Well: 50 Ways to Love Your Quinoa

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You'd think I would eventually run out of ideas for quinoa. I've posted over 50 recipes on this page over the years. But ideas keep coming and I keep loving this grain (O.K., Paleos, I know, it's a seed, not a grain. But we use it on the plate like a grain, so that's what I'll continue to call it.)

One of the culinary artists of our time, Deborah Madison, opened up a new world of quinoa ideas for me in her latest book, "Vegetable Literacy." In some of her recipes she uses quinoa more as a garnish than as the main ingredient. I thought about that when I started work on new quinoa salads.

Three of the salads I made were indeed quinoa salads with particular dressings, accompanying vegetables, condiments and other ingredients like nuts or seeds. But I also made a green bean and almond salad, where red quinoa plays second fiddle to the green beans; and a classic, pungent Mediterranean yogurt and cucumber salad, typical of yogurt/cucumber combos from the region except for the red quinoa I spooned over each serving. The quinoa contributed beautiful color as well as wonderful texture and substance to these light salads.

Quinoa keeps well in the refrigerator, so cook some up and make these salads through the week. They make great lunches or light suppers.

Red Quinoa Salad With Walnuts, Asparagus and Dukkah: This salad is garnished with steamed asparagus and the Middle Eastern nut and spice mix called dukkah.

Spicy Quinoa Salad With Broccoli, Cilantro and Lime: The grassy flavor of quinoa works well with cilantro in this main-dish salad.

Chickpea, Quinoa and Celery Salad With Middle Eastern Flavors: Chickpeas make this salad a substantial and comforting dish for a light supper.

Green Bean Salad With Lime Vinaigrette and Red Quinoa: Red quinoa is a colorful contrast to the green beans in a salad that is full of texture.

Mediterranean Cucumber and Yogurt Salad With Red or Black Quinoa: Red quinoa adds color and substance to a typically Mediterranean mix of yogurt and finely diced cucumber.

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Well: Ask Well: Fatty Liver and Diet

Recently, in "Threat Grows From Liver Illness Tied to Obesity," Anahad O'Connor described the growing epidemic of nonalcoholic fatty liver, an illness that affects at least one in five Americans, including many teenagers. Here he responds to reader questions about what to eat if you have fatty liver.

Q

My 22-year-old son has been diagnosed with fatty liver disease. What kinds of foods should be avoided in his diet?

Is there a recommended diet for nonalcoholic liver disease?

A

Nonalcoholic fatty liver, a disease tightly linked to the obesity crisis, is a strong risk factor for heart disease and Type 2 diabetes, and in severe cases it can lead to liver failure. There are no official dietary guidelines to treat it. But whether certain foods might fuel the disease is a subject that is drawing increasing attention from scientists.

Researchers have questioned the involvement of a number of dietary factors — trans fats, omega-6 oils, fried foods and fructose, to name a few. But one that has attracted perhaps the most attention is sugar, in part because it is metabolized in the liver and it is known to increase blood levels of triglycerides, a type of fat.

Studies suggest that sugar consumption contributes to liver fat accumulation. And there is some data indicating that people who carry genetic variants associated with fatty liver are particularly sensitive to increased fat accumulation in response to sugar and refined carbohydrates.

One of the first pieces of dietary advice that clinicians who treat fatty liver give to their patients is to eliminate sugary drinks from their diets. But doctors say that patients with the disease are typically consuming too many calories of all kinds, not just sugar.

Often, patients are told to avoid eating heavily processed foods, which are easy to consume in large quantities and usually stripped of their fiber and other naturally occurring nutrients. Preliminary studies have found so far that fatty liver patients respond well to the Mediterranean diet, which includes plenty of fresh produce, nuts, olive oil, poultry and fish.

One small clinical trial published in The Journal of Hepatology last year found that a Mediterranean diet had a more favorable impact on liver fat and insulin resistance than a low fat, high carbohydrate diet. And another study in the journal Clinical Nutrition, which involved 90 overweight patients with fatty liver, found similar success with a Mediterranean approach.

As funding for fatty liver research grows, scientists expect to carry out more dietary intervention studies.

Right now, the only proven method of reducing fat in the liver is weight loss. In the clinic, doctors tell fatty liver patients to aim for an initial weight loss of at least 10 percent of their body weight, which can be accomplished by limiting junk food and engaging in regular exercise. Dr. Kathleen Corey, the director of the Fatty Liver Clinic at Massachusetts General Hospital in Boston, advises her patients to exercise at least three times a week for 45 minutes.

Do you have a health question? Submit your question to Ask Well.

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Well: Longer Heart Monitoring Backed for Stroke Patients

More than a half-million Americans every year have an ischemic stroke, the most common form, which disrupts blood flow to the brain. And at least a quarter of these cases have no apparent underlying cause.

Now two major studies suggest that many of these strokes of unknown origin — up to a third — may stem from atrial fibrillation, a common irregularity of the heartbeat that often goes unrecognized.

The findings are likely to encourage doctors to look more aggressively for signs of atrial fibrillation in patients who suffer strokes of unknown cause.

After such strokes, doctors usually prescribe a mild blood thinner such as low-dose aspirin. But aspirin alone may not be enough to prevent additional strokes in patients with underlying atrial fibrillation. These patients generally require more powerful anticoagulant medications to prevent clotting that can lead to additional strokes.

Stroke patients are generally screened with electrocardiographic monitoring for 24 hours to rule out atrial fibrillation. But the new studies, published Wednesday in The New England Journal of Medicine, suggest that some patients may need their hearts monitored much longer to detect abnormal rhythms.

One of the studies, which was funded by the Canadian Stroke Network and known as the Embrace trial, found that atrial fibrillation was diagnosed in five times as many patients who wore special heart monitors for 30 days compared with those who underwent conventional 24-hour testing.

The second study, led by researchers in Italy and carried out at clinics in the United States and other countries, found that a third of patients who had had strokes of unknown cause and were followed for up to three years experienced at least one episode of atrial fibrillation — and in most cases, there were no obvious symptoms.

In both studies, the longer monitoring periods resulted in significantly more patients being prescribed anticoagulants to lower their risk of another stroke.

"If more patients with atrial fibrillation can be detected, then more patients can receive appropriate stroke prevention therapy, and the hope is that more strokes, deaths, disability and dementia can be avoided," said Dr. David Gladstone, an associate professor in the department of medicine at the University of Toronto and the lead author of the Embrace trial.

Some medical centers monitor patients beyond the usual 24 hours, and in May the American Heart Association updated its guidelines to say it was "reasonable" for patients with unexplained strokes to be monitored for 30 days.

But longer monitoring "hasn't been the standard of care," said Dr. Hooman Kamel, a neurologist at the Brain and Mind Research Institute at Weill Cornell Medical College in New York, who was not involved in the new research. "I think these two studies are really what was needed to put it on very firm footing and to make it more widespread."

Dr. Gordon F. Tomaselli, the chief of cardiology at the Johns Hopkins University School of Medicine and a past president of the heart association, said the findings would "reinforce the notion that if you don't have a good reason for a stroke, you really need to take a pretty intensive look for atrial fibrillation."

Nationwide, about three million Americans have a diagnosis of atrial fibrillation, which occurs when erratic electrical signals cause the heart's upper chambers, the atria, to contract abnormally. The fluttering can cause blood to pool in the atria, forming clots that can then travel to the brain. At least one in six strokes are attributed to atrial fibrillation, and they are often more debilitating and deadly than strokes stemming from other causes.

But atrial fibrillation can be difficult to detect. The episodes are typically sporadic, coming and going unpredictably and lasting minutes or days at a time. Some people experience heart palpitations, shortness of breath and dizziness. But many experience no symptoms at all.

"What we are learning is that many patients have clinically silent atrial fibrillation," said Dr. Gladstone, who is also a scientist at Sunnybrook Research Institute in Ontario. "Often the first manifestation is when it leads to a stroke."

In the Embrace trial, which was carried out at 16 medical centers in the Canadian Stroke Consortium, Dr. Gladstone and his colleagues followed 572 people who had had either a stroke or a mini-stroke whose cause remained unclear after a battery of diagnostic tests.

About half of the patients wore a conventional device, known as a Holter monitor, which recorded their heart rhythms for an additional 24 hours. But the rest were assigned to wear a new chest electrode belt for 30 days after they went home.

Atrial fibrillation was detected in just 3 percent of the patients monitored short term, and in 16 percent of those who wore the new device for one month.

Among the patients monitored for 30 days was William Russell, 71, a retired businessman from Collingwood, Ontario. Mr. Russell suffered a major stroke two years ago during a ski trip with his family in Calgary.

"There was no prior warning — it just hit," he said. "My left side became completely paralyzed and my speech was slurred. Fortunately my daughter noticed it immediately and called 911."

At the hospital, doctors gave Mr. Russell a powerful clot-busting drug that reversed his stroke. But their next challenge was to find what had caused it. They took scans of his heart and his brain and did an electrocardiogram to measure the electrical activity of his heart, but the cause remained unknown.

Mr. Russell was enrolled in the study, and after a month of wearing the electrode belt day and night, his doctor was able to make a proper diagnosis.

"His heart monitoring revealed that he was having silent episodes of atrial fibrillation," Dr. Gladstone said. "As a result, we've been able to treat him with anticoagulant medication."

Mr. Russell said that he was doing well on his new medication and had returned to hiking, cycling and playing golf. Wearing the monitor for 30 days was "a bit of a pain," he said. "But it was worth it. Well worth it."

A version of this article appears in print on 06/26/2014, on page A19 of the NewYork edition with the headline: Behind Strokes of Unknown Origin, 2 Studies Point to Flaw in Heartbeat.

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Well: Putting Us All at Risk for Measles

Doctor and Patient

Dr. Pauline Chen on medical care.

One of my 11-year-old twin daughters recently came home from school distraught. When I asked why, she lifted her foot.

There was dog poop on her sneakers.

She watched as I flicked away the doggy detritus with a twig, then scrubbed the sole of her shoe with an old brush and hot water. "We don't like to pick up Buddy's poop, either," I could hear her telling her sister, "but we do it because it's gross to leave it on the sidewalk."

When I handed her the shoe, cleaned and as good as new, she beamed. "Thanks, Mom," she said, lacing up. But after a few test twirls in the yard, she stopped.

"Didn't that dog's owner know he would cause so much trouble for other people?" she asked, brow furrowing. "He might have even caused trouble for himself if he came back and stepped in it!"

At the tender age of 11, she had seen how one person's bad decision could negatively affect others.

The same lesson is playing out for patients and doctors across the country, albeit under far graver circumstances.

This year, there has been a major resurgence of measles, a dangerous disease that for decades had been virtually unknown in the United States. And it's become clear that measles has re-emerged as a public health issue in this country because large numbers of individuals remain unvaccinated.

By choice.

Up until the late 1960s, measles was an unavoidable scourge, infecting millions of children each year. Highly contagious, it could lurk in the air for hours after an infected individual had passed by, resulting in more than 400 deaths and nearly 50,000 hospitalizations annually, as well as innumerable chronic disabilities when it spread to the lungs and brain.

Happily, in 1966 scientists developed a safe and effective vaccine. With this vaccine in hand, public health officials, pediatricians and infectious disease experts began a series of campaigns to eradicate the disease. Their principal strategy was to create "herd immunity," or "community immunity."

In any given population, there would always be individuals who would not develop immunity to measles, even after receiving the vaccine, or who could not receive the vaccine because they were too young (less than a year old) or had immune systems already weakened from diseases like cancer or AIDS. But health care experts discovered that if at least 95 percent of a community were immunized against measles, all the members of that group would be safe. Even if someone with the disease entered the community, the immunized majority would serve as a "buffer zone" preventing further spread to unimmunized individuals.

If, however, the rates of vaccination fell below 95 percent and community immunity dropped, that safety net would disappear.

In 2000, after three decades of intensive efforts, public health officials declared that endemic measles had been eradicated in the United States.

But just as the experts were claiming victory, Dr. Andrew Wakefield, a British gastroenterologist, published in The Lancet a study of 12 children that posited a causal link between the measles vaccine and an intestinal disorder and autism. Subsequently, dozens of peer-reviewed studies based on the experience of millions of children found nothing to support such speculation, and in 2010 The Lancet retracted the study, citing fraudulent data and ethics violations. The same year, the British Medical Council barred Dr. Wakefield from practicing medicine because of ethical lapses.

The retraction, the disciplinary actions and all the subsequent scientific findings that refuted Dr. Wakefield's assertion did little to dampen the enthusiasm of his most fervent supporters. They continued to promote his work and the idea that the measles vaccine could cause autism. Believing that they were protecting the young against neurological harm, these parents refused to vaccinate their children and encouraged others in their communities to do the same.

Pediatricians and infectious disease experts warned that these parents were putting their unvaccinated children at increased risk. Measles remains the eighth leading cause of mortality worldwide and the greatest vaccine-preventable cause of death among children. Studies have shown that unvaccinated children are 35 times more likely to contract the disease than immunized children.

Furthermore, the health care experts cautioned, it wouldn't be just their own family members that these parents were putting at risk.

This year the proverbial poop has hit the propeller. Over the last five months, there have been 16 outbreaks and almost 500 reported cases of measles. It's the highest number of cases since 2000, and the number continues to rise. Almost all the outbreaks can be traced to an unvaccinated individual who contracted the disease while traveling abroad, and the majority of people who subsequently caught the disease were unvaccinated by choice.

Moreover, because as many as a quarter of all parents in certain communities chose not to vaccinate their children, pockets of the population have lost the protective effects of herd immunity. In these communities, measles has spread like wildfire, infecting not only those who were unvaccinated by choice but also infants too young to be immunized, and children and adults with immune systems already compromised.

And, it gets worse.

Given the earlier success of the measles eradication campaign, most patients and their doctors no longer know how to recognize the disease. Patients, unaware that they are ill with such a contagious disease, go to hospitals and clinics assuming that the providers there will know what to do to help them.

But most practicing doctors, myself included, have never cared for a patient with measles. Confronted with a patient suffering from a fever, red eyes, runny nose, cough and blotchy rash, we don't even think of measles, let alone order the dramatic precautions necessary to prevent its spread, like mandating facial masks, isolating patients in rooms equipped with specialized ventilation systems and reporting to appropriate infection control experts.

And because measles was virtually nonexistent in the United States until this year, many clinicians still assume that patients are vaccinated against the disease and therefore not susceptible.

"We have a whole generation of physicians who have never seen measles," said Dr. Julia Sammons, medical director of infection prevention and control at the Children's Hospital of Philadelphia. Dr. Sammons has just published in The Annals of Internal Medicine a primer on the diagnosis, treatment, prevention and control of measles to help increase awareness among doctors. "You're not going to make the diagnosis or make efforts to control spread if it's not on your radar screen," she said.

While there have been no deaths yet associated with the recent outbreaks, the lesson for patients and doctors is clear.

When it comes to public health, bad personal choices can have potentially devastating effects on others.

"It's easy to believe that vaccines are harmful if you aren't seeing the consequences for yourself and other people," Dr. Sammons said. "But we need to remember that measles is a preventable disease."

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Well: Aspirin May Cut Pancreatic Cancer Risk

A new study adds to the evidence that low-dose aspirin, known to reduce the risk for heart disease, may also reduce the risk for pancreatic cancer.

Pancreatic cancer has a 93 percent fatality rate, and the National Cancer Institute estimates there will be about 46,000 new cases and 40,000 deaths from the disease this year.

In a five-year study, published online in Cancer Epidemiology, Biomarkers & Prevention, researchers compared aspirin use in 362 pancreatic cancer patients with 690 randomly chosen controls. Participants were asked about past and present regular use of aspirin, defined as at least once a week for three months.

After controlling for age, sex, race, smoking, diabetes and other variables, the researchers found that regular aspirin use lowered the risk for pancreatic cancer by 48 percent.

Patients who had been taking aspirin regularly for one to three years reduced their risk by 43 percent; those who had been taking it for seven to 20 years reduced risk by 56 percent.

Why aspirin would do this is unclear. "Pancreatic cancer takes 10 to 15 years to develop," said the senior author, Dr. Harvey A. Risch, of the Yale School of Public Health. "We don't know if the aspirin is preventing the formation of new tumors or helping the immune system to control them later on. Empirically it seems to do something, and at this point that's all we can say."

 

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Well: Cleaner Air Linked to Fewer Deaths

Air quality has improved significantly in the past 20 years because of federal and state laws and regulations, and researchers in North Carolina have found an associated decline in rates of death from respiratory disease.

A study, published Monday in The International Journal of Chronic Obstructive Pulmonary Disease, analyzed mortality trends for emphysema, asthma and pneumonia from 1993 to 2010, along with changes in air pollution levels as measured monthly.

Sulfur dioxide, particulate matter, nitrogen dioxide and carbon monoxide all decreased markedly month to month, and so did death rates from the three diseases.

Reductions in sulfur dioxide and carbon monoxide were associated with decreases in emphysema and pneumonia deaths, and reduced asthma mortality was associated with lower levels of sulfur dioxide, carbon monoxide and particulate matter.

The associations persisted after controlling for smoking and seasonal variations in respiratory death rates, but the authors did not control for socioeconomic status or access to medical care.

"We still have things to work on," said the lead author, Julia Kravchenko, a research scientist at Duke University Medical Center. "Even mild improvement in air quality will help reduce mortality from respiratory disease."

A version of this article appears in print on 06/24/2014, on page D4 of the NewYork edition with the headline: Hazards: Laws' Effect on Lung Deaths.

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Well: Vitamin D Screening Not Backed by Expert Panel

A government health panel on Monday chose not to endorse widespread screening for vitamin D levels in healthy adults, despite research suggesting that a majority of Americans may be deficient in the vitamin.

The United States Preventive Services Task Force, an independent group of health experts, decided not to recommend routine testing for vitamin D levels in part because it was not clear whether otherwise healthy adults with low levels would actually benefit from taking supplements of the vitamin. The panel members concluded that there was not enough evidence to either endorse or advise against regular vitamin D screening in most adults, and they suggested that testing is something that should be considered case by case.

"This is not a recommendation for or against it," said Dr. Douglas K. Owens, a panel member and director of the Center for Primary Care and Outcomes Research at Stanford medical school. "In our view, when people have concerns or questions about vitamin D, they should discuss them with their clinicians."

Dr. Owens said that the task force decided to look at the harms and benefits of screening since vitamin D testing is on the rise. Sales of vitamin D supplements have soared in recent years, fueled by a body of research suggesting that the vitamin may help protect against a range of chronic disease. Some studies estimate that more than two-thirds of Americans are deficient in it.

Earlier this year, two large and exhaustive studies in the journal BMJ found that people with low vitamin D levels were more likely to die from cancer, heart disease and to suffer from other illnesses. One of the studies found that middle-aged and older adults who took vitamin D3 — which is found in fish and dairy products and produced in the body in response to sunlight — had reductions in mortality from all causes. But a second study did not find persuasive evidence that vitamin D pills can protect against chronic disease.

There is some debate over whether low levels of the vitamin are a direct cause of disease, or simply an indicator of behaviors that contribute to poor health, like smoking, poor diet and a sedentary lifestyle.

The federal task force issued a draft recommendation based on a review of evidence from more than a dozen studies that evaluated the effects of vitamin D treatment in generally healthy adults. The studies used vitamin D3 doses ranging from 400 to 4,800 international units daily, and they lasted anywhere from two months to seven years.

The panel concluded that the current evidence was "insufficient to determine the net balance of benefits and harms of screening and early treatment of vitamin D deficiency" in generally healthy adults. Dr. Owens said the committee found a number of potential problems with screening.

For one, it is not clear exactly what constitutes a vitamin D deficiency in the first place. Some experts believe that deficiencies should be defined as a blood level of the vitamin that is under 30 nanograms per milliliter. Others say the cutoff should be lower. There are also numerous ways to test for vitamin D, and it is not clear whether some tests are better or more accurate than others.

Another complicating factor is that vitamin D screening can yield unreliable results depending on things like the ethnicity of the person being tested. Studies have found, for example, that the prevalence of low vitamin D is many times greater in African Americans compared to non-Hispanic whites, yet they do not have the higher risk of bone fractures typically associated with low vitamin D. One study last year found that even though African Americans tend to have lower circulating levels of vitamin D, the vitamin is in a more readily accessible form, so their low levels can be misleading.

That suggests that problems may lie with the method of testing, not necessarily the patients. People who are obese may also have paradoxically low levels of circulating vitamin D despite having forms of the vitamin that the body can use.

"Because the accuracy of the test is uncertain, you can misclassify people," Dr. Owens said. "You could tell someone who is not vitamin D deficient that they are. There are those kinds of problems with broader screening."

Dr. Roxanne Sukol, a preventive medicine specialist at Cleveland Clinic's Wellness Institute, said that she often tests her patients for vitamin D, but for varying reasons. In some cases she may have concerns about the quality of a patient's diet. In others, the concern may be that a patient is at risk of low bone density, or that he or she is not getting enough sun exposure to produce sufficient vitamin D.

Dr. Sukol said the draft recommendation would not change her approach to screening, and that she suspects many people may misinterpret the panel's conclusions.

"It doesn't mean you shouldn't test," she said. "They're saying that if doctors decide to do it, that we should tell the patient that we're not positive whether it will make a difference and we're not sure if more good will come from it or more harm."

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Well: For Fitness, Push Yourself

Intense exercise changes the body and muscles at a molecular level in ways that milder physical activity doesn't match, according to an enlightening new study. Though the study was conducted in mice, the findings add to growing scientific evidence that to realize the greatest benefits from workouts, we probably need to push ourselves.

For some time, scientists and exercise experts have debated the merits of intensity in exercise. Everyone agrees, of course, that any exercise is more healthful than none. But beyond that baseline, is strenuous exercise somehow better, from a physiological standpoint, than a relative stroll?

There have been hints that it may be. Epidemiological studies of walkers, for instance, have found that those whose usual pace is brisk tend to live longer than those who move at a more leisurely rate, even if their overall energy expenditure is similar.

But how intense exercise might uniquely affect the body, especially below the surface at the cellular level, had remained unclear. That's where scientists at the Scripps Research Institute in Florida stepped in.

Already, these scientists had been studying the biochemistry of sympathetic nervous system reactions in mice. The sympathetic nervous system is that portion of the autonomic, or involuntary, nervous system that ignites the fight or flight response in animals, including people, when they are faced with peril or stress. In such a situation, the sympathetic nervous system prompts the release of catecholamines, biochemicals such as adrenaline and norepinephrine that set the heart racing, increase alertness and prime the muscles for getaway or battle.

At Scripps, the scientists had been focusing on catecholamines and their relationship with a protein found in both mice and people that is genetically activated during stress, called CRTC2. This protein, they discovered, affects the body's use of blood sugar and fatty acids during moments of stress and seems to have an impact on health issues such as insulin resistance.

The researchers also began to wonder about the role of CRTC2 during exercise.

Scientists long have known that the sympathetic nervous system plays a part in exercise, particularly if the activity is intense. Strenuous exercise, the thinking went, acts as a kind of stress, prompting the fight or flight response and the release of catecholamines, which goose the cardiovascular system into high gear. And while these catecholamines were important in helping you to instantly fight or flee, it was generally thought they did not play an important role in the body's longer-term response to exercise, including changes in muscle size and endurance. Intense exercise, in that case, would have no special or unique effects on the body beyond those that can be attained by easy exercise.

But the Scripps researchers were unconvinced. "It just didn't make sense" that the catecholamines served so little purpose in the body's overall response to exercise, said Michael Conkright, an assistant professor at Scripps, who, with his colleague Dr. Nelson Bruno and other collaborators, conducted the new research. So, for a study published last month in The EMBO Journal, he and his collaborators decided to look deeper inside the bodies of exercising mice and, in particular, into what was going on with their CRTC2 proteins.

To do so, they first bred mice that were genetically programmed to produce far more of the CRTC2 protein than other mice. When these mice began a program of frequent, strenuous treadmill running, their endurance soared by 103 percent after two weeks, compared to an increase of only 8.5 percent in normal mice following the same exercise routine. The genetically modified animals also developed tighter, larger muscles than the other animals, and their bodies became far more efficient at releasing fat from muscles for use as fuel.

These differences all were the result of a sequence of events set off by catecholamines, the scientists found in closely examining mouse cells. When the CRTC2 protein received and read certain signals from the catecholamines, it would turn around and send a chemical message to genes in muscle cells that would set in motion processes resulting in larger, stronger muscles.

In other words, the catecholamines were involved in improving fitness after all.

What this finding means, Dr. Conkright said, is that "there is some truth to that idea of 'no pain, no gain.'" Catecholamines are released only during exercise that the body perceives as stressful, he said, so without some physical strain, there are no catecholamines, no messages from them to the CRTC2 protein, and no signals from CRTC2 to the muscles. You will still see muscular adaptations, he added, if your exercise is light and induces no catecholamine release, but those changes may not be as pronounced or complete as they otherwise could have been.

The study also underscores the importance of periodically reassessing the intensity of your workouts, Dr. Conkright said, if you wish to continually improve your fitness. Once a routine is familiar, your sympathetic nervous system grows blasé, he said, holds back adrenaline and doesn't alert the CRTC2 proteins, and few additional adaptations occur.

The good news is that "intensity is a completely relative concept," Dr. Conkright said. If you are out of shape, an intense workout could be a brisk walk around the block. For a marathon runner, it would involve more sweat.

"But the point is to get out of your body's comfort zone," Dr. Conkright, "because it does look like there are unique consequences when you do."

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Well: Too Hot to Handle

Personal Health

Jane Brody on health and aging.

Hot weather kills more Americans than all other natural disasters combined, and the casualties continue to climb despite decades of warnings about how to recognize the signs of heat stress and take prompt corrective action.

With climate change, some experts predict ever-worsening summer heat waves and even more related illnesses and deaths. The Natural Resources Defense Council estimates that excessive heat caused by climate change could kill more than 150,000 Americans by the end of the century in the 40 largest cities.

"As carbon pollution continues to rise, the number of dangerously hot days each summer will increase even further, leading to a dramatic increase in the number of lives lost," the council reported.

Extreme heat claims an average of 117 lives each year, but the real incidence is likely far higher. In addition, about 1,800 people die from illnesses made worse by heat, the council estimates.

"Death rates from many causes rise during heat waves that are related to heat but not reported as such," said Dr. Christopher B. Colwell, director of emergency medicine at Denver Health Medical Center. "Lots of deaths that occur during heat waves are attributed to natural causes like heart attacks, kidney disease or respiratory disease."

Especially at risk are the elderly, young children, athletes of all ages and weekend warriors whose bodies are not adapted to heat stress.

"As common as the problem is, it's not common enough to grab people's attention until it hits close to home," Dr. Colwell said in an interview.

Even a high-profile death, like that of Korey Stringer, 27, a Minnesota Vikings offensive tackle who suffered heatstroke after a summer morning practice in 2001, has not prompted all coaches to take necessary precautions.

"Many coaches have held practices in the heat for years and no one died, so they think a bigger deal is being made of the problem than it really is," Dr. Colwell said.

In the six years before Stringer's death, 19 high school and college players died from heatstroke, according to researchers at the University of North Carolina. Too often, a player suffering from heat exhaustion, the first stage of a potentially life-threatening heat illness, is sent back on the field after a brief rest instead of being benched for the day or longer.

While deaths of healthy young athletes tend to be well publicized, the elderly are much more likely to succumb to extreme heat. Dr. Colwell explained that with age, the body's ability to cool itself declines. Among other changes, blood vessels don't dilate as readily to allow heat to escape, a problem made worse by conditions like congestive heart failure and peripheral vascular disease.

Many older people without air-conditioning or fans may not know when to get out of the heat, or they may be physically unable to leave an overheated dwelling.

Dehydration, a common problem among the elderly as well as among younger people who exercise strenuously, raises the risk of heat illness by diminishing the body's ability to lose heat.

Medications taken by many older people also increase their vulnerability to heat stress, among them beta blockers prescribed for high blood pressure and anticholinergics used to treat lung problems and urinary incontinence.

Other drugs, too, can contribute to a hypersensitivity to heat, including lithium, tricyclic antidepressants, antihistamines and antispasmodics. Recreational drugs, like cocaine, amphetamines, PCP and alcohol, can be a problem as well.

Heat illness often occurs several days into a heat wave, as the effects on the body accumulate.

The body normally operates within a rather narrow temperature range. If body temperature rises above 105 degrees Fahrenheit, enzymes begin to break down and normal metabolic processes are disrupted. When Stringer collapsed, his temperature registered above 108 degrees.

Body heat is dissipated through four mechanisms: conduction, convection, radiation and evaporation. When the air temperature rises above 98.6 degrees, heat cannot be conducted away from the body unless a significant breeze creates a convection current, or windchill.

Heat radiates from the body when blood vessels are maximally dilated and the air temperature is lower than body temperature. But the most effective natural coolant is sweat; as it collects on the skin and evaporates, it draws heat from the body.

The risk of heat illness rises with the heat index, a combined measure of air temperature and relative humidity. When the humidity is high (or too much clothing is worn), sweat simply rolls off the skin without evaporating and cooling it.

Coaches, take note: depending on athletes' ages, intensity of activity and degree of acclimatization, you should consider canceling practice and games when the heat index exceeds 105, experts say. City dwellers are most at risk during heat waves because paved surfaces, tall buildings and minimal tree cover enhance heat absorption, creating a "heat island."

Heat illness is a form of hyperthermia, defined as a rise in core body temperature. But it does not respond to fever-reducing medications, making it extremely important to recognize heat exhaustion, an early sign of trouble. Common complaints include fatigue, dizziness, weakness, headache, nausea and muscle cramps.

Dr. Colwell explained that the brain's cerebellum is especially sensitive to heat, which explains the early signs of a heatstroke: unsteady gait, confusion and disorientation. Heatstroke, characterized by a rise in body temperature above 104 degrees, has a death rate as high as 50 percent. Symptoms typically include a change in mental status, like delirium, seizures or even coma.

Among the elderly, heatstroke most often develops gradually, over several hot days. But among otherwise healthy people engaged in strenuous exercise, it tends to occur suddenly, within minutes to hours, which demands particular attention to early symptoms.

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The New Old Age Blog: ‘You Can Do It, Shirley’

Chang W. Lee/The New York Times

Martin Luther King Addo, a 44-year-old bodybuilder who was twice crowned Mr. Ghana, opened a storefront gym in a N.O.R.C. — a naturally occurring retirement community — in Lower Manhattan. His clients, many of them older women, are glad he did. Read the full story, and watch the video, above.

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Well: Broccoli, Stems and All

Eat Well

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Are you searching for a new vegetarian or vegan recipe? Try our new Eat Well Recipe Finder, which offers hundreds of healthful soups, sides, main courses, salads and desserts.

Once upon a time, when you bought broccoli you bought the whole vegetable, stems and crowns. Then it became customary for grocery store produce departments to separate the crowns from the stems and to sell the crowns at a premium.

I'm not a fan of this practice, because I like both parts of the broccoli plant. The stems and crowns are equally nutritious when it comes to calcium, iron, magnesium, potassium, protein and vitamin A. The only nutrient that appears to be more concentrated in the crowns is beta carotene.

Sometimes I use the stems on their own, for such dishes as pickled broccoli stems or broccoli slaw. But just as often I use the two in the same dish. I like their different textures and flavors; the stems are crunchy if they aren't overcooked, and have a subtler flavor.

This week I focused on broccoli stems alone in two of my Recipes for Health. I seared broccoli stems cut crosswise into "coins" and came up with an addictive winner. I used shredded stems in spring rolls, and julienned stems and thinly sliced tops in a stir-fry. I shaved the stems and sliced the tops very thin for a salad and for a pasta dish, and cooked the ribbons separately from the top part of the crowns for the pasta. When broccoli is prepared differently for the same dish it's almost like using two different vegetables. And it's always nice to find new ways to pep up sometimes boring broccoli.

Pre-Summer Greek Salad With Shaved Broccoli and Peppers or Beets: Uncooked, paper-thin broccoli keeps its shape and color, but absorbs a dressing.

Stir-fried Broccoli Stalks and Flowers, Red Peppers, Peanuts and Tofu: Cutting broccoli stalks into two-inch julienne is almost like adding yet another vegetable to this quick stir-fry.

Pan-Fried Broccoli Stems: A swift way to turn broccoli into an irresistible snack or side dish.

Pasta With Mushrooms and Broccoli: Cooked separately, broccoli stems and flowers have different textures and shades of green.

Spring Rolls With Shredded Broccoli Stems, Vermicelli and Red Pepper: You can save time on these light, pungent spring rolls by using the already shredded broccoli stems available in some supermarkets.

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Well: A Long Way From Wonder Bread

SAN RAFAEL, Calif. — Pam Ross showed up at Ponsford's Place Bakery & Innovation Center at 5 p.m. sharp, just minutes after the owner, Craig Ponsford, put out the sidewalk "bread man" sculpture that alerts customers: Pizza night is on.

"It's just healthy," Ms. Ross said of the thin-crust pizzas, made with whole-milled, locally grown, whole-wheat flour. "There's nothing white about it, nothing processed. I don't eat pastries, but I'll eat these."

Ponsford's Place is part of a new movement in whole grains. Led by groups like the Oakland-based organization Community Grains, the grains are grown locally, and consist of varieties unlike most of the flour available today. The California-grown grains are milled without ever separating the germ, the embryo of a grain kernel, and the bran, the protective outer layer.

Customers swear by the difference. "After eating this pizza, I don't feel like I've eaten wet lead," said Deborah Stapleton, who tries hard not to miss a Ponsford pizza night. (This being Marin County, Ms. Stapleton is also among the regulars who bring their pizza boxes from last time for reuse.)

Currently, most of the flour we get is processed by industrial-scale roller milling that removes a wheat kernel's nutrient-rich germ and bran, turning the remaining endosperm – the starchy, least nutritious part — into white flour. Many of today's products that are labeled "whole wheat" are made with this refined flour, with the germ and bran added back in. The only requirement for a product to be labeled "whole grain" is that the three parts be represented in their natural proportions.

This industrial milling, many healthy food advocates argue, is taking its toll, not just on our taste buds, but on our health. As the author Michael Pollan noted at a recent whole grains conference at Oliveto restaurant in Oakland in March, which some referred to as "the Woodstock of the whole grains movement," every innovation in food processing improved human health — until we hit the roller mill.

Whole grains include foods like brown rice, quinoa, oatmeal, popcorn and whole wheat. But the varieties of wheat we know are bred for a large, easily separated endosperm, so that they can best be refined. By contrast, this new system involves, well, a return to the old system. Local farmers grow different wheat varieties and sell them to bakers, who use in-house mills. The result is locally grown, freshly milled, freshly baked whole-grain products.

Local grain economies are cropping up in a number of areas on a small scale, such as The Mill in San Francisco and Beck's Bakery in Humboldt County farther north. Others include Hayden Flour Mills, in Arizona; the Maine Grain Alliance, which is hosting its "2014 Kneading Conference" in July; and The Bread Lab in Washington State, which is hosting its "2014 Grain Gathering" in August. The goal, says Bob Klein, the founder of Community Grains, is to scale up so that it can be profitable for farmers and competitively priced for consumers. "We want it to be a true alternative to an industrial economy," he said.

Eating whole grains has been linked to better health in numerous studies, including a reduced risk of Type 2 diabetes, heart disease and some cancers. "Whole grains is the single greatest indicator of overall health that I have ever seen," said David Jacobs, a public health professor at the University of Minnesota.

But few studies have been conducted on these minimally processed whole grains, largely because it is hard to get funding for studies that are about whole foods rather than isolated nutrients, researchers involved with the movement say. Some researchers suggest that the whole kernel, with bran and germ intact, may have a synergistic effect, in which benefits — such as improved control of blood sugar levels — are greater than the sum of the constituent parts.

David Killilea, a staff scientist in the Nutrition and Metabolism Center at Children's Hospital Oakland Research Institute, says that boosting the percentage of whole grains of any kind in the diet may blunt one's overall exposure to gluten. Gluten is predominantly found in the endosperm, but the germ and bran contain many other proteins that may lower the likelihood of gut irritation, Dr. Killilea says. (Refined flour discards these protective components of wheat.)

Someone with celiac disease would still not be able to tolerate whole grains, he says, but some people who say they are gluten sensitive have reported that they can enjoy breads made from whole grains. Dr. Killilea recently began a collaboration with The Bread Lab to assess how the milling process might affect a person's sensitivity to gluten.

Public health professionals have struggled for years to get people to eat more whole grains, without much success. A paper published last year in The Journal of Nutrition noted that the top barriers to consumption of whole grains included color, price, texture and taste. The authors write, "the products benefit no one if they fail to provide the taste profile consumers expect."

That's where many in the new whole grains movement are stepping in. By hosting "wheat tastings" and helping farmers breed different varieties of wheat, Community Grains is introducing people not only to new tastes but also to terroir, the sense of place dear to French winemakers.

"Once you have a chocolate-chip cookie with whole-wheat flour, you never go back," said Sherry Yard, a former executive pastry chef for Wolfgang Puck, who also bakes with Community Grains flour. She notes its "layers of flavors" and "beautiful richness."

In 2012, she revamped Spago's entire menu to whole grains. "I crossed my fingers on opening night, thinking, 'I'm gonna get hung on Sunset Boulevard,'" Ms. Yard said. Instead, "No one missed it." Now heading up Culinary Direction at iPic Entertainment, Ms. Yard is planning to open her own shop next year in Los Angeles, Helms Bakery, where whole grains will take center stage.

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Well: Putting Fun in Fatherhood

As every dad knows, fatherhood isn't all fun and games. But our recent Father's Day question, "Are you a fun dad?" did prompt a number of amusing stories. We heard about dads who moonwalk, sing ZZ Top songs, play "name that potato," dress up as the Grim Reaper on holidays and find various other ways to connect with their sons and daughters.

A common theme from dads was a desire to embarrass their kids.

One reader, Russell Abbott of Tulsa, Okla., told us how he spotted his daughter's school bus and started honking incessantly just to mortify her.

I think playfully and harmlessly embarrassing kids is one of the most profound joys of fatherhood.

Apparently, embarrassing your child on the school bus is an international tradition for dads. Another reader, S.T. from Amherst, Mass., recalled a childhood memory in India.

We once dropped my older sister off at the interstate bus that would take her back to college. We were in a small town in India with many parallel roads intersecting the main one, and once we waved her goodbye, my father would zoom around the block to the next intersection and wait for her bus to pass so we could all wave to her again. She was most embarrassed, but I found it hilarious.

PB of Washington also enjoys taunting his teenage son.

I have a pair of running shoes that squeak when I walk in them. This doesn't bother me, but it really annoys my 17-year-old son. Thus, I try to wear them all the time when he's around.

Sometimes the embarrassment turned into pride, wrote Becky Siefert, who learned her father was gay when she was a fifth grader.

This was in the early '90s. I was embarrassed at first to tell my friends. I was embarrassed to walk around with him and his boyfriend because I figured everyone knew and would make fun of me at school. At the same time, he was my favorite person in the world — he liked "Ren & Stimpy," Matt Groening and "Seinfeld" … and every year he brought us to the Christmas display at the bank downtown, with all of the animatronic stuffed animals in fake snow. This year I'm grateful that we can celebrate Wisconsin's recently won marriage equality, something I never envisioned would happen when I was a kid.

We also heard from a few dads who had rather risky definitions of "fun."

From rbpasker in New York City:

Yesterday I got on my 5-year-old daughter's bike and rode it around the living room. When she complained that I was going to break her bike, told her to stand on the training wheels and hold on to my shoulders. Then I put my 3-year-old son on the handlebars.

Scott from Los Angeles generated some outrage from fellow readers when he described his fun dad antics behind the wheel. (He claims he was only pretending to close his eyes.)

I would speed up over dips or speed bumps in my capable Jeep. I would then name the bump after a Disney character. … When a bit older, again in the car we would play the "how long can Daddy keep his eyes closed while driving" game.

Nancy McDermott recalls a father who was quite protective.

My father threatened to disembowel my boyfriends if they ever hurt me. Makes me smile just to think of it.

Music was also something shared by fun dads and their kids.

A Tennessee dad wrote to us from the Bonnaroo music festival, which he was attending with his teenage son and adult daughters.

I have hung with them at shows here that have ended at 3:00 a.m. or later for the past three nights, and I have been doing this for the past 10 years. I am not sure but I am almost positive that they would agree this is at least part of what makes our relationships fun. As it turns out, quality time really starts with quantity time.

Monroe of Santa Fe wrote that her husband made music a part of their children's lives.

He was convinced that our children needed to know the history of rock, especially punk, at a very early age. They would be pajamaed and ready for bed when his lessons would begin and late into the night he would play "one more song" to their delight. My concerns for the sleep requirements of small children were no match for the Ramones.

Claire, a reader from Washington, said her father made his own music.

He would play the piano for my siblings and I, laughing and cracking jokes as he tried to get us to sing along with Sondheim show tunes and ZZ Top songs. … He was the fun in everything.

Some readers described fun dads who donned costumes.

One reader from New York remembered how his father, a city sanitation worker, wore a circus clown costume every Halloween.

Face paint, hat with two brims, ginormous shoes, carried a big loud horn and surprised the elementary school class I happened to be in that year. At the time I wanted to hide under my desk, but looking back on it — I was so lucky.

Andrea S of New Haven recalled how her father selflessly helped her complete a history project.

He dressed up as Babe Didrikson for my fifth grade historical women project. He was my Girl Scout troop leader (the best ever), he taught me how to sew, and coached our soccer teams.

Sometimes the dads who are the most fun aren't fathers at all, wrote Desiree Roundtree of Brooklyn.

All throughout my childhood, my grandpa was there — sharing magic tricks with me, spending Saturday mornings in Roy Rogers and shopping for comic books on Chambers Street. He let me give him manicures and facials while we watched "Jeopardy."

Some dads had their own dances …

Even at 56, he insists that he can perfectly execute the moonwalk, all the while dragging the soles of his feet backwards in the most bewildering fashion. (Huiqun Ong of London)

And languages …

Daddy would say "boogie" and I would say "boo" and then in unison we would say "boogiebooboogiebooboogieboo." We did this every single day. (Leigh Sanders of North Carolina)

Victoria of Bainbridge Island, Wash., wrote about a fun dad of five children who took on a new role when her mother died.

Daddy was both father and mother after my mom died when I was 7. … He took us on summer car trips across the U.S., peppering us with history and geography questions. … He bought us books nonstop. He didn't hover over us, but let us follow our adventures independently, ready to listen when we came home.

Some fun dads really knew how to celebrate life's important moments, wrote Anna.

One day when I was a senior in high school I was unexpectedly called into the principal's office. I arrived to find my father sitting there with a stony look on his face. I was sure I was in big trouble (though for what I had no idea). They asked me to sit down and said they needed to discuss a very serious issue with me. All of a sudden my dad broke into a huge smile and pulled out a large envelope from my first-choice college with "congratulations" scrawled across the front.

And we are giving the final word to Honeybee from Dallas, who wrote about her husband and reminded us that many fun dads aren't always taking part in the fun.

He's also the dad in the sports stands in 20-degree weather. He's the dad who drives 45 minutes to watch his kid warm the bench. He's the dad who wakes up at 5:30 a.m. and sings while he makes everyone's lunches. He's the dad who drops everything to be wherever, whenever.

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Well: Who Can Speak for the Patient?

Our patient was never going to wake up. He had an unrecoverable brain injury. The prognosis had become clear over time. As the patient's attending physician in the intensive care unit, I arranged a meeting with his sister, the only visitor we'd seen for days, and explained. She was resolute. "He'll wake up," she said. "He's a fighter. Do everything you can to keep him alive."

The next day I told the social worker what the patient's sister had said. "What about the wife?" the social worker asked.

That was the first I'd heard of a wife. A spouse is the official next of kin. No decision should ever be made without the spouse. But I hadn't known she existed. I discovered that she visited the patient after her work shift, usually at 8 p.m. By that hour, our team was gone. The doctors on night duty were on for emergencies, not conversation. And so she was invisible to us.

How could we have missed this most basic and vital piece of information? It's easier than you might think. The sister didn't get along with the wife and apparently wasn't moved to tell us of her existence. The social worker had been out sick, and his replacement assumed that we knew. And we had a concerned sibling at the bedside who fulfilled our mental checkbox for who makes an acceptable surrogate decision-maker.

We hastily called a meeting with the wife. She arranged to leave work early, and she met us in our conference room. Feeling a combination of shame and relief at the averted disaster, we apologized for not being in touch. We didn't mention that we hadn't even known about her.

She was shocked by our grim prognosis. Angry. But then, with resolve, she stepped into her role as decision-maker. He would never want to live this way, she said. His father had suffered a devastating stroke years ago and her husband had remarked several times, "Don't keep me alive if I'm like that." She wanted to bring him home immediately with hospice support. Another day in the I.C.U. would have gone completely against his wishes.

As Dr. Atul Gawande described so beautifully in his book "The Checklist Manifesto," checklists improve medical care. I use a variety of them on my daily I.C.U. rounds. One assesses each organ in the body, moving systematically from nose to toes. Another evaluates settings on the breathing machine.

By systematizing my approach, I'm confident that I'll always remember the many different steps involved in treating a patient with cardiac arrest. I'll be more prepared to start tube feedings or begin to wean the patient off the ventilator when the time is right.

But despite my checks and balances, I had almost allowed the wrong person to make crucial decisions for this vulnerable patient. And I had nearly excluded a wife from her rightful place on her husband's team. Missing this crucial piece of information would have caused far more suffering and damage than any miscalibration of a ventilator.

I realized then that I needed another checklist, one that puts patients, and not just their organs, in the center. It would account for the human needs that we weren't always taught to prioritize, ones that didn't seem fatal if overlooked — clearly identifying the patient's next of kin, communicating with the family and identifying the goals of care, asking about symptoms like pain, delirium, shortness of breath. My critical oversight would not have happened had I sought out the social worker on the first day to confirm the true next of kin. He thought I knew. I thought I knew. We both were wrong.

Now, years after that incident, I use my patient-centered checklist on every critically ill patient I see in intensive care. After I go through the cardiovascular system, the pulmonary system, the kidneys and the ventilator settings, I turn to the presenting resident and say, "Now let's do the patient-centered checklist."

I have never since misidentified a surrogate decision-maker. And I know that I am doing a better job at managing my patients' symptoms. A checklist that addresses the human needs of a vulnerable patient is as crucial as those that deal with his organ function. After all, care is about the whole patient, not just his parts.

Jessica Nutik Zitter is an attending physician at Alameda County Medical Center in Oakland, Calif. She is board-certified in both critical-care and palliative-care medicine.

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Well: Putting Fun in Fatherhood

As every dad knows, fatherhood isn't all fun and games. But our recent Father's Day question, "Are you a fun dad?" did prompt a number of amusing stories. We heard about dads who moonwalk, sing ZZ Top songs, play "name that potato," dress up as the Grim Reaper on holidays and find various other ways to connect with their sons and daughters.

A common theme from dads was a desire to embarrass their kids.

One reader, Russell Abbott of Tulsa, Okla., told us how he spotted his daughter's school bus and started honking incessantly just to mortify her.

I think playfully and harmlessly embarrassing kids is one of the most profound joys of fatherhood.

Apparently, embarrassing your child on the school bus is an international tradition for dads. Another reader, S.T. from Amherst, Mass., recalled a childhood memory in India.

We once dropped my older sister off at the interstate bus that would take her back to college. We were in a small town in India with many parallel roads intersecting the main one, and once we waved her goodbye, my father would zoom around the block to the next intersection and wait for her bus to pass so we could all wave to her again. She was most embarrassed, but I found it hilarious.

PB of Washington also enjoys taunting his teenage son.

I have a pair of running shoes that squeak when I walk in them. This doesn't bother me, but it really annoys my 17-year-old son. Thus, I try to wear them all the time when he's around.

Sometimes the embarrassment turned into pride, wrote Becky Siefert, who learned her father was gay when she was a fifth grader.

This was in the early '90s. I was embarrassed at first to tell my friends. I was embarrassed to walk around with him and his boyfriend because I figured everyone knew and would make fun of me at school. At the same time, he was my favorite person in the world — he liked "Ren & Stimpy," Matt Groening and "Seinfeld" … and every year he brought us to the Christmas display at the bank downtown, with all of the animatronic stuffed animals in fake snow. This year I'm grateful that we can celebrate Wisconsin's recently won marriage equality, something I never envisioned would happen when I was a kid.

We also heard from a few dads who had rather risky definitions of "fun."

From rbpasker in New York City:

Yesterday I got on my 5-year-old daughter's bike and rode it around the living room. When she complained that I was going to break her bike, told her to stand on the training wheels and hold on to my shoulders. Then I put my 3-year-old son on the handlebars.

Scott from Los Angeles generated some outrage from fellow readers when he described his fun dad antics behind the wheel. (He claims he was only pretending to close his eyes.)

I would speed up over dips or speed bumps in my capable Jeep. I would then name the bump after a Disney character. … When a bit older, again in the car we would play the "how long can Daddy keep his eyes closed while driving" game.

Nancy McDermott recalls a father who was quite protective.

My father threatened to disembowel my boyfriends if they ever hurt me. Makes me smile just to think of it.

Music was also something shared by fun dads and their kids.

A Tennessee dad wrote to us from the Bonnaroo music festival, which he was attending with his teenage son and adult daughters.

I have hung with them at shows here that have ended at 3:00 a.m. or later for the past three nights, and I have been doing this for the past 10 years. I am not sure but I am almost positive that they would agree this is at least part of what makes our relationships fun. As it turns out, quality time really starts with quantity time.

Monroe of Santa Fe wrote that her husband made music a part of their children's lives.

He was convinced that our children needed to know the history of rock, especially punk, at a very early age. They would be pajamaed and ready for bed when his lessons would begin and late into the night he would play "one more song" to their delight. My concerns for the sleep requirements of small children were no match for the Ramones.

Claire, a reader from Washington, said her father made his own music.

He would play the piano for my siblings and I, laughing and cracking jokes as he tried to get us to sing along with Sondheim show tunes and ZZ Top songs. … He was the fun in everything.

Some readers described fun dads who donned costumes.

One reader from New York remembered how his father, a city sanitation worker, wore a circus clown costume every Halloween.

Face paint, hat with two brims, ginormous shoes, carried a big loud horn and surprised the elementary school class I happened to be in that year. At the time I wanted to hide under my desk, but looking back on it — I was so lucky.

Andrea S of New Haven recalled how her father selflessly helped her complete a history project.

He dressed up as Babe Didrikson for my fifth grade historical women project. He was my Girl Scout troop leader (the best ever), he taught me how to sew, and coached our soccer teams.

Sometimes the dads who are the most fun aren't fathers at all, wrote Desiree Roundtree of Brooklyn.

All throughout my childhood, my grandpa was there — sharing magic tricks with me, spending Saturday mornings in Roy Rogers and shopping for comic books on Chambers Street. He let me give him manicures and facials while we watched "Jeopardy."

Some dads had their own dances …

Even at 56, he insists that he can perfectly execute the moonwalk, all the while dragging the soles of his feet backwards in the most bewildering fashion. (Huiqun Ong of London)

And languages …

Daddy would say "boogie" and I would say "boo" and then in unison we would say "boogiebooboogiebooboogieboo." We did this every single day. (Leigh Sanders of North Carolina)

Victoria of Bainbridge Island, Wash., wrote about a fun dad of five children who took on a new role when her mother died.

Daddy was both father and mother after my mom died when I was 7. … He took us on summer car trips across the U.S., peppering us with history and geography questions. … He bought us books nonstop. He didn't hover over us, but let us follow our adventures independently, ready to listen when we came home.

Some fun dads really knew how to celebrate life's important moments, wrote Anna.

One day when I was a senior in high school I was unexpectedly called into the principal's office. I arrived to find my father sitting there with a stony look on his face. I was sure I was in big trouble (though for what I had no idea). They asked me to sit down and said they needed to discuss a very serious issue with me. All of a sudden my dad broke into a huge smile and pulled out a large envelope from my first-choice college with "congratulations" scrawled across the front.

And we are giving the final word to Honeybee from Dallas, who wrote about her husband and reminded us that many fun dads aren't always taking part in the fun.

He's also the dad in the sports stands in 20-degree weather. He's the dad who drives 45 minutes to watch his kid warm the bench. He's the dad who wakes up at 5:30 a.m. and sings while he makes everyone's lunches. He's the dad who drops everything to be wherever, whenever.

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The Consumer: Dense Breasts May Obscure Mammogram Results

The Consumer

Advice on money and health.

The doctors were pleased to inform me, the letter said, that the results of the mammogram were normal. Early detection of cancer is important, a report was sent to my referring physician, I should report any lumps, see my health provider, have a physical.

A sentence in the fourth paragraph grabbed me by the throat. "Your breast tissue is dense."

In journalism, we call this "burying the lead" — tucking the really significant information far down in the story. I knew that having dense breast tissue makes it hard to read mammograms and may increase the risk of breast cancer. I just never knew I had dense breasts.

I've had at least half a dozen mammograms, and each one has come back normal. Now I discover these images have been obscured. Dense tissue shows up white on the scans. So do tumors.

"It's like looking through a window with snow on it, searching for a drop of milk," said Dr. Carolyn D. Runowicz, a professor of obstetrics and gynecology at the Herbert Wertheim College of Medicine at Florida International University in Miami.

No wonder mammograms miss half of all breast cancers in women with dense tissue.

About 40 percent of women who have mammograms have dense breast tissue, which means they have more connective and fibrous tissue than usual. Until recently, that information was rarely relayed to women, though it was routinely noted in the radiologist's medical report to the doctor (as "dense parenchyma" that "lowers the sensitivity of mammography").

Now women from Hawaii to California, New Jersey to New York, are receiving letters about their breast density because of state legislation championed by Nancy Cappello, a 61-year-old Connecticut woman. Her breast cancer had spread to her lymph nodes by the time it was diagnosed 10 years ago, even though she had had normal mammograms every year.

Her tumor was an inch in size when it finally became palpable, Ms. Cappello said in an interview. Her doctor estimated it had been growing for four or five years, even as Ms. Cappello went faithfully for mammograms and received assurances that she was cancer-free. No one warned her that dense breast tissue could obscure the radiologist's view.

Unfortunately, there's still no clear medical guidance on how women should proceed once they've been told they have dense breasts. Some experts even question whether having dense breasts significantly increases breast cancer risk.

The letters mandated by New York law suggest women "use this information to talk to your doctor about your own risks for breast cancer" and ask their doctor "if more screening tests might be useful." The Connecticut law goes further; women with dense breasts are told to consider an ultrasound or magnetic resonance imaging test.

But the American Congress of Obstetricians and Gynecologists doesn't recommend using additional screening tests just because a woman has dense breasts. The American College of Radiology acknowledges that other types of scans may detect tumors missed on mammograms, but notes that there are no good data showing that women who add an ultrasound or an M.R.I. to mammography live longer.

I did what the New York letter suggested: I called my doctor. He emailed back right away, saying he was not concerned. The density of my breasts was not news to him.

I called my health plan to see if it would cover an ultrasound. I was pleasantly surprised: It would, though not at the same rate as a mammogram, which is considered preventive care that most health plans must cover in full.

Then I called the radiology center to make an appointment, and learned I could drive over and pick up a CD with my mammography images on it at no charge.

I picked up the disc and popped it in my computer. As soon as the images appeared on screen, I could see what the doctors were talking about: Big white clouds were floating in the middle of each dark half-moon image.

"One thing women shouldn't do is start to worry that there is something wrong" if she has dense breast tissue, said Dr. Carol Lee, a diagnostic radiologist at Memorial Sloan Kettering.

Although the benefits of routine mammography have been debated for years, many women continue to choose it, and experts say they need not stop just because they have dense breasts.

"Mammograms pick up cancers in women with dense breasts every day," Dr. Lee said.

For dense breasts, however, a digital mammogram is preferable to film, and a three-dimensional mammogram is even better, Dr. Runowicz said.

But there's a definite downside, other experts note: Additional scans will pick up other suspicious spots that may require intervention, such as biopsy to rule out cancer, even though most of them will turn out to be harmless. Learn about your risk factors for breast cancer at cancer.gov (breast density is not listed here), and use the online calculator to gauge your risk. A woman's risk increases with age.

Talk to a trusted physician and consider adding an ultrasound or an M.R.I. scan to your screening if you have dense breasts. An ultrasound is cheaper and less invasive, said Dr. Regina Hooley, an assistant professor of diagnostic radiology at Yale.

Mammograms pick up two to seven cancers per 1,000 women screened, and subsequent ultrasounds pick up another three to four small invasive cancers, Dr. Hooley said. Even though there may not be scientific evidence proving a survival benefit from the additional scans, she said, "these are exactly the cancers we want screening to detect."

A version of this article appears in print on 06/17/2014, on page D6 of the NewYork edition with the headline: Obscuring Mammogram Results.

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Well: Exercise and the ‘Good’ Bugs in Our Gut

Phys Ed

Gretchen Reynolds on the science of fitness.

Being physically active may encourage beneficial germs to thrive in your gut, while inactivity could do the reverse, according to an innovative new study. The findings suggest that, in addition to its other health benefits, frequent exercise may influence our weight and overall health by altering the kinds of organisms that live inside of us.

In recent years, there has been an explosion of interest in the role that gut microbes play in whole-body health. A multitude of studies have shown that people with large and diverse germ populations in their digestive tracts tend to be less prone to obesity, immune problems and other health disorders than people with low microbial diversity, and that certain germs, in particular, may contribute to improved metabolic and immune health.

But little science had examined the interplay between physical activity and gut bugs in people. So, for a study published this month in Gut, researchers at University College Cork, part of the National University of Ireland, and other institutions, set out to learn more by turning to a group of people who exercise a lot: the national rugby team of Ireland.

"We chose professional athletes as a study group, because we wanted to be sure not to miss any effect of exercise and needed a group who were safely performing at the extremes of human endeavor," said Dr. Fergus Shanahan, an author of the study who is a professor of gastroenterology and director of the Alimentary Pharmabiotic Center at University College Cork.

Forty of the players agreed to participate. At the time of the study, the men's national team was in preseason training and the players were exercising strenuously for several hours every day.

For the sake of comparison, the researchers also recruited two groups of healthy adult men, none of them athletes. One group consisted of men with a normal body mass index. Most of the men in this group exercised occasionally but lightly.

The men in the final group were generally sedentary and had a body mass index that would qualify them as overweight or obese. This group was included, Dr. Shanahan said, because the rugby players, although supremely fit, were physically huge, with body masses well above normal. The researchers wanted to compare their gut microbes to those of men whose weight was similar, if not their musculature.

The scientists drew blood and collected stool samples from all of the men, rugby players and non-athletes alike. The volunteers also completed lengthy questionnaires about their exercise routines and diet, and spoke with a nutritionist about their typical daily food intake.

Then the scientists analyzed the men's blood for markers of muscle damage and inflammation, which would indicate how much each volunteer had — or had not — been moving and exercising recently. The scientists also used sophisticated genetic sequencing techniques to identify and enumerate the particular microbes living in each man's gut.

As it turned out, the internal world of the athletes was quite different from that of the men in either of the control groups. The rugby players had considerably more diversity in the make-up of their gut microbiomes, meaning that their intestinal tracts hosted a greater variety of germs than did those of the other men, especially the men in the group with the highest B.M.I.

The rugby players' guts also harbored larger numbers of a particular bacterium, uneuphoniously named Akkermansiaceae, that has been linked in past studies with a decreased risk for obesity and systemic inflammation.

Interestingly, the rugby players' blood showed low levels of markers for inflammation, even though the men were exercising intensely. Their muscles were being pummeled but, in physiological terms, recovering well.

The men in both of the control groups, on the other hand, especially those with the highest B.M.I.s and who rarely exercised, had relatively low numbers of Akkermansiaceae in their guts and elevated markers for inflammation in their bloodstreams.

These findings "draw attention to the possibility that exercise may have a beneficial effect on the microbiota," Dr. Shanahan said, in ways that improve bodily health.

However, the results are still preliminary, he said. This study was small and, because of its methodology, the researchers can't determine how exercise alters gut germs or tease out the effects of intense exercise from those of diet. The rugby players consumed far more calories than did the other men, with a much larger percentage of their diet consisting of protein. Such nutritional differences can affect which microbes thrive in the gut. The athletes also were training at a level that few of us would be able or willing to emulate.

Dr. Shanahan and his colleagues have begun a follow-up study examining whether and how moderate exercise changes the gut environment in both men and women. The results should be available later this year.

But even in advance of those findings, he said, it seems likely that any amount of exercise should make your gut more welcoming to the bacteria that you want residing there.

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DealBook: Supreme Court Rejects Argentina’s Debt Appeal

Updated, 7:57 p.m. | The Supreme Court handed Argentina two major defeats on Monday in cases brought by bondholders who refused to accept reduced payments after the country's 2001 default.

The developments are likely to add to the turmoil in Argentina's already unsettled bond market.

In a one-line order issued at 9:30 a.m., the court refused to hear Argentina's appeal of a lower court's decision requiring it to pay holdouts who did not participate in debt restructurings in 2005 and 2010. About 45 minutes later, the court issued a 7-to-1 decision allowing the bondholders to issue subpoenas to banks in an effort to trace Argentina's assets abroad.

The holdouts include NML Capital, an affiliate of Elliott Management, the hedge fund founded by Paul Singer. It brought 11 lawsuits in federal court in Manhattan to collect the billions it said it was owed, winning each one.

The case the court declined to hear, Argentina v. NML Capital, No. 13-990, concerned the larger question of whether those rulings were correct.

The United States Court of Appeals for the Second Circuit, in New York, ruled last August that Argentina had violated a contractual promise to treat all bondholders equally.

In the Supreme Court, Argentina asked the justices to refer the case to New York's highest court for a definitive resolution of the proper interpretation of that contractual language, as it is a question of state law.

Separately, Argentina asked the justices to decide whether the lower court had misinterpreted a federal law on sovereign immunity.

The bondholders had urged the justices not to hear the case, in part because they said Argentina had vowed not to comply with a ruling against it in the case, "This court does not grant review to render decisions that the parties are free to ignore," their brief said.

Argentina replied that it would try to comply but that another default would be a possibility given the overall sums at stake for all holdout bondholders.

"Since Argentina lacks the financial resources to pay the holdouts in full (what would amount to $15 billion) while also servicing its restructured debt to 92 percent of bondholders," the country's lawyers wrote, "Argentina will have to face, objectively, a serious and imminent risk of default."

The case in which the justices actually ruled, Argentina v. NML Capital, No 12-842, was by comparison less significant. It concerned whether federal courts in the United States may issue subpoenas to banks to help creditors who have won judgments against Argentina find its assets around the world.

Justice Antonin Scalia, writing for the majority, said the subpoenas were proper and did not offend the protections Congress granted to Argentina and other countries in the Foreign Sovereign Immunities Act.

For starters, he said, Argentina had waived its immunity from the jurisdiction of courts in the United States in the contracts it signed when it sold the bonds.

The law also makes some kinds of property owned by a foreign country in the United States ineligible to be seized to pay a court judgment.

"That is the last of the act's immunity-granting sections," Justice Scalia wrote. "There is no third provision forbidding or limiting discovery," or court-ordered factual investigation, "in aid of execution of a foreign-sovereign judgment debtor's assets."

Argentina argued that subpoenas meant to uncover assets held abroad were improper if those assets could not be seized under the relevant foreign law. Justice Scalia conceded the point. "But the reason for these subpoenas," he said, "is that NML does not yet know what property Argentina has and where it is, let alone whether it is executable under the relevant jurisdiction's law."

In a dissent, Justice Ruth Bader Ginsburg said such subpoenas were improper unless the bondholders could first show that there was something to be seized.

"A court in the United States," she wrote, "has no warrant to indulge the assumption that, outside our country, the sky may be the limit for attaching a foreign sovereign's property in order to execute a U.S. judgment against the foreign sovereign."

Justice Scalia responded that there was no reason to require creditors to prove up front that they were entitled to seize property turned up through a subpoena.

The Obama administration had urged the justices to rule for Argentina in the subpoena case. "The United States would be gravely concerned about an order of a trial court in a foreign country, entered at the behest of a private person, seeking to establish a clearinghouse in that country of all the United States' assets," Edwin S. Kneedler, a deputy solicitor general, said at the argument of the case in April.

In its brief, the administration said a ruling for the bondholders would harm international relations and could provoke "reciprocal adverse treatment of the United States in foreign courts.

Justice Scalia said those concerns should be addressed to Congress, which enacted the Foreign Sovereign Immunities Act in 1976 in an effort to address what he called the bedlam of "the old executive-driven, factor-intensive, loosely common-law-based immunity regime."

The administration's apprehensions, Justice Scalia wrote, "are better directed to that branch of government with authority to amend the act — which, as it happens, is the same branch that forced our retirement from the immunity-by-factor-balancing business nearly 40 years ago."

Justice Sotomayor recused herself in both cases. As is the court's custom, she offered no explanation for the move.

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Bits Blog: Looking at Link Between Violent Video Games and Lack of Empathy

The sound of machine guns rattled through the building as explosions shook the walls.

No, I wasn't at a weapons convention or shooting range or in an impromptu war. I was at the annual Electronic Entertainment Expo here, also known as E3.

With shootings happening with alarming frequency in schools, malls, movie theaters and streets across America, people are again asking if video games contribute to gun violence. And do so-called first-person shooter games have a particular impact on people — usually young men — who suffer from the types of mental illnesses that make them more prone to violent behavior?

In the halls of E3, where toy guns are everywhere and fantasy mayhem is encouraged, such questions are unavoidable.

A first-person shooter is a game in which you, the player, carry a weapon into some sort of video game conflict. It can be a simulation of a battlefield, like the beaches of Normandy on D-Day. It can be a simulation of violent city streets. And sometimes you get to be the villain, targeting police or the unfortunate workers in a bank that is about to be robbed.

The mass shootings in recent years in Newtown, Conn. and Aurora, Colo., were both committed by young men who had regularly played first-person shooters. But of course, tens of millions of young men play these games and never commit acts of violence.

Studies on the impact of video game violence by research institutes, universities and psychologists have been inconclusive. For seemingly every report that says video games lead to real-world shootings, there have been others rebutting those claims.

But new psychological studies are finding that as violent games become more realistic, constantly playing them can lead to a desensitization toward real violence.

"The research is getting clearer that over the long term, people with more exposure to violent video games have demonstrated things like lower empathy to violence," said Dr. Jeanne Brockmyer, a clinical child psychologist and professor emeritus at the University of Toledo. "Initially, people are horrified by things they see, but we can't maintain that level of arousal. Everyone gets desensitized to things."

Ms. Brockmyer has written a paper, set to be published later this summer, that will show how areas of the brain responsible for empathy become muted by violent images when teens are exposed to them over long periods of time.

The paper comes on the heels of a study from Canada's Brock University, published in February, which found that when children play violent video games for significant lengths of time, they are not as morally mature as other children their age. Researchers believe that the constant flood of violent images takes away a child's ability to feel empathy for people who have been through similar situations in real life.

But while the study found evidence of slowed moral growth in teens who play games, it was unable to determine if these effects happen to people who play first-person shooter games for two hours a day, once or a week, or any other specific amount of time.

At video game conferences, asking the game-violence questions some psychologists are trying to answer is considered unacceptable. When I approached attendees and developers at E3 and asked if there was any evidence tying video game violence to real violence, or even if we should be talking about such a link, most people simply scoffed.

"Ha — umm, no," one young man said snidely, rolling his eyes at me before returning to the first-person shooter he was playing.

People noted that mass shootings happened before there were video games. And guns and violence have been a part of video games since the mid-1970s, when Gun Fight, an early, very pixelated, two-player shooter was released in arcades.

But it is hard to argue that there isn't some level of desensitization after a day spent at E3. At the main entrance of the Los Angeles Convention Center, where the conference was held, people lined up to play the new game Payday 2. In this game, you team up with friends to rob a bank. Killing police is a big part of succeeding.

As I watched people picking off cops and security guards with sniper rifles and handguns, news broke that a real-life shooting in Las Vegas had resulted in the death of two police officers and three civilians (including the two shooters).

I asked Almir Listo, manager of investor relations at Starbreeze Studios, which makes Payday 2, if he felt in any way uncomfortable about making a game that promotes shooting police.

"If you look hard enough, you can find an excuse for everything; I don't think there is a correlation," he said. "In Sweden, where I am from, you don't see that stuff happen, and we play the same video games there."

After the Sandy Hook shootings in Connecticut, when it became clear that Adam Lanza was a fan of first-person shooters, including the popular military game Call of Duty, President Obama said Congress should find out once and for all if there was a connection between games and gun violence.

"Congress should fund research on the effects violent video games have on young minds," he said. "We don't benefit from ignorance. We don't benefit from not knowing the science." Yet more than a year later, we don't conclusively know if there is a link.

And gun violence in the real world — and the gaming world — goes on.

Email: bilton@nytimes.com

A version of this article appears in print on 06/16/2014, on page B6 of the NewYork edition with the headline: Linking Violent Games To Erosion of Empathy .

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Well: Steering Clear of Poison Ivy

Personal Health

Jane Brody on health and aging.

I was once among those who claim, "I could walk through a field of poison ivy and not get it." One day I learned otherwise: On a hike, I needed to relieve myself in the great outdoors and ended up with an impossibly itchy, blistering rash on a most delicate body part.

Too late I learned that you can develop an allergic reaction to poison ivy after previously uneventful exposures, which induce a sensitivity to the plant's oily sap, urushiol. Once sensitized, your skin is likely to react to every subsequent exposure. Even people repeatedly exposed who appear to be immune may react to high concentrations of the toxin.

I also learned not to rely on the popular warning, "Leaves of three, let them be," to alert me to the presence of Toxicodendron radicans, as the poison ivy plant is aptly called by botanists. It is not just the leaves that can provoke a reaction; the stems, roots, flowers and berries all contain urushiol.

Touching or brushing against any of these plant parts, even if they are dead, can cause a reaction. The sap is hardy and can cause a rash in the dead of winter, or even a year after contaminating clothing or shoes that are not thoroughly cleaned.

Urushiol shows up elsewhere, including in the skin of mangoes (and the leaves and bark of the mango tree), as I discovered when I ate a mango still in the rind and ended up with a blistering rash on my mouth. Cashew shells also have the toxin, which is why cashews are sold shelled and processed (either roasted or in the case of "raw" cashews, steamed) at a temperature high enough to destroy urushiol. Poison ivy is not the only problem plant one might encounter while hiking, camping or simply strolling in the countryside. T. radicans has two relatives, poison oak and poison sumac, that don't always form the classic clusters but are equally toxic troublemakers.

Myths and misconceptions abound about these three plants and the reactions they can cause. Knowing the facts can help to spare you and your family considerable distress.

First, learn to recognize the plants in their various growth patterns. While poison ivy is most often encountered as a small ground plant, it also grows as a shrub and vine. The vines, which turn bright red in fall, were once used to adorn buildings in England.

Poison oak, which has compound leaves made up of three (or sometimes five) leaflets, usually grows as a shrub, but will form a vine in the Western states.

Poison sumac, which grows as a tall shrub or small tree, produces leaves with rows of paired leaflets and a single leaflet at the end. It likes a wet habitat, growing in peat bogs in the Northeast and Midwest and swamps in the Southeast.

Urushiol can penetrate cloth. Although long sleeves, pants and gloves can reduce the risk of exposure, they cannot guarantee protection. Even rubber gloves can be breached. If you must handle the plants or are likely to contact poison ivy when gardening, wear vinyl gloves.

You don't have to touch the plant directly to react to urushiol. Gardening tools, sporting equipment, even a pet that has been in a patch of poison ivy — all can cause a reaction. My brother, who has been sensitive to urushiol since childhood, once developed the rash on his arm after retrieving a baseball that had rolled through poison ivy.

Before possible exposure, use an over-the-counter skin-care product containing bentoquatam (IvyBlock) to prevent or reduce absorption of urushiol. The combination of this barrier product and protective clothing is your best defense against an inadvertent encounter.

But there is no scientific evidence that jewelweed, feverfew, plantain or other herbal remedies prevent or cure a urushiol-induced rash.

Nor do you become immune to urushiol through repeated exposures to small amounts. Quite the opposite. There is no way to desensitize a person to urushiol as there is with pollen and peanut allergies. Eating mangoes or cashews will not work.

Contrary to popular belief, a poison ivy rash is not contagious. It cannot be spread by oozing blisters, or by scratching or touching the rash. Only direct contact with urushiol causes a reaction. (Scratching can result in an infection, however.)

The rash can appear on different parts of the body at various times. This may happen because the parts were exposed at different times, or because areas with thicker skin are less easily penetrated by the oil. The delicate skin of the genital and perianal areas, for example, is more easily breached than tougher skin on the hands.

Repeated tilling or mowing can eventually kill poison ivy plants, as can repeated applications of an herbicide like Roundup. The latter should be applied with serious caution and only on a warm, sunny day with little or no wind when the plants are actively growing.

If you are highly allergic, or wary of applying herbicides, clearing your property of the plants may be best left to a professional. While goats are said to have a hearty appetite for poison ivy plants, they may eat everything else in the yard, too.

Never try to burn a poison plant. Burning releases the toxin, which may land on skin or, worse, be inhaled and cause a serious internal reaction.

Should you contact a urushiol-containing plant, the American Academy of Dermatology recommends washing your skin immediately. Lukewarm, soapy water is best, but even plain water can limit exposure to the sap. Take care in removing contaminated clothing, and wash it separately as soon as possible.

You can relieve a rash by applying cool compresses with an astringent like Burow's solution, soaking the affected area in colloidal oatmeal, or using calamine lotion; all are sold over the counter. Do not apply products containing a topical antihistamine, like Benadryl, which can cause a sensitivity reaction that makes matters worse.

Severe reactions may require medically prescribed treatment with an oral corticosteroid like prednisone.

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Well: Threat Grows From Liver Illness Tied to Obesity

Despite major gains in fighting hepatitis C and other chronic liver conditions, public health officials are now faced with a growing epidemic of liver disease that is tightly linked to the obesity crisis.

In the past two decades, the prevalence of the disease, known as nonalcoholic fatty liver, has more than doubled in teenagers and adolescents, and climbed at a similar rate in adults. Studies based on federal surveys and diagnostic testing have found that it occurs in about 10 percent of children and at least 20 percent of adults in the United States, eclipsing the rate of any other chronic liver condition.

There are no drugs approved to treat the disease, and it is quickly becoming a leading cause of liver transplants around the country.

Doctors say that the disease, which causes the liver to swell with fat, is particularly striking because it is nearly identical to the liver damage that is seen in heavy drinkers. But in this case the damage is done not by alcohol, but by poor diet and excess weight.

"The equivalent of this is foie gras," said Dr. Joel E. Lavine, the chief of pediatric gastroenterology, hepatology and nutrition at NewYork-Presbyterian Morgan Stanley Children's Hospital. "You have to force feed ducks to get fatty liver, but people seem to be able to develop it on their own."

Gavin Owenby, a 13-year-old in Hiawassee, Ga., learned he had the disease two years ago after developing crippling abdominal pain. "It's like you're being stabbed in your stomach with a knife," he said.

An ultrasound revealed that Gavin's liver was enlarged and filled with fat. "His doctor said it was one of the worst cases she had seen," said Gavin's mother, Michele Owenby. "We had no idea anything was going on other than his stomach pain."

With no drugs to offer him, Gavin's doctor warned that the only way to reverse his fatty liver was to exercise and change his diet. "They told me to stay away from sugar and eat more fruits and vegetables," Gavin said. "But it's hard."

Most patients have a less severe form of the disease, with no obvious symptoms. But having nonalcoholic fatty liver is a strong risk factor for developing heart disease and Type 2 diabetes. And in 10 to 20 percent of patients, the fat that infiltrates the liver leads to inflammation and scarring that can slowly shut down the organ, setting the stage for cirrhosis, liver cancer and ultimately liver failure. Studies show that 2 to 3 percent of American adults, or at least five million people, have this more progressive form of the disease, known as nonalcoholic steatohepatitis, or NASH.

"This is the face of liver disease in the United States," said Dr. Shahid M. Malik of the Center for Liver Diseases at the University of Pittsburgh Medical Center. "If you're at any liver transplant center in the country, there's no doubt that this is a big problem."

Three decades ago, NASH was so rare that there was no medical name for it. Many doctors assumed that fat that accumulated in the liver was fairly harmless. But today, NASH is a growing strain on liver clinics and the fastest rising cause of liver transplants.

A study by the Mayo Clinic found that the percentage of all transplants performed nationwide because of NASH had reached 10 percent by 2009, up from 1 percent in 2001, even as the rates for hepatitis C, alcoholic liver disease and other conditions remained stable. NASH is projected to surpass hepatitis C as the leading cause of liver transplants by 2020, in part because of new drugs that can effectively cure hepatitis C, but also because of the rapid growth of fatty liver disease.

Fatty liver strikes people of all races and ethnicities. But it is particularly widespread among Hispanics because they frequently carry a variant of a gene, known as PNPLA3, that drives the liver to aggressively produce and store triglycerides, a type of fat. The variant is at least twice as common in Hispanic Americans compared with African-Americans and non-Hispanic whites.

In Los Angeles, liver disease is diagnosed in one out of two obese Hispanic children, and it is a leading cause of premature death in Hispanic adults.

At the University of California, Los Angeles, home to one of the largest liver transplant centers in the world, nearly 25 percent of all liver transplants are performed because of NASH, up from 3 percent in 2002. If the prevalence of NASH continues to increase at its current rate and effective treatments are not found, about 25 million Americans will have the disease by 2025, and five million will need new livers, said Dr. Ronald W. Busuttil, chief of the division of liver transplantation at the David Geffen School of Medicine at U.C.L.A.

"I'm really afraid that the explosion of this condition is going to overrun the resources available to the transplant centers around the country," Dr. Busuttil said. "In the United States right now, we do about six to seven thousand liver transplants a year. Can you imagine if we have millions of people on the list? It's unfathomable."

With NASH rates rising rapidly, drug companies are racing to produce the first drug to treat it.

In January, Intercept Pharmaceuticals, a small biotechnology firm, announced that its clinical trial of obeticholic acid showed promise in treating NASH, causing its stock price to soar. The National Institutes of Health, which sponsored the trial, are expected to present results from it later this year.

Another company, Galectin Therapeutics, was granted a special fast-track designation by the Food and Drug Administration to speed its development of GR-MD-02, a drug that may help reverse some of the more advanced symptoms of the disease.

But it will be several years before any drugs for NASH reach the market, said Dr. Kathleen Corey, the director of the Massachusetts General Hospital Fatty Liver Clinic, which was founded four years ago.

"We see patients with undiagnosed cirrhosis in their teens and 20s," she said. "That's something we never would have thought was possible in the past."

Yubelkis Matias, 19, an honors student at Bronx Community College, was told she has NASH several years ago. She is reminded of the trouble brewing in her liver by the sharp abdominal pains that come and go. Like Gavin, she has been told by her doctors that diet and exercise may be her only shot at reversing the disease. But at 5-foot-5 and 200 pounds, she finds every day a struggle.

"I'm on a roller coaster," she said. "I eat healthy, then not healthy — pizza, McDonalds, the usual. My doctor told me I have to quit all of that. But it's cheap, and it's always there."

Like many hepatologists, Dr. Corey helps her patients manage their high cholesterol, blood sugar and other metabolic problems that coincide with fatty liver. She counsels them to avoid sugar and alcohol, and she offers them high dosages of vitamin E, an antioxidant that studies show can relieve some symptoms of the disease. And she urges them to lose weight, the only proven way to reduce fat in the liver.

In adults, the rising prevalence of fatty liver has mirrored the increase in obesity. But in children, fatty liver is increasing at a rate "faster and above" the increase in childhood obesity, said Dr. Miriam Vos, the lead author of a study in The Journal of Pediatrics last year that estimated that one in 10 adolescents have the disease.

"That suggests that there's something else going on," said Dr. Vos, a pediatric hepatologist at Children's Healthcare of Atlanta. "We don't know, but some of the research has shown there may be early exposures in pregnancy or diet exposures that could be helping to drive this."

In studies, Dr. Vos and other researchers have found that when children with fatty liver consume sugar, they produce far more triglycerides than children without the disease, and this may be exacerbating fat accumulation in the liver. Cutting out sugary drinks often leads to "a big improvement" in her patients, Dr. Vos said. "But I don't know if that improvement is specifically because of the sugar or because they cut back on a lot of calories" and have lost weight.

Some researchers believe that insulin resistance, a hallmark of Type 2 diabetes, may be an underlying cause of fatty liver. But not everyone who has the disease is insulin resistant. Nor is every fatty liver patient overweight. People of Asian descent, for example, develop the disease at a lower body mass index than others, said Dr. Rohit Loomba, a fatty liver specialist at the University of California, San Diego, School of Medicine.

Doctors are also trying to figure out why some people with fatty liver progress to NASH and cirrhosis, while others do not. Dr. Loomba said that continual weight gain seems to be one driving force behind the progression.

As a result, doctors who treat fatty liver stress the urgency of diet and exercise to their patients. But many find it too hard, especially those who are obese and in the late stages of the disease, said Dr. Malik at the University of Pittsburgh.

"A lot of times when I see a patient with fatty liver," he said, "the first thing out of their mouth is, 'Well, is there a pill for this?' And there's not. There just isn't. You have to make lifestyle changes, and that's a much more difficult pill for people to swallow."

A version of this article appears in print on 06/14/2014, on page A1 of the NewYork edition with the headline: Threat Grows From Liver Illness Tied to Obesity.

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