prescriptions and new procurement procedures. About 20 doctors have been arrested for corruption.

But little has gone smoothly.

Government officials acknowledge some problems, but say that the system was simply unsustainable. In the next year, they say, adjustments can be made.

“We have had two years of emphasis on the financial, now we will pass to evaluation,” said Nikos Polyzos, the secretary general of the Health Ministry.

But many doctors say the new emphasis on cutting costs has gone too far. In addition to shortages, they say that the supplies they do have are of poor quality. They complain that bugs have been found in new syringes imported from China, sutures fall apart and generic drugs do not seem to do the job. And the hiring freeze has caused such a shortage of nurses, some doctors said, that procedures frequently have to be postponed.

Dimitris Bounias and Nikolas Leontopoulos contributed reporting.

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Personal Health: High Sodium-to-Potassium Ratio in Diet Is a Major Heart Risk

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Well, think again. A major study, based on data from more than 12,000 American adults, took into account all those risk factors for death from heart disease. The researchers found that while a diet high in sodium — salt is the main source — increases your risk, even more important is the ratio of sodium (harmful) to potassium (protective) in one’s diet.

When people whose meals contained little sodium relative to potassium were compared with those whose diets had a high sodium-to-potassium ratio, the latter were nearly 50 percent more likely to die from any cause and more than twice as likely to die from ischemic heart disease during a follow-up period averaging 14.8 years.

Although there has been on-and-off controversy about the value of limiting dietary salt, there is no question that a high level of sodium in the diet raises blood pressure and the risk of chronic hypertension by stiffening arteries and blocking nitric oxide, which relaxes arteries. Hypertension, in turn, contributes to heart disease and stroke, leading causes of death.

Potassium, on the other hand, activates nitric oxide and thus reduces pressure in the arteries, lowering the risk of hypertension.

“We controlled for all the major cardiovascular risk factors and still found an association between the sodium-potassium ratio and deaths from heart disease,” said Dr. Elena V. Kuklina, a nutritional epidemiologist at the Centers for Disease Control and Prevention and an author of the study, published earlier this year in Archives of Internal Medicine. “With age, the risk of high blood pressure increases. The lifetime risk in this country is 90 percent. If you live long enough, you’re at risk.”

According to an Institute of Medicine report on sodium released last year, “No one is immune to the adverse health effects of excessive sodium intake.”

Our High-Salt Diet

Ninety percent of the sodium in the American diet comes from salt, three-fourths of which is consumed in processed and restaurant foods. Salt added in home cooking and at the table accounts for only a minor proportion of sodium intake.

The body’s requirement for sodium is very low — only 220 milligrams a day — but the average American consumes more than 3,400 milligrams daily. The current Dietary Guidelines for Americans recommend a maximum of 2,300 milligrams (about a teaspoon of salt) for people over age 2, but only 1,500 milligrams for the 70 percent of adults at high risk of sodium-induced illness: people older than 50, all African-Americans, and everyone with high blood pressure, diabetes or chronic kidney disease.

Despite widespread efforts to get people to consume less sodium, intake of this nutrient has increased significantly since the early 1970s as consumption has risen of processed and restaurant foods, which rely heavily on salt as a cheap way to enhance flavor and texture and preserve food. Because salt is categorized by the Food and Drug Administration as G.R.A.S., or “generally recognized as safe,” there is no limit to the amount food producers can use in a product.

To make matters worse, not only does the amount of sodium rise precipitously when foods like tomatoes and potatoes are processed, but the natural potassium in these foods declines significantly, worsening the sodium-potassium ratio.

The profligate use of salt in foods prepared outside the home has created an American preference for a salty taste, a preference that can be reversed with no loss of consumer pleasure if done slowly, said Dr. Thomas A. Farley, commissioner of New York City’s Department of Health and Mental Hygiene.

His department is leading a national effort started in 2008 to get food producers and restaurants to gradually reduce the salt in their products. Thus far, 28 national food companies, retailers and supermarket chains, including Kraft, Subway, Target and Delhaize America, have made a commitment to the National Salt Reduction Initiative to cut sodium in their products by an average of 25 percent by 2014.

But Dr. Jane E. Henney, chairwoman of the committee that produced the Institute of Medicine report, said this is still just a voluntary effort, and to make a lasting nationwide difference in sodium intake, the government needs to push harder for change. The report said, “What is needed is a coordinated effort to reduce sodium in foods across the board by manufacturers and restaurants — that is, create a level playing field for the food industry.”

Dr. Henney, a public health specialist at the University of Cincinnati College of Medicine, said it is time to modify the G.R.A.S. status of salt because it can no longer be considered safe under current conditions of use. This would allow the Food and Drug Administration to place limits on the amounts of salt that can be used commercially in preparing various types of foods.

The report stated that “population-wide reductions in sodium could prevent more than 100,000 deaths annually.”

It can be done, if there is a will. Through decades of voluntary efforts and regulation, Finland managed to cut sodium intake by one-third, which has resulted in a decrease in hypertension and premature deaths from stroke and coronary heart disease.

What You Can Do

Dr. Kuklina recommends eating fewer processed foods, especially processed meats, and more fresh fruits and vegetables and dairy products that are low in sodium, like yogurt and milk. Increase your potassium intake not by taking supplements, but by eating more cantaloupe, bananas, oranges, grapes, grapefruit, blackberries, yogurt, dried beans, leafy greens, potatoes and sweet potatoes.

When ordering in a restaurant, she suggests, ask that your food be prepared without added salt and your vegetables steamed, and always request that salad dressings and sauces be served on the side, enabling you to use far less than the chef might. Consider splitting an order between two people, which would cut the salt intake in half. And if a dish arrives that is too salty, send it back to the kitchen.

Avoid fast-food restaurants, where a single meal can contain a day’s worth of sodium.

When shopping, Dr. Farley said, “read labels and compare products, then choose those with lower sodium.” He acknowledged that products labeled “low sodium” or “no added salt” can turn off consumers, who think they’ll be tasteless. But you can always add a modest amount of salt at the table.

He also suggested asking food companies to use less salt in your favorite products and supporting the government’s efforts to reduce sodium consumption by commenting on a proposal published on Sept. 15 in the Federal Register (Docket No. FDA-2011-N-0400 and Docket No. FSIS-2011-0014). The easiest way to comment is through the American Heart Association’s Web site: www.heart.org/sodium, then click on “Send your comment letter today.”

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Vital Signs: Trace Elements and Levels of Pancreatic Cancer Risk

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A new study has found that high bodily levels of the trace elements nickel and selenium may be associated with reduced risk for pancreatic cancer, and that high levels of arsenic, cadmium and lead may increase the risk.

The study, published online Dec. 19 in the journal Gut, included 118 pancreatic cancer patients and 399 patients with other diagnoses at several hospitals in Spain. Researchers analyzed toenail samples with plasma mass spectrometry, a highly sensitive technique for detecting trace elements.

After controlling for age, sex, smoking, diabetes and other factors, the scientists found that the subjects with the highest levels of arsenic were at twice the risk for pancreatic cancer, compared with those with the lowest concentrations. Those with high levels of cadmium were at three times the risk for pancreatic cancer, while those with the highest levels of lead were at six times the risk.

Those with the highest levels of nickel and selenium, on the other hand, were at significantly lower risk for pancreatic cancer.

Dr. Núria Malats, an epidemiologist at the Spanish National Cancer Research Center and the senior author of the new study, said that it was the first to provide these kinds of results with trace elements, and that it did not mean that people should take dietary supplements.

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Recipes for Health: Turnips: Versatile and Nutritious in Any Season — Turnips: Versatile and Nutritious in Any Season

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The turnips we get now are not sweet and tender like young spring turnips, which are almost a different vegetable altogether. They stand up to longer cooking times, so they’re perfect for soups, stews and gratins. But I found them equally welcome in a frittata and a stir-fry. I’ll be using the young ones next spring in tender vegetable braises, but for now I’m very happy with my robust winter turnips.

Couscous With Turnips and Sweet Potatoes

This spicy, comforting couscous demands little in the way of prep time. It’s the long simmer on the stove that results in the tasty broth. As it simmers, the sweet potato falls apart into small bits that tint the broth.

1 onion, chopped

1 leek, white and light green parts only, cut in thick slices and cleaned

4 large garlic cloves, minced

Salt, preferably kosher salt, to taste

2 teaspoons cumin seeds, lightly toasted and ground

1 teaspoon coriander seeds, lightly toasted and ground

1 teaspoon caraway seeds, lightly toasted and ground

1/2 teaspoon cayenne (more to taste)

A bouquet garni consisting of 8 sprigs each parsley and cilantro

1 tablespoon tomato paste

1 tablespoon harissa (more to taste), plus additional for serving

1 large sweet potato (about 10 ounces), peeled and cut in large dice

1 pound turnips, cut in wedges

1 large carrot, peeled and cut in thick slices

6 cups water

Salt to taste

1 can chickpeas, drained and rinsed, or 1 1/2 cups cooked chickpeas

1/2 cup chopped fresh parsley or cilantro, or a combination

1 1/2 to 2 cups couscous, preferably whole-wheat couscous (1/4 to 1/3 cup unreconstituted couscous per person)

1. Combine all the ingredients except the chickpeas and chopped parsley or cilantro and bring to a boil. Reduce the heat to low, cover and simmer for 1 hour. Taste and adjust salt. The stew should be spicy and flavorful. Stir in the chickpeas and parsley or cilantro and heat through.

2. Reconstitute and steam the couscous. Serve the couscous in wide bowls or mound onto plates and top with the stew and a generous amount of broth. Pass more harissa at the table.

Yield: 6 servings.

Advance preparation: The stew can be made a day ahead and reheated. Leftovers will keep for 3 or 4 days in the refrigerator. The couscous can be reconstituted up to a day ahead, then steamed before serving.

Nutritional information per serving: 363 calories; 0 grams saturated fat; 1 gram polyunsaturated fat; 1 gram monounsaturated fat; 0 milligrams cholesterol; 76 grams carbohydrates; 14 grams dietary fiber; 330 milligrams sodium (does not include salt to taste); 14 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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Pressure to Link Drugs and ‘Companion Diagnostics’

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The Food and Drug Administration last year rejected the company’s drug to treat a subset of leukemia patients whose tumors had a particular genetic mutation. The main problem was not the drug itself, the agency said. Rather, ChemGenex had not specified a companion test that could reliably detect the mutation so that the drug could be given to the patients it is intended to help.

These days, it is often not enough for pharmaceutical companies simply to bring a drug to market. Regulators and insurers are also prodding the companies to develop tests to pinpoint which patients are most likely to benefit from a drug, thereby sparing other patients from needless side effects and expense.

The pressure has thrust drug and diagnostics companies into sometimes awkward partnerships aimed at developing such tests, which are called companion diagnostics. There were at least 25 such deals in 2010 and 15 in the first half of 2011, up from only seven in 2008, according to PricewaterhouseCoopers, a consulting firm.

“The tests are becoming almost gatekeepers to the drug,” said M. Trevor Page, director of business development at Dako, a Danish diagnostics company.

The F.D.A. issued guidance to the industry on companion diagnostics in July, including its preference for having the test ready for approval at the same time as the drug. The following month, as if to show how it should be done, it approved two drugs and their accompanying tests.

One of the drugs, Pfizer’s Xalkori for lung cancer, works wonders — but only for the roughly 5 percent of patients whose tumors have a particular chromosomal abnormality, as determined by a test from Abbott Laboratories.

The other drug, Zelboraf, from Roche and Plexxikon, can also produce remarkable improvements, but only for the roughly half of melanoma patients whose tumors have a particular mutation. The F.D.A. approved a test from Roche’s diagnostics division to detect that mutation.

But the simultaneous approval of new drugs and tests is still rare. Before August, the only other dual approval was of Genentech’s breast cancer drug Herceptin and Dako’s test for the related HER2 protein in 1998. There are more than 70 other tests that guide drug use in some way, according to the Personalized Medicine Coalition, but they are rarely required and often developed well after the drug reaches the market.

There are numerous economic, scientific and regulatory obstacles to developing companion diagnostics, executives and analysts say.

Often, scientists simply do not know what to test for to predict a drug’s effectiveness, or they don’t find out until near the end of the drug’s clinical trials. And coordinating development and approval of a drug and a test — by two separate companies reviewed by two F.D.A. divisions — can raise the cost of drug development if not done well.

“This is like trying to choreograph a dance,” said Dr. Mace L. Rothenberg, who runs cancer clinical trials for Pfizer.

Moreover, it is often a dance between a giant and a pixie, locked in an embrace but with a tendency to move in opposite directions.

Pharmaceutical companies can spend hundreds of millions of dollars to develop a drug, then can reap billions of dollars a year in sales with high profit margins. Diagnostic companies typically spend several million dollars to develop a test, with annual revenues also around that level, and low profit margins.

“You are really trying to get two very disparate industries to understand each other,” said Mollie Roth, chief operating officer of Diaceutics, a consulting firm specializing in companion diagnostics.

For pharmaceutical companies, the risk is that a test can lower sales of their drugs by restricting use to a fraction of potential patients.

An often cited example of such a problem involved Selzentry, a Pfizer drug approved in 2007 to treat people with a certain subtype of H.I.V.

The test of a patient’s virus, offered by Monogram Biosciences, cost about $2,000, and all samples had to be sent to Monogram’s laboratory in California. Analysts say the cost and inconvenience of the testing deterred use of Selzentry, especially since it was competing with drugs that could be used by all patients, with no need for testing.

“Top management still sees companion diagnostics as an obstacle between their product and the market,” said Jorge Leon, a consultant to both drug and diagnostic companies.

Still, drug companies are embracing companion diagnostics because of pressures to control health spending. Also, in the rare cases where a test is available early in the drug’s development, as was the case with Xalkori and Zelboraf, clinical trials can be made smaller and less costly by restricting them to patients most likely to benefit from the drug.

For diagnostic companies, there is a risk of developing a test in advance for a drug that may never reach the market.

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Vital Signs: Vitamins B, C, D and E and Omega-3 Strengthen Older Brains

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Higher blood levels of omega-3 fatty acids, vitamin B, vitamin C, vitamin D and vitamin E are associated with better mental functioning in the elderly, a new study has found.

Researchers measured blood levels of these nutrients in 104 men and women, whose average age was 87. The scientists also performed brain scans to determine brain volume and administered six commonly used tests of mental functioning. The study is in the Jan. 24 issue of Neurology.

After controlling for age, sex, blood pressure, body mass index and other factors, the researchers found that people with the highest blood levels of the four vitamins scored higher on the cognitive tests and had larger brain volume than those with the lowest levels.

Omega-3 levels were linked to better cognitive functioning and to healthier blood vessels in the brain, but not to higher brain volume, which suggests that these beneficial fats may improve cognition by a different means.

Higher blood levels of trans fats, on the other hand, were significantly associated with impaired mental ability and smaller brain volume.

The lead author, Gene L. Bowman, a neurologist at Oregon Health and Science University, said that the study could not determine whether taking supplements of these nutrients would decrease the risk for dementia. But he added: “What’s the harm in eating healthier? Fish, fruits, vegetables all have these nutrients, and staying away from trans fats is one key thing you can do.”

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EmblemHealth Could Become For-Profit, Bloomberg Says

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The conversion of the insurer, EmblemHealth, which provides health coverage for most New York City public workers, would most likely provide at least $1 billion in one-time revenue for New York’s cash-hungry state government.

The Bloomberg administration has objected for years to such a move, saying it could drive up the city’s health insurance costs. But on Friday, although there was no evidence that a deal was imminent, the mayor said he had “no interest in stopping the governor from getting a billion dollars for the state budget.”

“We will find some way, I’m convinced,” Mr. Bloomberg said on his weekly radio program on WOR-AM (710). He added: “If it looks like a good deal for the city, or the city doesn’t get hurt — because we do get benefits when the state gets money because it stops them from cutting us back — we’re going to be there. And I think that’s the way it will work out.”

Emblem first initiated the process of becoming a for-profit company during the administration of Gov. Eliot Spitzer, and the State Legislature approved rules in 2007 on how such a conversion could take place.

The city unsuccessfully sued in federal court in an effort to block the merger of the two insurers that now make up Emblem, Group Health Inc. and the Health Insurance Plan of Greater New York, and the city has since that time urged state regulators to prevent the combined company from becoming for-profit.

Emblem put its efforts on hold in mid-2008. But the company and state officials in recent months have been preparing to proceed, most likely in an effort to sell Emblem to another insurer, according to several state officials who have been briefed on the matter. A spokeswoman for EmblemHealth declined to comment.

Some lawmakers suggested this month that the Emblem issue had become linked to the tense negotiations between Mr. Cuomo and Mr. Bloomberg over legislation to allow livery cabs to be hailed on most New York City streets. They said they suspected that Mr. Cuomo was holding out approval of the livery deal in an effort to press Mr. Bloomberg into agreeing to drop the city’s resistance to the Emblem deal.

A spokesman for Mr. Cuomo insisted that was not the case. Mr. Cuomo signed the livery cab legislation this week.

“The city has been arguing the same point for five years — if there is an Emblem sale, they want more of the proceeds than the Legislature has previously authorized,” the spokesman, Josh Vlasto, said. “However, the entire issue is irrelevant because there is no potential sale on the horizon.”

A high-ranking state official said Mr. Cuomo’s budget proposal, which he will unveil next month, would not presume any revenue from a possible Emblem deal.

If Emblem does find a buyer, Mr. Bloomberg would have considerable leverage in trying to win concessions from the insurer.

Mr. Bloomberg noted in his radio appearance that Emblem would be worth far less if the city — the insurer’s biggest customer — took its business elsewhere. And the city is keeping its options open; about a month ago, it circulated a request for information from other health insurers as the Bloomberg administration considered seeking other possible providers.

“If we didn’t exist, they would still exist, but they would be worth a lot less in the marketplace,” Mr. Bloomberg said of Emblem. “So that’s why everybody cares, and nobody is going to buy Emblem unless they talk to the city.”

Mr. Bloomberg hinted that it was possible, for example, that as part of a sale, the city would pledge to keep its business with Emblem for a certain period of time. In return, the city might ask Emblem to promise that health insurance rates would not increase more than a certain percent annually.

Harry Nespoli, the chairman of the Municipal Labor Committee, the umbrella group for the city’s public employee unions, said labor leaders had expressed concerns to Mr. Cuomo’s office about how a possible conversion would affect workers’ benefits.

“The exact services that our members have and the structure for our health coverage has to be the same,” Mr. Nespoli said in a telephone interview. “If it’s going to affect our members, we are definitely going to get louder with our voices.”

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Vital Signs: Blood Pressure Changes in Middle Age Can Affect Heart Risk

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Competing histories across the Strait of Gibraltar contribute to its peculiar exclaves.

Medicare should demand evidence that a costly cancer treatment is more effective than cheaper options.

In Nigeria, designating Boko Haram as a foreign terrorist group will only inflame anti-Americanism among Muslims.

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Face and Voice Recognition May Be Linked in the Brain, Research Suggests

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If you saw her walking down the street it would match your imagined vision. But what if you saw nothing at all?

James Cooke, 66, of Islip, N.Y., can’t recognize other people. When he meets someone on the street, he offers a generic “hello” because he can’t be sure if he’s ever met that person before. “I see eyes, nose, cheekbones, but no face,” he said. “I’ve even passed by my son and daughter without recognizing them.”

He is not the only one. Those with prosopagnosia, also known as face blindness, can see perfectly well, but their brains are unable to piece together the information needed to understand that a collection of features represents an individual’s face. The condition is a neurological mystery, but new research has shed light on this strange malady.

One of the keys to understanding face recognition, it seems, is understanding how the brain comes to recognize voices. Some scientists had believed that faces and voices, the two main ways people recognize one another, were processed separately by the brain. Indeed, a condition parallel to prosopagnosia, called phonagnosia, similarly leaves a person unable to distinguish a familiar voice from an unfamiliar one.

But by testing for these two conditions simultaneously, researchers at the Max Planck Institute for Human Cognitive and Brain Sciences in Germany recently found evidence that face and voice recognition may be linked in a novel person-recognition system.

Using M.R.I., the scientists looked at the brain activity of 19 healthy volunteers as they were led through tasks that tested their ability to recognize both faces and voices. The researchers found that regions of the brain already associated with facial recognition, like the fusiform face area in the occipital lobe, are directly linked to regions responsible for voice recognition, mostly in the temporal lobe.

This research helps explain why a person with prosopagnosia may still have difficulty determining who a person is even after she has begun to speak. “People with prosopagnosia don’t have the benefit of learning voices with faces,” said Katharina von Kriegstein, author of the study, which was published in September in The Journal of Neuroscience.

The challenge for scientists is to find out where this system breaks down. Are these connections in the brain missing entirely, or are people unable to recognize faces and voices simply unable to use these links in some way?

It is unclear how many people have these conditions. Many don’t even realize they have problems with facial or voice recognition. While some develop these difficulties after a brain injury or trauma, others develop it in childhood.

For Mr. Cooke, who lives with his two grown children, face blindness first surfaced after brain surgery for an unrelated condition. Three physicians stood by his bed in the hospital the day after surgery to ask how he was feeling. Mr. Cooke didn’t think he had met the doctors before, so he gave some generic responses. After the doctors left, Mr. Cooke’s mother came in to find out what his surgeon had to say.

Mr. Cooke was shocked to discover he had just been speaking with his own doctor. “I didn’t recognize that I didn’t recognize him,” he said.

He went home, and the face blindness continued. Months later, he still couldn’t recognize his son, let alone his son’s friends when they visited. The cashiers at the grocery store had turned into strangers. Neighbors’ faces were completely foreign.

He went from neurologist to neurologist until one recognized that he had prosopagnosia, most likely a side effect of his surgery.

While there is no treatment or cure for Mr. Cooke, figuring out why he was no longer able to recognize his own children was a relief. “It was good to hear that what I was experiencing was real and not in my imagination,” he said.

Dori Frame, 51, of Brooklyn, is less certain about the cause of her face blindness, as she doesn’t remember having difficulty recalling faces as a child. She did suffer a severe head injury at age 16 while horseback riding, but it is unclear whether that caused her prosopagnosia as an adult.

“My eyes see just fine,” said Ms. Frame. “But when I look away, I can’t recall the picture in my mind.”

Ms. Frame didn’t realize she had a problem until she learned about prosopagnosia in a psychology class. “It’s like colorblindness,” she said. “You don’t realize you see colors differently than anyone else until someone points it out to you.”

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The New Old Age Blog: The Unspoken Diagnosis: Old Age

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Dr. Alexander K. Smith is a brave man.

It has taken physicians a very long time to accept the need to level with patients and their families when they have terminal illnesses and death is near — and we know that many times those kinds of honest, exploratory conversations still don’t take place.

Now Dr. Smith, a palliative care specialist at the University of California, San Francisco, who also practices at the San Francisco Veterans Affairs Medical Center, and two co-authors are urging another change, one they acknowledge would “radically alter” the way health care professionals communicate with their very old patients.

In a recent article in The New England Journal of Medicine, they suggested offering to discuss “overall prognosis,” doctorspeak for probable life expectancy and the likelihood of death, with patients who don’t have terminal illnesses. The researchers favor broaching the subject with anyone who has a life expectancy of less than 10 years or has reached age 85.

“Advanced age itself is the greatest predictor of poor prognosis,” Dr. Smith told me in an interview.

By age 85, the article points out, the average remaining life expectancy for Americans is six years. An 85-year-old has a 75 percent chance of living another three years, but only a one in four chance of surviving for 10. Which category a particular old person falls into has much to do with the medical problems he or she has, or doesn’t have, and with his or her ability to function.

When the odds are that they have only a few remaining years, should doctors discuss that with them?

Dr. Smith and his co-authors, Dr. Brie Williams and Dr. Bernard Lo — a geriatrician and an internist, respectively — vote yes. “This is about empowering patients to make informed choices and encouraging individual decision-making,” he said.

Sadly, it takes guts to propose this when mention of the D word to patients still raises alarms. The Obama administration had to cancel plans for Medicare to reimburse doctors when they discuss end-of-life care with their patients. Death panels! Rationing!

But to Dr. Smith, understanding how much time remains could help his older patients make the most of those years and help them ward off interventions, tests and treatments whose benefits, if any, are years away but whose harms could be immediate.

A “substantial minority” of older patients won’t want to have this discussion, Dr. Smith acknowledged. “It’s important to offer the information, not force it on people,” he said.

But in his experience, it’s the protective family caregivers who object to talking about prognosis, more than their older relatives. “A lot of very elderly patients realize they’re in their final years,” he said. “This doesn’t come as a surprise to them. My friends in their 90s are already thinking about it.”

He cited a study he and colleagues published in The Journal of General Internal Medicine, based on interviews with 60 older people with disabilities, their average age 78 — an admittedly small but ethnically diverse sample. About two-thirds told researchers they’d want their doctors to tell them if they had less than five years to live. (Readers here had even stronger opinions: see this post about public access to longevity indexes.)

And when they do think about it, Dr. Smith continued, “they want to get their finances in order, plan for long-term care, spend time with children and friends.” They may be able to take fewer medications and undergo fewer procedures, with the emphasis on quality of life, or otherwise shift priorities.

“This is a challenge to people,” Dr. Smith acknowledged. “I’ve had reactions from ‘This is terrific; I’ve been arguing for this for years,’ to a mentor at U.C.S.F. who said, ‘This is ridiculous; my patients don’t want to hear this, and there is no way to predict life expectancy anyway.’”

But while it’s true that no one can foretell a particular individual’s death with any certainty — and health care workers should be clear about those limitations, Dr. Smith emphasized — a number of geriatric calculators do provide reasonably good projections, based on several health factors, age, cognitive status and functional abilities and sometimes laboratory test results. An index developed by Dr. Smith’s U.C.S.F. colleague Sei Lee, for example, can correctly predict mortality within four years about 75 percent of the time.

Still, it’s O.K. with Dr. Smith if professionals and patients have strong reactions, pro and con. “The point of the article is to get a national conversation started about this,” he said. It’s a conversation you’re invited to join in the comments section below.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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F.D.A. Finds Short Supply of Attention Deficit Drugs

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The shortages are a result of a troubled partnership between drug manufacturers and the Drug Enforcement Administration, with companies trying to maximize their profits and drug enforcement agents trying to minimize abuse by people, many of them college students, who use the medications to get high or to stay up all night.

Caught in between are millions of children and adults who rely on the pills to help them stay focused and calm. Shortages, particularly of cheaper generics, have become so endemic that some patients say they worry almost constantly about availability.

While the Food and Drug Administration monitors the safety and supply of the drugs, which are sold both as generics and under brand names like Ritalin and Adderall, the Drug Enforcement Administration sets manufacturing quotas that are designed to control supplies and thwart abuse. Every year, the D.E.A. accepts applications from manufacturers to make the drugs, analyzes how much was sold the previous year and then allots portions of the expected demand to various companies.

How each manufacturer divides its quota among its own A.D.H.D. medicines — preparing some as high-priced brands and others as cheaper generics — is left up to the company.

Now, multiple manufacturers have announced that their medicines are in short supply. The F.D.A. has included these pills on its official shortages list, as has the American Society of Health-System Pharmacists, which tracks the problem for hospitals. And the American Academy of Child and Adolescent Psychiatry has told the more than 8,000 doctors in its membership that shortages seem to be “widespread across a number of states” and are “devastating” for children.

Officials at the Food and Drug Administration say the shortages are a result of overly strict quotas set by the Drug Enforcement Administration, which, for its part, questions whether there really are shortages or whether manufacturers are simply choosing to make more of the expensive pills than the generics, creating supply and demand imbalances.

The situation has made for a rare open disagreement between two federal agencies.

“We have reached out to the D.E.A. and told them that there are shortage issues,” said Valerie Jensen, associate director of the F.D.A.’s drug shortage program. “But the quota issues are outside of our area of responsibility.”

Still, Special Agent Gary Boggs of the Drug Enforcement Administration’s Office of Diversion Control, said in an interview, “We believe there is plenty of supply.”

Some high-priced pills are indeed readily available, and D.E.A. officials said that so long as that is the case, they believe that A.D.H.D. drug supplies are adequate. Agent Boggs attributed any supply disruptions to decisions made by manufacturers.

Novartis, for instance, makes both branded and generic versions of Ritalin; Shire Pharmaceuticals does the same for Adderall XR. In both cases, the companies have ensured that supplies of branded drugs are adequate while allowing generic versions to go wanting.

“We are working diligently to ensure our supply of these products meets demand, including discussions with D.E.A. regarding our quota levels for these controlled substances,” said Kathy Bloomgarden, a spokeswoman for Novartis.

But those who rely on the drugs can react very differently to apparently similar medicines, so an adequate supply of one drug does them no good when their preferred medicine is unavailable, patients and their doctors say. And prices can vary so much that some patients say they cannot afford to switch.

Lynn Whitton of Westport, Conn., who has an attention deficit hyperactivity disorder, expressed disbelief when told that the Drug Enforcement Administration said there were no shortages of A.D.H.D. medicines. “What?” she said. “I’m just flabbergasted!”

Ms. Whitton said she had recently gone to more than a dozen pharmacies in Westport and New York City before finding one that would partially fill Ritalin prescriptions for her and her 18-year-old son, who also has the disorder.

Erin Fox, manager of the drug information service at the University of Utah, said problems arise when there is a mismatch between what manufacturers choose to make and what patients are prescribed.

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The New Old Age Blog: When Doctors Face Death

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A telling essay about the way doctors choose to die, as opposed to the way most of their patients will, appeared on a Web site called Zocalo Public Square last month and has been ricocheting around the Internet ever since — to its author’s astonishment.

Steve FuhrmanDr. Ken Murray

I first saw the essay, “How Doctors Die,” on Twitter. Others came across it via Andrew Sullivan’s blog on The Daily Beast. It’s popped up on news sites, religious and medical sites, and probably thousands of individual blogs.

So I’m a bit late to this party, but with an excuse. I wanted to talk to Dr. Ken Murray, the retired family practitioner in Los Angeles who wrote the essay, before I posted the link. That wasn’t so easy to do, in part because of Dr. Murray’s extremely energetic definition of “retirement.” Since closing his practice four years ago — with the way medicine has changed, he told me, “each day it was a little less fun” — he hasn’t been sitting around waiting for reporters to call.

He reads three to four books a week (one recent week: an anthology of creative nonfiction, a military adventure, a Bob Woodward investigation and an obscure tome on communications). He attends 10 to 15 lectures each month. He’s a certified sailing instructor and a volunteer forester who, the day we finally spoke, had just clambered down from an 80-foot Ponderosa pine.

“How Doctors Die” was the third of three posts Dr. Murray had agreed to write for Zocalo. His first received one comment and the second two – all from people he knew. When I last checked, the third had drawn nearly 400 and has by now surely reached hundreds of thousands of readers. “I am in shock,” said Dr. Murray, who’s 59. “This was a nerve that was ready to be hit.”

Dr. Murray contends in his post that doctors know too much about the futility of aggressive end-of-life treatment to subject themselves to it. His argument is anecdotal, based on people he has known but lacking statistical underpinnings. “It’s a fair criticism,” he said.

But recently an alert reader e-mailed him a study, published in 2008 in The Archives of Internal Medicine, of more than 800 physicians who graduated from Johns Hopkins University between 1948 and 1964. Most had reached their late 60s and 70s, so questions about end-of-life treatment were not purely hypothetical.

Asked what treatment they would accept if they’d suffered irreversible brain damage that left them unable to speak or recognize people but was not terminal, the doctors overwhelmingly said they’d decline CPR, feeding tubes and a host of other common interventions. “So there is actual evidence about this,” Dr. Murray said, pleased.

He’s also pleased that the subject of how we die, doctors or otherwise, has such resonance. “Twenty or 30 years ago, it was not socially acceptable to talk about this stuff, so these discussions didn’t happen,” he said. “Now we are having them, even though we’re all uncomfortable with them because there’s so much emotion tied up with this.”

“But it has to happen,” he added. “We’re finding our way.”

We talk about this stuff all the time, of course, but rarely so eloquently. Read “How Doctors Die.” I’m sure Dr. Murray will be interested to hear what you think.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Letters: Watching Them Grow Up (1 Letter)

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To the Editor:

Re “Now We Are Six” (Basics, Dec. 27): Recent research on middle childhood gives valuable new information and insight, but why does David Lancy think that middle childhood as a research topic has been overlooked?

I am 95, and my memory is much longer. The present researchers had a lot to build on. The 1920s, ‘30s and ‘40s were times when basic research was done on children between birth and adulthood. Mental and physical growth were studied through repeated measurements of children of all ages. Results included physical growth charts, norms for skeletal growth and tooth eruption, the Stanford-Binet test of mental development, the California mental and motor development scales.

The grand stage theorists of our time also made essential contributions to understanding childhood. Piaget showed that children develop; they create different modes of thinking. Erickson’s model of personality development made middle childhood distinct. Even earlier, Gesell contributed mental and motor scales, and before that, his principles of growth. Stage theorists actually date back to Greek and Roman times, even Biblical times.

Mollie S. Smart

Ridgefield, Wash.

The writer is emerita professor of child development, University of Rhode Island.

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State House Journal: Medicaid Cuts Are Part of Larger Battle in Maine

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Yes, he could. “If you come across from New Hampshire at 8 o’clock in the morning, by 4 o’clock in the afternoon you will have subsidized housing in the state of Maine,” the governor declared. “We need to change the rules.”

Mr. LePage, a first-term Republican whose destitute childhood is a well-known piece of his biography, is seeking to do just that. Calling the state’s entitlement system “a runaway train,” he has proposed contentious changes, including some of the most drastic Medicaid cuts in the nation.

This month Mr. LePage announced a plan to reduce Maine’s Medicaid rolls by 65,000 people — about 18 percent of the total. He is asking the Republican-controlled Legislature to make childless adults and all 19- and 20-year-olds ineligible for the program, known as MaineCare, and to tighten income requirements for parents. He also wants to eliminate an array of optional benefits, including dental care and room and board at assisted living centers.

Hundreds of people descended on the State House last week to protest the cuts, which Mr. LePage says are crucial not just to put the state on sound financial footing but to change a national perception that Maine, more than most states, encourages dependency.

“The issue is basically fairness and equity,” Mr. LePage said at the town hall meeting in Salem Township, where he answered pre-screened questions from a polite crowd of about 100. “We have a very small population of people who pay their taxes, want an efficient government, and they are very generous in wanting to help. What they do not like is people taking advantage of the system.”

With his combative style, Mr. LePage, the first Republican to win the governor’s office here in two decades, has brought more tumult to Augusta than the low-key capital has seen in years. Soon after his inauguration in January, he clashed with the state’s N.A.A.C.P. leaders after they questioned why he had declined invitations to meet with them. In March, he ordered a mural depicting Maine’s labor history removed from a state building, saying it was too favorable to unions.

With his fellow Republicans in the Legislature, who last year won control of both chambers for the first time since the 1970s, Mr. LePage cut taxes by $150 million, streamlined regulations and pushed for a right-to-work bill, with the goal of drawing more businesses and higher-income residents to Maine.

The Medicaid battle will be his biggest fight to date. Even if the Legislature approves Mr. LePage’s Medicaid cuts, the federal government could reject some of them. The new federal health care law prohibits lowering Medicaid eligibility, and only a few states have received waivers to do so on a limited basis.

Responding to questions in a news conference at the State House about whether the cuts might fall afoul of federal law, Mr. LePage said, “Well, put me in jail, and we will go from there.”

Mr. LePage declined, through a spokeswoman, to be interviewed for this article.

The state’s Department of Health and Human Services, which administers the program, is facing a $221 million budget shortfall. But Democrats maintain that the gap is due more to poor planning by the LePage administration than to growth in Medicaid enrollment and that Mr. LePage is using a false pretense to push an ideological agenda. His administration has said that enrollment growth accounted for only $6.5 million of the shortfall.

“This is absolutely about philosophy,” said State Representative Emily Cain, a Democrat from Orono who is the House minority leader. “The governor has taken every opportunity to try to build up the perception that MaineCare is fraught with fraud when in fact it’s not.”

Kevin Raye, the Republican president of the State Senate, said he agreed with Mr. LePage that Maine was overly generous with public benefits and needed to pull back. “It was expanded by design, and I really think it’s part of the reason the Democrats lost their majority in Maine,” Mr. Raye said. “We need to make sure the folks who are the most vulnerable are the priorities: those with disabilities, poor elderly and children.”

According to the Kaiser Family Foundation, 27 percent of Mainers were covered by Medicaid in 2008, the most recent year for which complete data is available, compared with 20 percent of the population nationally. Only California and the District of Columbia had higher percentages enrolled, the foundation said. ?

?Maine’s spending on Medicaid is also higher than the national average, according to the National Association of State Budget Officers: it spent 28.6 percent of its budget on Medicaid in 2010, the group found, compared with 22.3 percent nationally.

?Last week, lawmakers heard testimony from several hundred people who oppose the cuts, including Medicaid recipients, advocates, doctors and owners of assisted living facilities that might close if the cuts are approved. The Maine Center for Economic Policy, an independent nonprofit group, said the cuts would eliminate more than 4,000 jobs around the state, and the Maine Hospital Association said that hospitals would lose at least $30 million in state and federal payments.

Pauline Gudas of Lewiston testified that she would have to quit her job to care for her elderly mother if the cuts passed because Medicaid would no longer pay for her assisted living facility. But Ms. Gudas, 55, said she had voted for Mr. LePage and agreed with him that the state was too generous.

“There needs to be changes, and I absolutely understand that,” she said.

But David Neverland of Benton, who is disabled and would lose a portion of his health care coverage under the plan, said that because Mr. LePage had pulled himself out of poverty and succeeded in life, he unfairly expected the same of all poor Mainers.

“He seems out of touch with what the reality is here,” said Mr. Neverland, 58. “This is a state of poor people, and most of us who get this support, 95 to 97 percent of us, really need it.”

Murray Carpenter contributed reporting.

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Recipes for Health: Soba With Black-Eyed Peas and Spinach — Recipes for Health

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AppId is over the quota

1 cup (6 ounces) black-eyed peas, rinsed

1 quart water

1 onion, cut in half

3 garlic cloves, minced

A bouquet garni made with a bay leaf, a Parmesan rind and a sprig each of parsley and thyme

Salt to taste

2 tablespoons extra virgin olive oil

1 red bell pepper, cut in small (1/4-inch) dice

1 12-ounce bunch spinach, stemmed and washed, or a 6-ounce bag of baby spinach

Freshly ground pepper

8 ounces soba

Freshly grated Parmesan

1. Combine the black-eyed peas and water in a large saucepan or soup pot and bring to a gentle boil over medium-high heat. Skim off any foam, then add the onion, 2 of the minced garlic cloves, the bouquet garni and salt to taste. Reduce the heat to low, cover and simmer 40 minutes, or until the beans are thoroughly tender but intact. Taste the broth and adjust salt. Remove the onion and bouquet garni and discard.

2. Fill a large pot two-thirds of the way full with water (soba will bubble up, and if you fill the pot too full the foamy water will overflow) and bring to a boil.

3. Meanwhile, heat the olive oil over medium heat in a large, heavy skillet and add the red pepper. Cook, stirring often, until it is just tender, 3 to 5 minutes. Add the garlic and cook, stirring, until it is fragrant, 30 seconds to a minute. Add the beans with their liquid to the pan and bring to a boil. Boil over medium-high heat until the broth reduces a bit, and stir in the spinach. Stir just until it is wilted, and remove the pan from the heat. Add salt and freshly ground pepper to taste.

4. When the soba water comes to a boil, add salt to taste and the soba. Let the water bubble up until it is just about to reach the top of the pot, then turn the heat down to low so that the water retreats. Turn the heat up again and let the water come back up, then turn the heat back down. Repeat one more time. The soba should be cooked by the end of the third round. If it is not, repeat one more time. Drain and toss with the bean and spinach mixture, either in the pan or in a wide bowl. Serve with freshly grated Parmesan.

Yield: 4 servings.

Advance preparation: The black-eyed peas can be cooked ahead through Step 1 up to 4 days ahead and stored in the refrigerator.

Nutritional information per serving (4 servings): 410 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 0 milligrams cholesterol; 71 grams carbohydrates; 12 grams dietary fiber; 124 milligrams sodium (does not include salt to taste); 19 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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Genome Research Points to Adaptation Among Early African-Americans

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The scientists, led by Li Jin of the Chinese Academy of Sciences in Shanghai, report in the journal Genome Research that certain disease-causing variant genes became more common in African-Americans after their ancestors reached American shores — perhaps because they conferred greater, offsetting benefits. Other gene variants have become less common, the researchers say, like the gene for sickle cell hemoglobin, which in its more common single-dose form protects against malaria. The Shanghai team suggests the gene has become less common in African-Americans because malaria is much less of a threat.

The purpose of studying African-American genomes is largely medical. Most searches for variant genes that cause disease take place in people of European ancestry, and physicians want to make sure they have not missed variants that may be more common in African-Americans and helpful for developing treatments or diagnosis.

Such searches often reveal events in a population’s history by pinpointing genes that have changed under the pressure of natural selection.

The unusually common variants identified by the Shanghai team are associated with higher risk of hypertension, prostate cancer, sclerosis and bladder cancer.

“Most of the genes associated with African-American ethnic diseases,” they write, “may have played an important role in African-Americans’ adaptation to local environment.” But the authors have not yet been able to identify the benefits they believe such genes conferred.

Mark D. Shriver, a geneticist at Penn State, said it was plausible that some versions of a gene would become more common as African-Americans adjusted to a new environment. “It’s very valid to expect that there will be factors subject to genetic adaptation and that are now more prevalent in contemporary African-Americans than in the ancestral group,” he said.

But Alkes L. Price, a geneticist at the Harvard School of Public Health, said the Shanghai team’s results, though plausible, fell short of proof. “This paper does not provide evidence of selection having occurred post-Africa,” he said.

The Shanghai researchers used a method for studying admixture, a geneticist’s term for when two populations or races intermarry; China has several such populations, perhaps accounting for the team’s interest. Using gene chips that analyze common variations in the human genome, researchers can deconstruct the chromosomes of an African-American, say, assigning each chunk of DNA to an African or European origin.

The scientists found that of the African-American genomes in their sample, 22 percent of the DNA came from Europeans, on average, and the rest from African ancestors, a figure in line with other estimates.

They then looked for sites along the genome where either European or African ancestry was present at statistically significant levels above the average, finding four regions with very common European ancestry and two with very common African ancestry. Most of these sites harbored genes of unknown function, but one, of European origin, holds a gene that combats influenza, suggesting it has become more common in African-Americans by conferring protection from the disease.

Dr. Price, however, said that two other research teams had applied the same method to African-American genomes without finding any statistically significant excess of European or African ancestry. The Chinese team, in his view, should have applied a correction factor to their statistics and, had they done so, would have obtained the same result.

In another approach, the Shanghai team focused on all the DNA segments of the African origin in the African-American genomes, discarding all the European DNA. They then compared the African component of African-American genomes with the DNA of the Yoruba of Nigeria, a well-studied population that happens to be genetically very close to the West African population from which many slaves were taken.

The Shanghai team then asked how the African genome had changed after Africans arrived in the United States. They found that versions of some genes had become more common and others less so. The less common genes included several known to be involved in protection against malaria.

Dr. Price, however, said the decrease in gene frequency might have another explanation — the fact that resistance to malaria varies in strength in different regions of West Africa. The Shanghai team may be looking at the difference in malaria resistance between the Yoruba and other African populations, not the difference between today’s African-Americans and their African ancestors, he said.

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Personal Health: The Twice-Victimized of Sexual Assault

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Yet few told anyone about it at the time, or reported it to the police.

I have clear memories of three such episodes from my childhood, one of which involved a man who owned a store in my neighborhood. Not knowing at age 11 anything about reproduction (in 1952, expectant teachers had to take leave when they “showed”), I was terrified that I could become pregnant from having been forced to touch his penis.

I had trouble sleeping, and I avoided the block where the store was. Yet, fearing that the assault was somehow my fault, I said nothing to my parents.

Experts on sexual assault and rape report that even today, despite improvements in early sex education and widespread publicity about sexual assaults, the overwhelming majority of both felony and misdemeanor cases never come to public or legal attention.

It is all too easy to see why. More often than not, women who bring charges of sexual assault are victims twice over, treated by the legal system and sometimes by the news media as lying until proved truthful.

“There is no other crime I can think of where the victim is more victimized,” said Rebecca Campbell, a professor of psychology at Michigan State University who for 20 years has been studying what happens legally and medically to women who are raped. “The victim is always on trial. Rape is treated very differently than other felonies.”

So, too, are the victims of lesser sexual assaults. In 1991, when Anita Hill, a lawyer and academic, told Congress that the Supreme Court nominee Clarence Thomas had sexually harassed her repeatedly when she worked for him, Ms. Hill was vilified as a character assassin and liar acting on behalf of abortion-rights advocates.

Credibility became the issue, too, for Nafissatou Diallo, an immigrant chambermaid who accused the head of the International Monetary Fund, Dominique Strauss-Kahn, of forcing her to perform fellatio in a Manhattan hotel room. Prosecutors eventually dropped the case after concluding that Ms. Diallo had lied on her immigration form and about other matters, though not directly about the encounter with Mr. Strauss-Kahn.

When four women, two of whom identified themselves publicly, said they had been sexually harassed by Herman Cain, the Republican presidential hopeful, they, too, were called liars, perhaps hired by his opponents.

Charges of sexual harassment often boil down to “she said-he said” with no tangible evidence of what really took place. But even when there is DNA evidence of a completed sexual act, as there was in the Strauss-Kahn case, the accused commonly claim that the sex was consensual, not a crime.

“DNA technology has not made a dramatic change in how victims are treated,” Dr. Campbell said in an interview. “We write off a lot of cases that could be successfully prosecuted. It’s bunk that these cases are too hard to prosecute.”

Victims must be better supported with better forensics, investigations and prosecutions, Dr. Campbell said. “This is a public safety issue. Most rapists are serial rapists, and they must be held accountable.”

In one study, published in 1987 in the Journal of Interpersonal Violence, 126 admitted rapists had committed 907 rapes involving 882 different victims.

Rapists are not the only serial sexual offenders. Witness the all-too-frequent revelations of sexual abuse of children involving multiple victims and persisting for decades even when others in positions of authority knew it was going on.

In the latest such scandal, an assistant football coach at Penn State University stands accused of molesting 10 boys. The charges led to the firing of a revered head coach, Joe Paterno, and forced the resignation of the university president for failing to take more immediate action.

The Risks

Last year, according to the Department of Justice, 188,280 Americans were victims of sexual violence.

Among female victims, nearly three-quarters are assaulted by men they know — friends, acquaintances or intimate partners, according to federal statistics.

But fewer than 40 percent of rapes and sexual assaults are reported to the police. Underreporting is more common among male victims and women raped by acquaintances or domestic partners. Only one-quarter of rapes are committed by strangers.

The result of underreporting and poor prosecution: 15 of 16 rapists will never spend a day in jail, according to the network. Dr. Judith A. Linden, associate professor of emergency medicine at the Boston University School of Medicine, reported in The New England Journal of Medicine in September that in the United States, “fewer than half of rape cases are successfully prosecuted.”

Victims may be reluctant to report a rape because they are embarrassed, fear reprisals and public disclosure, or think they won’t be believed. “Victims often think they somehow brought it on themselves,” said Callie Rennison, a criminologist at the University of Colorado in Denver. “Rape is the only crime in which victims have to explain that they didn’t want to be victimized.”

These feelings are especially common among college women who may have been drinking alcohol or taking illicit drugs when raped by a date or acquaintance.

Victims may not realize that any form of sexual behavior that is not consented to and that causes discomfort, fear or intimidation is considered sexual assault in most jurisdictions. That includes indecent exposure, unwanted physical contact (including kissing and fondling) and lascivious acts, as well as oral and anal sex and vaginal rape, whether with a body part or an instrument.

A minor — in general, 16 or 17, depending on the state — can legally consent to sexual activity. A person of any age who is forced or threatened, developmentally disabled, chronically mentally ill, incapacitated by drugs or alcohol, unconscious or preparing to undergo a medical procedure cannot legally consent to sexual activity.

Among young children, girls and boys are equally at risk of being sexually abused. But as they age, girls increasingly become targets; among adults, women represent about 90 percent of cases.

Experts have long debated whether rape should be seen as an act of aggression and control or the product of an irresistible sexual urge. To the victim, the distinction is moot.

The consequences can include pregnancy and sexually transmitted disease; feelings of helplessness, hopelessness and low self-esteem; self-blame and depression; substance abuse and eating disorders; fears of intimacy; numbness; post-traumatic stress disorder (nightmares, flashbacks, anxiety attacks, difficulty functioning); borderline personality disorder; unexplained physical problems; and even suicide.

Thus, even if rape victims choose not to report the attacks, prompt medical attention and psychological counseling can be critically important to their long-term well-being.

Next week: care for victims of sexual assault.

This article has been revised to reflect the following correction:

Correction: December 15, 2011

The Personal Health column on Tuesday, about factors that stifle the reporting of sexual assault, described the law on sexual activity involving minors incorrectly. The legal age of consent in many states is 16 or 17, so it is not the case that “a minor cannot legally consent to sexual activity.”

This article has been revised to reflect the following correction:

Correction: December 17, 2011

The Personal Health column on Tuesday , about factors that stifle the reporting of sexual assault, using outdated information from an advocacy group’s Web site, misstated the number of Americans who were victims of sexual violence last year, according to the Department of Justice. It is 188,830 — not 272,350, the corresponding figure from 2006. (The error was repeated on Thursday in an article about a survey by the Centers for Disease Control and Prevention on sexual violence and domestic abuse.)

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Global Update: New H.I.V. Cases and AIDS Deaths Plummet in British Columbia

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New H.I.V. cases and AIDS deaths are both going steadily down in British Columbia, according to data released last week.

“We’re particularly pleased to see that our treatment-as-prevention strategy has taken off big-time,” said Dr. Julio S. G. Montaner, director of the British Columbia Center for Excellence in H.I.V./AIDS. His center was a pioneer in the strategy, which involves searching aggressively for people at risk of H.I.V. infection, talking them into being tested and putting those who are infected on antiretroviral drugs immediately, which lowers by 96 percent the chances that they will infect others.

In Vancouver, where he works, AIDS is concentrated in two largely separate groups: gay men and drug addicts. To reach the addicts, the city opened a center where they can inject under a nurse’s supervision without fear of arrest; the nurses also offer medical care, including tests.

Testing is increasing, and syphilis rates are holding steady, Dr. Montaner said, so the drop in new cases is not a result of fewer tests or greater condom use.

AIDS cases remain steady in Canada’s other provinces, except for those in the Prairies region, where they tripled, mostly among Indian addicts in Saskatchewan, which has no safe-injection center.

Last week, Science magazine named the treatment-as-prevention strategy, with the clinical trial of 1,763 couples on four continents that proved it worked, as its 2011 “Breakthrough of the Year.”

Dr. Montaner said he is frustrated that rich countries will not donate enough money to roll out the strategy in poor countries with huge H.I.V. epidemics.

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Nowhere to Go, Patients Linger in Hospitals, at a High Cost

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As a result, hospitals are absorbing the bill for millions of dollars in unreimbursed expenses annually while the patients, trapped in bureaucratic limbo, are sometimes deprived of services that could be provided elsewhere at a small fraction of the cost.

“Many of those individuals no longer need that care, but because they have no resources and many have no family here, we, unfortunately, are caring for them in a much more expensive setting than necessary based on their clinical need,” said LaRay Brown, a senior vice president for the city’s Health and Hospitals Corporation. Under state law, public hospitals are not allowed to discharge patients to shelters or to the street.

Medicaid often pays for emergency care for illegal immigrants, but not for continuing care, and many hospitals in places with large concentrations of illegal immigrants, like Texas, California and Florida, face the quandary of where to send patients well enough to leave. Officials in New York City say they have many such patients who are draining money from the health system as the cost of keeping people in acute-care hospitals continues to escalate.

But even if Medicaid pays for some care, taxpayer dollars are ultimately being consumed by patients who could be cared for in nursing homes or other health facilities, and even at home if supportive services were available. Care for a patient languishing in a hospital can cost more than $100,000 a year, while care in a nursing home can cost $20,000 or less.

Patients fit to be discharged from hospitals but having no place to go typically remain more than five years, Ms. Brown said. She estimated that there were about 300 patients in such a predicament throughout the city, most in public hospitals or higher-priced skilled public nursing homes, though a smattering were in private hospitals.

One patient, a former hospital technician from Queens, has lived at the city’s Coler-Goldwater Specialty Hospital and Nursing Facility on Roosevelt Island for 13 years because the hospital has no place to send him, Ms. Brown said. The patient, who is in his mid-60s, has been there since an arterial disease cost him part of one leg below the knee and left him in a wheelchair. The city’s public health system declined to provide the names of any long-term patients or make them available for interviews, citing confidentiality laws.

Five years ago, Yu Kang Fu, 58, who lived in Flushing, Queens, and was a cook at a Chinese restaurant in New Jersey, was dropped off by his boss at New York Downtown Hospital, a private institution in Manhattan, complaining of a severe headache. Mr. Yu was admitted to the intensive-care unit with a stroke.

Within days, he was well enough for hospital personnel to begin planning for his release, but as an illegal immigrant (he had overstayed a work visa a decade ago), he was ineligible for health benefits. And no nursing home or rehabilitation center would take him. Neither would his son in China nor the Chinese government, although the hospital volunteered to fly him there at its expense.

Mr. Yu’s protracted hospital stay was first chronicled in an article in The New York Times in 2008 about the treatment of uninsured immigrants.

Mr. Yu remained in the hospital for over four years until he was transferred last spring to the Atlantis Rehabilitation and Residential Health Care Facility, a private center in Fort Greene, Brooklyn, after the federal government certified him as a “permanent resident under color of law,” essentially acknowledging that he could not be returned to China and qualifying him for medical benefits.

“This gentleman cost us millions of dollars,” said Jeffrey Menkes, the president of New York Downtown. “We try to provide physical, occupational therapy, but this is an acute-care hospital. This patient shouldn’t be here.”

Mr. Yu said that the hospital had treated him well, but that he had made enormous progress in regaining his ability to walk through his rehabilitation regimen at Atlantis. He hopes to return to China when he is well enough to be discharged.

“Here, I am very happy,” he said. “This is very nice — No. 1.”

New York Downtown serves a largely immigrant population, and many patients have no insurance or proof that they are in the United States legally, which is necessary for discharge purposes and eventual reimbursements, said Chui Man Lai, assistant vice president of patient services at the hospital.

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