Well: Pregnant Weight Lifter Stirs Debate

Most Americans are being told they are not exercising enough. Lea-Ann Ellison is being told she has taken her exercise routine too far.

The 35-year-old Ms. Ellison found herself on the receiving end of a firestorm of criticism after pictures of her doing a heavy weight-lifting routine two weeks before her due date appeared on Facebook. The photos quickly went viral, showing Ms. Ellison, a stay-at-home mother from California, doing kettlebell swings, pull-ups and Olympic-style barbell lifts like squats and overhead presses.

Ms. Ellison is a follower of CrossFit, the popular strength and conditioning program that uses grueling, high-intensity workouts. The caption on one of her photos reads in part:

8 months pregnant with baby number 3 and CrossFit has been my sanity. I have been CrossFitting for 2-and-a-half years and strongly believe that pregnancy is not an illness, but a time to relish in your body's capabilities.

One photo showed Ms. Ellison in midlift, hoisting a barbell over her head. It was shared almost 4,000 times on Facebook and drew nearly 2,000 comments. Many notes applauded Ms. Ellison and celebrated her devotion to stay fit and active through pregnancy. Some were from other mothers who spoke of their own training regimens through their pregnancies. One woman, Carol Metzger Bollonger, wrote:

I'm 6 months pregnant with triplets and am still CrossFitting as much as I can. I coached as well as participated in CrossFit classes through my whole first pregnancy, too! My doctors – the specialists included – totally support it and have said I am the healthiest triplet mom they have ever seen come through their practice!

But there was also a barrage of criticism, with many people calling Ms. Ellison irresponsible and the photos "shocking." One woman asked Ms. Ellison why she would risk "hurting your baby just to stay in shape."

In response to her critics, Ms. Ellison told one parenting Web site, Parentdish, that she had previously had two healthy, drug-free births and was planning a water birth at home for her baby. She said the weights she was using in the photos that went viral were lighter than what she would typically lift because, "I don't go all out anymore."

But she also defended her weight-lifting routine, saying it has helped her avoid many of the ailments that pregnant women often experience.

No back aches. No sciatic nerve issues. No sickness or cravings. I attribute this all to being healthy and strong. And studies show that strong fit mums have strong healthy babies. Exercise keeps weight issues down and that of course keeps diabetes rates low. Exercise also produces endorphins from the mother that get passed along to the baby. Happy mom equals happy baby.

Generally, women are advised to take on an exercise program during pregnancy so long as they are not at high risk of premature labor or certain chronic conditions, like high blood pressure or heart or lung disease. Walking, jogging, swimming and light weight lifting are some of the activities doctors typically encourage.

But Dr. Daniel Roshan, an assistant professor at New York University Medical School and a maternal fetal medicine specialist, said pregnant women should be careful not to push their heart rates above 140 beats per minute or raise their body temperatures above 100 degrees Fahrenheit. The goal is to avoid exercising to exhaustion.

Dr. Roshan said that heavy weight lifting during pregnancy is generally discouraged because it could put pressure on the abdomen, uterus and cervix, which could increase the likelihood of premature labor. But he also pointed out that a woman who lifts regularly, uses good technique and is well conditioned might be an exception.

"This woman obviously has been lifting for a long time," he said. "Normally we tell patients not to do this. But this woman is probably putting less pressure on her belly and more on her arms. With somebody who is trained and has strong arms, their arms will carry more weight than regular people. So they can get away with it without complications. But for a regular person, it's not advisable."

Dr. Roshan said that pregnant women should exercise for their own health and the health of their babies. But long hours and strenuous activity could create complications.

He said that nurses, for example, who work 12-hour shifts while pregnant, spending most of their days on their feet, are more prone to delivering smaller babies than those who work eight-hour shifts.

"This is because the blood gets shifted from the womb and goes toward the arms and legs," he said. "That's another reason we say don't do strenuous activity in pregnancy."

But at the same time, staying moderately active and following a healthy diet low in sugar can help control blood sugar during pregnancy, reducing the likelihood of delivering a heavy baby, Dr. Roshan said.

"It helps the baby not get too big," he said. "The more sugar there is in your circulation, the more sugar goes to the baby. And the bigger the baby gets, the more chances of complications like the shoulders getting stuck on the way out, tears and lacerations, and C-sections. In general we prefer to deliver seven pound babies as opposed to 9 or 10 pound babies."

The exercise recommendations for healthy pregnant women are essentially the same for most adults – three to five hours a week – with the caveat that they should take it a little easier. A moderate exercise routine during pregnancy not only lowers the rate of complications, it can make for a smoother recovery, Dr. Roshan said.

"Somebody who is athletic and active always has a better and easier recovery after any procedure," he said. "In general, the healthier you are, the easier the recovery."

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Rules Sought for Workplace Wellness Questionnaires

Joshua Roberts/Getty Images

Representative Louise Slaughter hopes to prevent discrimination based on intimate health data.

A federal lawmaker is asking the Equal Employment Opportunity Commission to investigate employer wellness programs that seek intimate health information from employees, and to issue guidelines preventing employers from using such programs to discriminate against workers.

The request, by Representative Louise M. Slaughter, Democrat of New York and a staunch advocate for health privacy rights, came a few days after Pennsylvania State University suspended part of its new employee wellness program that had drawn objections from faculty members.

"What happened at Penn State was appalling to me," Ms. Slaughter said in an interview on Tuesday, referring to the university's requiring employees to pay a monthly surcharge of $100 if they did not fill out detailed health risk questionnaires.

Called Take Care of Your Health, the Penn State program initially required employees, including faculty and staff members, to fill out the questionnaires — which asked about workplace stress, marital problems and women's pregnancy plans — or pay the surcharge. After faculty members complained that the program seemed coercive and invaded their privacy, the university suspended the penalty.

Ms. Slaughter, who made her request on Monday in a letter to the commission, is the author of the Genetic Information Nondiscrimination Act, a federal law that protects Americans against discrimination in employment or health insurance based on their genetic information.

"While the employer wellness program has recently suspended this fee, their plan still raises concerns about the type of information that can be collected through wellness programs and the definition of 'voluntary' participation," she wrote. "It is my strong hope that E.E.O.C. promptly drafts subregulatory guidance stopping this type of abuse and ensuring strong nondiscrimination protections for employees in wellness programs."

It is legal for employers to use financial incentives to encourage workers to fill out health risk assessment forms as long as that reward is based on completion of a wellness form and not tied to specific questions related to an employee's health status.

In fact, employer use of financial inducements is likely to increase under new wellness rules, scheduled to take effect in January as part of the Affordable Care Act. The rules allow employers to offer incentives of up to 30 percent of health coverage costs to employees who complete participatory wellness programs like health risk questionnaires, or biometric assessments like body-fat percentage measurements.

In her letter, however, Ms. Slaughter raised questions about whether the lack of federal guidelines on the design of such questionnaires could put employees at risk for discriminatory practices.

As a hypothetical example, a workplace wellness questionnaire that asked female employees questions about their pregnancy plans might cause a disproportionate number of women to decline to participate in the program, said Matthew T. Bodie, a professor at Saint Louis University School of Law. If that employer also fined its employees for not filling out the questionnaire, its wellness program could potentially have a discriminatory financial impact on that company's female employees, he said.

"Down the road, the law could get a little firmer on this if there is a consensus that employers are going overboard in what they are asking," said Professor Bodie, who specializes in labor and employment law.

The Equal Employment Opportunity Commission had a special meeting in May on wellness programs in which its legal expert concluded that the agency should issue guidance on the potential intersection of wellness programs and federal antidiscrimination laws. In particular, the expert said, the agency should clarify the meaning of "voluntary" employee participation.

But it has yet to issue that guidance, prompting Ms. Slaughter's letter. "I'm deeply upset with the E.E.O.C. for delaying this," she said.

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Hits to the Head Don’t Differ With Age, Research Indicates

Football players as young as 7 sustain hits to the head comparable in magnitude to those absorbed by high school and adult players, and most of the hits are sustained in practices, not games, according to research to be released Wednesday.

The findings, which may influence how youth football organizations handle training methods and rules, were included in four studies published by researchers at the Virginia Tech-Wake Forest University School of Biomedical Engineering and Sciences. The research, though limited, is considered by experts to be a step in the effort to address the relatively shallow understanding of the potential long-term effects of head trauma on young players.

More than 25,000 football players from 8 to 19 years old are taken to emergency rooms seeking treatment for concussions every year, but most of the research on head injuries in football has focused on professional and college players.

The new research, which was presented at the annual Biomedical Engineering Society conference this week, tracked about 120 players in Virginia and North Carolina from 7 to 18 over two seasons. Each young athlete wore six devices, known as accelerometers, in their helmets to measure the force, position and direction of the hits, and every practice and game was videotaped to determine how they occurred.

To help determine any changes in brain structure and function, many of the players received magnetic resonance imaging brain scans before and after the season, and after they sustained a concussion. Some players also received magnetoencephalography scans, or MEG scans, to map their brain activity.

"This is a basic study on how many times kids get hit in the head," said Professor Stefan Duma, who runs the School of Biomedical Engineering and Sciences and oversaw the youth football studies. "The number of hits and magnitude was a lot higher than people would have estimated. When we present it to the parents, everyone is surprised."

In the first of the four studies, 19 boys ages 7 and 8 were found to have absorbed 3,061 hits to the head during the 2011 and 2012 seasons, with 60 percent of those hits coming in practice. The players sustained an average of 9 hits per practice and 11 in games, which are less frequent. Although none of the boys received a diagnosed concussion, they absorbed 11 hits of 80g of force, or greater, a level that represents a higher risk of concussion.

"This study demonstrated that some head impacts at this level are similar in magnitude to high-severity impacts at the high school and collegiate level," the authors wrote.

A second study tracked three teams of players from 9 to 12 for one season. Nearly 12,000 hits were recorded, or an average of 240 per player. Again, players absorbed more hits during practice, and at higher acceleration rates than younger players. As a result, "these data suggest that rules designed to restrict player contact in practice are capable of reducing head impact exposure in youth football," the authors wrote.

Under increased scrutiny from parents, lawmakers and others, youth leagues have tightened rules to reduce the amount of hits children absorb. Pop Warner, the national organization made up of volunteer coaches and hundreds of thousands of children, some as young as 5, has reduced the amount of contact players can have in practice, and increased training for coaches, steps based partly on the medical belief that the brains of young players are particularly vulnerable because they have not fully developed.

"The professionals have a players union to protect them, but in many ways, the athletes that need the most protection have the least formal protection," said Dr. Vernon Williams, a neurologist at the Sports Concussion Institute, which advises high school, college and pro teams on baseline testing and when to return to play after concussions. "As you get earlier in age, the contrast is more striking."

Jon Butler, the executive director of Pop Warner, had not seen the results of the Virginia Tech-Wake Forest studies. But he applauded any work that accurately reflects the exposure of young players.

"There is a crying need for more research," Butler said. "There has been a lot of misinformation handed out. We're doing what we can with limited resources, but we don't have the funding to pay for major research studies."

The authors of the study note that their research has several limiting factors, most notably its size and length. Only a dozen or two athletes were tracked in each age category, and only for one or two seasons. More young athletes need to be studied to create a fuller set of data to determine the long-term effect of the hits they absorbed.

"While we have immediate data and finding, we're looking at 5- and 10-year students to help us answer the big questions about how much is too much," Duma said. "We are just at the beginning."

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Well: Why Runners Don’t Get Knee Arthritis

Phys Ed

Gretchen Reynolds on the science of fitness.

One of the most entrenched beliefs about running, at least among nonrunners, is that it causes arthritis and ruins knees. But a nifty new study finds that this idea is a myth and distance running is unlikely to contribute to the development of arthritis, precisely and paradoxically because it involves so much running.

It's easy to understand, of course, why running is thought to harm the knee joint, since with every stride, ballistic forces move through a runner's knee. Common sense would suggest that repeatedly applying such loads to a joint should eventually degrade its protective cartilage, leading to arthritis.

But many of the available, long-term studies of runners show that, as long as knees are healthy to start with, running does not substantially increase the risk of developing arthritis, even if someone jogs into middle age and beyond. An impressively large cross-sectional study of almost 75,000 runners published in July, for instance, found "no evidence that running increases the risk of osteoarthritis, including participation in marathons." The runners in the study, in fact, had less overall risk of developing arthritis than people who were less active.

But how running can combine high impacts with a low risk for arthritis has been mysterious. So for a new study helpfully entitled, "Why Don't Most Runners Get Knee Osteoarthritis?" researchers at Queen's University in Kingston, Ontario, and other institutions looked more closely at what happens, biomechanically, when we run and how those actions compare with walking.

Walking is widely considered a low-impact activity, unlikely to contribute much to the onset or progression of knee arthritis. Many physicians recommend walking for their older patients, in order to mitigate weight gain and stave off creaky knees.

But prior to the new study, which was published last week in Medicine & Science in Sports & Exercise, scientists had not directly compared the loads applied to people's knees during running and walking over a given distance.

To do so now, the researchers first recruited 14 healthy adult recreational runners, half of them women, with no history of knee problems. They then taped reflective markers to the volunteers' arms and legs for motion capture purposes, and asked them to remove their shoes and walk five times at a comfortable pace along a runway approximately 50 feet long. The volunteers likewise ran along the same course five times at about their usual training pace.

The runway was equipped with specialized motion-capture cameras and pads that measured the forces generated when each volunteer struck the ground.

The researchers used the data gathered from the runway to determine how much force the men and women created while walking and running, as well as how often that force occurred and for how long.

It turned out, to no one's surprise, that running produced pounding. In general, the volunteers hit the ground with about eight times their body weight while running, which was about three times as much force as during walking.

But they struck the ground less often while running, for the simple reason that their strides were longer. As a result, they required fewer steps to cover the same distance when running versus walking.

The runners also experienced any pounding for a shorter period of time than when they walked, because their foot was in contact with the ground more briefly with each stride.

The net result of these differences, the researchers found, was that the amount of force moving through a volunteers' knees over any given distance was equivalent, whether they ran or walked. A runner generated more pounding with each stride, but took fewer strides than a walker, so over the course of, say, a mile, the overall load on the knees was about the same.

This finding provides a persuasive biomechanical explanation for why so few runners develop knee arthritis, said Ross Miller, now an assistant professor of kinesiology at the University of Maryland, who led the study. Measured over a particular distance, "running and walking are essentially indistinguishable," in terms of the wear and tear they may inflict on knees.

In fact, Dr. Miller said, the study's results intimate that running potentially could be beneficial against arthritis.

"There's some evidence" from earlier studies "that cartilage likes cyclical loading," he said, meaning activity in which force is applied to the joint, removed, and then applied again. In animal studies, such cyclical loading prompts cartilage cells to divide and replenish the tissue, he said, while noncyclical loading, or the continued application of force, with little on-and-off pulsation, can overload the cartilage, and cause more cells to die than are replaced.

"But that's speculation," Dr. Miller said. His study was not designed to examine whether running could actually prevent arthritis but only why it does not more frequently cause it.

The results also are not an endorsement of running for knee health, he said. Runners frequently succumb to knee injuries unrelated to arthritis, he said, and his study does not address or explain that situation. One such ailment is patellofemoral pain syndrome, which is often called 'runner's knee.'

But for those of us who are — or hope to be — still hitting the pavement and trails in our twilight years, the results are soothing. "It does seem to be a myth," Dr. Miller said, that our knees necessarily will wear out if we continue to run.

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Quandary of Hidden Disabilities: Conceal or Reveal?

A YOUNG woman with hearing loss wrote to me recently about being interviewed for a senior position in a major library system. She was well qualified for the job, and as her interviews progressed through the day, she sensed that she was about to be offered the job.

Then the top executives invited her to continue the discussion over drinks. The bar was noisy and she couldn't keep up with the conversation. She didn't get the job.

The woman, who asked me not to use her name, is among those whom the Americans With Disabilities Act can have a hard time protecting: people with hidden disabilities.

What should she have done? During the interview process she might have disclosed her hearing loss in a way that showed how effectively and creatively she compensated for it. When the drinks suggestion was made, she might have said: "I'd prefer we met in a quiet place so I could respond more easily. Would that be O.K.?"

But the woman's choice not to disclose her disability was understandable. In fact, Joyce Bender, who owns a search firm in Pittsburgh that helps place people with disabilities, says that revealing a disability in an interview should be avoided if possible. And it should not be mentioned on a résumé, she says, as doing so may mean never reaching the interview stage.

Ms. Bender herself has epilepsy, a factor in her decision to focus the work of Bender Consulting Services on people with disabilities. "People with epilepsy have been viewed as mentally insane, degenerate, demonic or intellectually diminished," she said. "Today the stigma for people with epilepsy is that you are strange, dangerous, weird and someone to avoid."

An employee is not required to disclose a disability after being hired, but may choose to do so. Someone with epilepsy may want to ensure that the employer will know how to deal with a seizure. A diabetic might need to be away from work for insulin shots. Someone with mental illness may need a flexible schedule to allow for psychiatrist visits. A recovering alcoholic or drug abuser might need time off to meet with a substance abuse support group.

But it's a hard decision to make: If you announce your condition, you risk being stigmatized; if you keep it a secret, you risk poor performance reviews or even being fired.

AS someone who suffers from hearing loss, I understand this quandary all too well. When I was an editor at The New York Times, I was hesitant to discuss my condition. I told a few close colleagues about my disability, but I never explained how serious it was. Nor did I admit to myself how much it affected me professionally.

Former colleagues have since told me that they sometimes thought I was aloof, or bored, or maybe burned out. The fault was mine, in not disclosing the disability and asking for accommodations. I could have asked for a captioned phone, for instance, which would have made my job much easier and reduced a lot of the stress. I could have used a hearing assistive device, a small FM receiver, to pick up voices at staff meetings.

So why didn't I say anything? I feared being perceived as old. For nearly three decades I tried to fake it, as my hearing loss worsened to the extent that I could barely manage in the workplace even with a hearing aid and a cochlear implant.

My experience, and that of others, shows that invisible disabilities in the workplace may lead managers and colleagues to view employees as difficult, lazy or not team players.

Most companies are in compliance with the Americans With Disabilities Act, and many seek out employees with disabilities. But there are subtler, gray areas of discrimination, usually unintentional. These can start with the application process.

Some big retail companies use prescreening tests with job applications that can exclude certain employees, said Jan Johnston-Tyler, founder and chief executive officer of EvoLibri, a company in Santa Clara, Calif., whose services include job placement for people with disabilities.

One of Ms. Johnston-Tyler's clients, a 25-year-old with Asperger's syndrome, applied for a position at Subway. While most of the online application was routine, the last step was a multiple choice questionnaire. One of the 60 questions was, "Sometimes I have a hard time figuring out how I am supposed to behave around others."

Most of us would check off the "disagree" option, but as Ms. Johnston-Tyler pointed out, many people with Asperger's "are generally honest to a fault." She contacted Subway's corporate parent and was told that her client could fill out a different application without social suitability questions.

The interview process can be another minefield, as the woman who wrote to me about the library position found. And once people with hidden disabilities start their jobs, they face more risks.

Ms. Johnston-Tyler sees a lot of inadvertent discrimination. She told me about a client with Asperger's who was working for a community college as an accountant and was having a very difficult time interacting with others because of his poor social skills and boundaries. He was lonely and wanted social time with others, and got in trouble for asking too many questions.

Katherine Bouton is the author of "Shouting Won't Help: Why I — and 50 Million Other Americans — Can't Hear You."

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Robert McCabe Jr., a Kidney Donation Specialist, Dies at 88

The clock was ticking. The kidneys of a 14-year-old girl who had died in a Virginia hospital had been removed from her body with her parents' consent, in the hope that the organs might extend the life of others. But with only a rudimentary computer network available to help them in 1979, officials at the hospital, Norfolk General, could not find a suitable recipient for one of the kidneys, and they knew they had only 72 hours, at most, to do so.

So they reached out to St. Luke's Hospital Center in New York, where Dr. Robert E. McCabe Jr., an early specialist in kidney transplantation, was head of the renal preservation laboratory. He began scouring the New York area for potential recipients but found none. Nationally, not a single compatible recipient could be found among 6,000 or so people awaiting a transplant. He called colleagues in Italy and Kuwait. No luck.

Then, cutting through the cold war tensions of the time, he called the Soviet Embassy in Washington and told them to relay a message to Dr. Valery I. Shumakov, a prominent transplant surgeon he had met that April: a kidney was on the way — please find it a home.

The girl, who had suffered head trauma in a traffic accident, had died shortly after noon on a Tuesday in June. The next day, working with the embassy, St. Luke's put the kidney on a Soviet Aeroflot flight to Moscow out of Kennedy International Airport (after fending off security officials who wanted to check the storage container for explosives). The kidney arrived safely, and Dr. Shumakov soon reported that he had successfully transplanted the organ into a 36-year-old man that Thursday afternoon. (The girl's other kidney was implanted in a 51-year-old man in Newark.)

In the worlds of medicine and international politics, Dr. McCabe's determination to link donors with recipients had brought about a rare collaboration with the Soviets. But for Dr. McCabe, who died at 88 on Aug. 29, the episode underscored the shortcomings in the American system of kidney donations.

"We should have been able to use those kidneys at home, but we weren't organized adequately in New York City to use them all locally, or in the States themselves," he said in a recent interview on the Web site of the American Society of Transplant Surgeons, of which he was a founding member. "We shouldn't have had to go that far."

The first successful kidney transplant was conducted in 1954, and the procedure was rapidly adopted around the world. But by the late 1970s, hospitals faced challenges in preserving an organ during the out-of-body interim and in matching donors with recipients.

Dr. McCabe, who performed transplants at St. Luke's, taught himself to become a specialist in organ preservation using cold storage as well as a machine developed by the transplant surgeon Dr. Folkert O. Belzer. The process, known as machine perfusion, uses a blend of fluids to simulate a kidney's natural function until the kidney is transplanted. Dr. McCabe helped refine the blend.

But even with these preservation efforts, a kidney could be kept functional outside the body only for up to 72 hours.

The 1979 episode was not the first kidney transplant between the United States and the Soviet Union — there had been at least two others — but it exemplified the improvisational nature of transplant surgery and organ donation at the time.

Dr. McCabe's photograph, showing him helping to push free a police car that had become stuck in the mud while transporting a kidney into Manhattan, had once appeared in The Daily News in New York. On another occasion he delivered a kidney to Italy using a perfusion machine, the fluid inside frothing as the car in which he transported it through Rome bumped along cobblestone streets.

"In those days it was a free-for-all," said Dr. Thomas G. Peters, a surgeon who is the historian for the transplant society. "This was cowboy time."

But the New York-to-Moscow episode had a positive effect in generating publicity for the transplant program — the account appeared on the front page of The New York Times — and that in turn led to a noticeable rise in kidney donations.

Over time, databases of kidney donors and recipients became more sophisticated, as did preservation methods, enabling transplants to be accomplished far more speedily. In 1984, to prevent entrepreneurs from profiting from transplantation and hospitals from moving wealthy patients to the top of the waiting list, Congress passed the National Organ Transplant Act, which outlawed the sale of organs and established a regulatory framework for donations.

Dr. McCabe said that one benefit of tighter regulations was a more efficient process of determining when an organ donor was dead so that the organ could be harvested.

"We'd hear about a donor on Tuesday or Wednesday, and we couldn't get the neurologist to declare brain death," he said in the online interview. "They were some of the skeptics too, frankly, and they would not declare brain death until Friday afternoon at 5, when they were tired of caring for the patient and wanted us to take over. So we would be busy every weekend."

Robert Emmet McCabe Jr. was born on Feb. 20, 1925, in Charleston, W.Va. His father, Robert, was a lawyer, and his mother, the former Margaret Ward, was a homemaker. He graduated from Williams College in 1948 and received his medical degree in 1953 from Cornell University Medical College in Manhattan. He served as a surgeon in the Army from 1955 to 1957.

Dr. McCabe died of cancer at his home in Londonderry, Vt., his family said. Survivors include four daughters, Elsie Smith, Coco McCabe, Rue Sherwood and Kay McCabe; a son, Robert Emmet III; and nine grandchildren. His wife of 58 years, the former Katherine Robinson, died last year.

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Lower Health Insurance Premiums to Come at Cost of Fewer Choices

WASHINGTON — Federal officials often say that health insurance will cost consumers less than expected under President Obama's health care law. But they rarely mention one big reason: many insurers are significantly limiting the choices of doctors and hospitals available to consumers.

Andrea Morales for The New York Times

Peter L. Gosline, the chief executive of Monadnock Community Hospital in Peterborough, N.H.

From California to Illinois to New Hampshire, and in many states in between, insurers are driving down premiums by restricting the number of providers who will treat patients in their new health plans.

When insurance marketplaces open on Oct. 1, most of those shopping for coverage will be low- and moderate-income people for whom price is paramount. To hold down costs, insurers say, they have created smaller networks of doctors and hospitals than are typically found in commercial insurance. And those health care providers will, in many cases, be paid less than what they have been receiving from commercial insurers.

Some consumer advocates and health care providers are increasingly concerned. Decades of experience with Medicaid, the program for low-income people, show that having an insurance card does not guarantee access to specialists or other providers.

Consumers should be prepared for "much tighter, narrower networks" of doctors and hospitals, said Adam M. Linker, a health policy analyst at the North Carolina Justice Center, a statewide advocacy group.

"That can be positive for consumers if it holds down premiums and drives people to higher-quality providers," Mr. Linker said. "But there is also a risk because, under some health plans, consumers can end up with astronomical costs if they go to providers outside the network."

Insurers say that with a smaller array of doctors and hospitals, they can offer lower-cost policies and have more control over the quality of health care providers. They also say that having insurance with a limited network of providers is better than having no coverage at all.

Cigna illustrates the strategy of many insurers. It intends to participate next year in the insurance marketplaces, or exchanges, in Arizona, Colorado, Florida, Tennessee and Texas.

"The networks will be narrower than the networks typically offered to large groups of employees in the commercial market," said Joseph Mondy, a spokesman for Cigna.

The current concerns echo some of the criticism that sank the Clinton administration's plan for universal coverage in 1993-94. Republicans said the Clinton proposals threatened to limit patients' options, their access to care and their choice of doctors.

At the same time, House Republicans are continuing to attack the new health law and are threatening to hold up a spending bill unless money is taken away from the health care program.

In a new study, the Health Research Institute of PricewaterhouseCoopers, the consulting company, says that "insurers passed over major medical centers" when selecting providers in California, Illinois, Indiana, Kentucky and Tennessee, among other states.

"Doing so enables health plans to offer lower premiums," the study said. "But the use of narrow networks may also lead to higher out-of-pocket expenses, especially if a patient has a complex medical problem that's being treated at a hospital that has been excluded from their health plan."

In California, the statewide Blue Shield plan has developed a network specifically for consumers shopping in the insurance exchange.

Juan Carlos Davila, an executive vice president of Blue Shield of California, said the network for its exchange plans had 30,000 doctors, or 53 percent of the 57,000 doctors in its broadest commercial network, and 235 hospitals, or 78 percent of the 302 hospitals in its broadest network.

Mr. Davila said the new network did not include the five medical centers of the University of California or the Cedars-Sinai Medical Center near Beverly Hills.

"We expect to have the broadest and deepest network of any plan in California," Mr. Davila said. "But not many folks who are uninsured or near the poverty line live in wealthy communities like Beverly Hills."

Daniel R. Hawkins Jr., a senior vice president of the National Association of Community Health Centers, which represents 9,000 clinics around the country, said: "We serve the very population that will gain coverage — low-income, working class uninsured people. But insurers have shown little interest in including us in their provider networks."

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Well: Dietary Report Card Disappoints

From time to time, the Center for Science in the Public Interest, a Washington-based advocacy group, prepares an updated "report card" on changes in the American diet. The latest, collated by the nutritionist Bonnie Liebman and published in the September issue of the center's Nutrition Action Newsletter, is not one Americans should be especially proud of.

The analysis of changes in food consumption from 1970 to 2010 reveals that we still have a long way to go before we come close to meeting dietary guidelines for warding off obesity and chronic health problems like diabetes and heart disease.

The news isn't all bad. Our consumption of added sweeteners, though still significantly higher than it was in 1970, has come down from the "sugar high" of 1999 when the average was 89 pounds per person. Nonetheless, an average of 78 pounds per person in 2010, mostly as sugar and high-fructose corn syrup, is still too much, Ms. Liebman points out.

Even our B-plus for cutting back on fats and oils, the highest grade Ms. Liebman awarded, is a mixed bag. Yes, we've dramatically reduced consumption of heart-damaging trans fats and, to a lesser extent, saturated solid fats like margarine and shortening. But there's been a steady, steep climb in total fats added to the diet in the form of salad oils and cooking oils.

As a country, we have definitely not been on a "low-fat diet." The average person consumes 20 pounds more in total fat yearly than in 1970, which partly explains why the obesity rate among adults has more than doubled since then, when only 15 percent of Americans were obese.

In 2005, the Agriculture Department has reported, the average American consumed 645 calories a day in added fats and oils, not counting the fats naturally present in foods like meats and dairy products.

Americans seem to think that if a food is considered a healthier alternative, it's O.K. to swallow as much of it as one might like. People forget, or never knew, that a tablespoon of olive oil or canola oil has about the same number of calories as a tablespoon of lard (about 115), and even more calories than a tablespoon of butter or margarine.

"We never were on a low-fat diet," Ms. Liebman said in an interview. "We increased our fat intake from pizzas, burgers, French fries, baked goods and restaurant-prepared foods."

Likewise, grain products. "There's been a huge increase in grains in the last 30 years — bread, cereal, pasta, rice, burritos, pizza crust, panini, muffins, scones — mostly made from white flour," she said. "We've been blaming the obesity epidemic on sweets, and we are eating too much sugar, but we need to pay more attention to grains.

"It would not be great to simply replace refined grains like white flour and white rice with whole grains," she added. "We need to cut back on grains, period."

Whether made from white flour or whole wheat, one unadorned New York-style bagel supplies about 500 calories, and a 21st century muffin often contains as many as 800 calories.

For the average adult, who should aim for a daily intake of 2,000 calories, these grain foods displace far more nutritious (and relatively low-calorie) fruits and vegetables. Our consumption of those earned a B-minus on Ms. Liebman's report card.

"We need to replace sandwiches with salads, swap starches for veggies, and trade cookies, cupcakes and chips for fresh fruit," she wrote. "We started eating more vegetables, not counting potatoes, in the 1980s, but the rise has stalled."

Ms. Liebman was surprised to find that combined consumption of beef and pork is still higher than that of chicken and fish. Although chicken itself is now slightly more popular than beef, our consumption of fish has remained relatively flat.

In the July/August edition of the Nutrition Action Newsletter, Barton Seaver, the director of the Healthy and Sustainable Food Program at the Harvard School of Public Health, noted that Americans "eat only about 16 pounds of seafood per person per year, and about 95 percent of that comes from only 10 species."

Mr. Seaver, a former chef, encourages diners to stray from the familiar to more sustainable — and wholesome — species like pollock, sablefish, Spanish mackerel, haddock, and farm-raised barramundi and shrimp. He champions farm-raised mussels, clams and oysters as sources of "fabulous" lean protein that clean the aquatic environment.

Contrary to popular thought, frozen fish is "comparable to, if not better than, fresh fish," because it is frozen on ships within hours of being caught, Mr. Seaver said.

Ms. Liebman applauded the steady, precipitous decline in whole milk consumption and the booming popularity of mostly low-fat yogurt. But she noted that consumption of low-fat and fat-free milk has remained low (displaced by sugary soft drinks) and that our consumption of cheese, rich in dairy fat, is at an all-time high, up threefold since 1970 and still climbing.

"And we're not just eating more sweets, grains, meat and cheese. We're eating more, about 500 more calories a day per person than in 1970," Ms. Liebman said. "We've lost track of what a normal portion of food should look like."

She blamed restaurants for portion distortion. "If you eat what restaurants serve, you will end up like two-thirds of Americans, overweight or obese," she said. "People should assume that restaurants serve double what you should be eating and either share a meal or take half of it home to eat the next day."

While some restaurants have added lean or light meals to their menus, "those should be the standard because that's what we all should be eating, not just dieters," Ms. Liebman said. "And vegetables and fruits should fill up half the plate, not just be treated as a little side dish."

Take or order a salad instead of a sandwich for lunch. And try cut vegetables with a yogurt dip for a munch between meals or before dinner.

This summer I discovered a great new way to enhance the family's fruit intake. It's a gadget called Yonanas: using frozen, slightly overripe bananas as a base and other frozen fruits for color and flavor (like strawberries, pineapple, or mango), it produces a sweet, creamy dessert or snack with the consistency of frozen yogurt but no added sugar or cream. With a 20-percent off coupon from Bed Bath & Beyond, this tool costs $40 and — who knows? — could ultimately save hundreds in medical bills.

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Once Suicidal and Shipped Off, Now Battling Nevada Over Care

Jim Wilson/The New York Times

David Theisen, a homeless man at the center of a lawsuit against the State of Nevada, said, "Technically, they shouldn't have been allowed to send me anywhere. They should have put me in a little room until I got better." More Photos »

SAN FRANCISCO — David Theisen keeps his legal papers in a frayed yellow envelope in his tiny transients' hotel room, a toilet down the hall, the covers of his beloved comic books, with titles like "Dark Mysteries" and "Vault of Horror," lining the drab walls.

A lot has changed in the year and a half since Mr. Theisen, 52 and homeless, threatened to kill himself with a butcher knife and ended up in a Las Vegas psychiatric center. After one night, Mr. Theisen found himself on a bus to San Francisco, several sack lunches and a day's worth of medication clutched in his lap.

"Technically, they shouldn't have been allowed to send me anywhere," Mr. Theisen said. "They should have put me in a little room until I got better."

Now, Mr. Theisen is at the center of a class-action lawsuit brought this month by San Francisco's city attorney, Dennis Herrera, against the State of Nevada on behalf of 24 mentally ill and homeless people. They were all, like Mr. Theisen, bused out of Nevada and left on the streets of San Francisco with little or no medication.

But that is just a small sampling, Mr. Herrera says, of the estimated 1,500 people who were bused all over the country in recent years from the state-operated Rawson-Neal Psychiatric Center in Las Vegas and other Nevada institutions, 500 of them to California.

"It's horrifying," Mr. Herrera said. "I think we can all agree that our most vulnerable and at-risk people don't deserve this sort of treatment: no meds, no medical care, a destination where they have no contacts and know no one."

But what makes it "even more tragic," Mr. Herrera said, "is that on top of the inhumane treatment, the State of Nevada was trying to have another jurisdiction shoulder the financial responsibility for caring for these people."

Attorney General Catherine Cortez Masto of Nevada, who has several weeks to respond to Mr. Herrera's lawsuit, has declined to comment in the meantime.

Mary Woods, a spokeswoman for the Nevada Department of Health and Human Services, laid out the state's position in an e-mail. Outside a handful of instances, the state believes that its Client Transportation Back to Home Communities program was operated properly and that it is not dissimilar from programs in other jurisdictions, including San Francisco.

Hospitals in several cities have programs intended to reunite discharged psychiatric patients with their families and hometowns. Where abuses occur, Mr. Herrera and others say, is when patients are shipped off with little or no oversight about where they are going and what will happen once they get there.

Nevada officials say that besides a single, well-documented case, they believe that the Rawson-Neal staff followed proper release procedures in almost all of the remaining cases they have investigated.

That single case, involving a man named James F. Brown who was sent by bus to Sacramento, a city where he knew no one, from the Vegas hospital in February, was the subject of an article in The Sacramento Bee.

That newspaper article not only prompted the San Francisco city attorney's office to look into the Nevada policy, but it also led to a federal investigation.

"This has certainly elevated attention of a practice that, frankly, has probably gone on for many years in a number of states," said Ronald S. Honberg, legal director for the National Alliance on Mental Illness in Washington. "We've never done a study, and I've never seen one anybody else did, but we have certainly heard over the years a number of stories that this sort of practice goes on. It's something we refer to, euphemistically, as Greyhound therapy."

Mr. Theisen's experience began when he and another homeless man tried to hitchhike across the Mojave Desert from Las Vegas to San Diego. They made it about 45 miles to the small town of Primm, little more than a cluster of casinos.

The two men, desperate and hungry, ordered a meal and then ran before the bill arrived. They did not make it. His friend was arrested, but Mr. Theisen went to a pay phone and called the authorities. "I told them I had a knife and was going to kill myself," he said. "After the dine-and-dash, I just gave up."

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News Analysis: Is This a Hospital or a Hotel?

As the new St. Joseph's Hospital in Highland, Ill., prepared to open in August, its chief executive exulted, "You feel like you could be at the Marriott."

In the $63 million community hospital, patients all enjoy private rooms, with couches, flat-screen TVs and views of nature. Its lobby features stone fireplaces and a waterfall.

Some hospitals in the United States, like Cedars-Sinai in Los Angeles, have long been associated with deluxe accommodations, and others have always had suites for V.I.P.'s. But today even many smaller hospitals often offer general amenities, like room service and nail salons, more often associated with hotels than health care.

In the current boom of hospital construction, private rooms have become the norm. And some health economists worry that the luxury surroundings are adding unneeded costs to the nation's $2.7 trillion health care bill.

There are some medical arguments for the trend — private rooms, for example, could lower infection rates and allow patients more rest as they heal. But the main reason for the largess is marketing.

In a highly competitive field, patients — sometimes now referred to as "guests" — appreciate amenities. The tactic works. "We found that patient demand correlates much better to amenities than quality of care," said Dr. John Romley, a research professor at the Leonard D. Schaeffer Center for Health Policy and Economics of the University of Southern California, who has studied the trend. That means that hospitals can improve their bottom line and their reputation by focusing more on hospitality than health care — offering organic food by a celebrity chef rather than lowering medication errors, for example.

As a result, American hospitals are looking less and less like their more utilitarian counterparts in Europe, where the average hospital charges per day are often less than a quarter of those in the United States, according to the International Federation of Health Plans.

The Henry Ford health system in Michigan caused a stir after it hired a hotel industry executive, Gerard van Grinsven of the Ritz-Carlton Group, in 2006 to run its new hospital, Henry Ford West Bloomfield. He had opened 20 hotels and his "focus on people and service excellence" has helped the hospital thrive in a competitive market, said Nancy M. Schlichting, Henry Ford's chief executive, who decided to hire him. The idea was to take care of patients' needs, she said, clinical and otherwise.

While no one is getting nostalgic for traditional hospital food, open wards or revealing gowns, some worry that hospitals are going too far with the creature comforts. They are particularly concerned since most hospitals are nonprofit, so construction — directly or indirectly — is subsidized with public money.

With the prospect on the horizon of the Affordable Care Act's lowering reimbursement, and interest rates rising, the hospital construction boom appears to be slowing. And, in choosing a hospital, patients should probably think beyond room service anyway. Many years ago, when I was a doctor-in-training, I was assigned to work on a hospital floor with V.I.P. rooms. Though the views were spectacular, the cardiac arrest team could not get there as quickly as it could to the regular wards. We called it "a hotel near a major teaching hospital."

Can you tell the difference between a hotel and a hospital? Take the quiz.

Take the quiz.

Elisabeth Rosenthal is a reporter for The New York Times who is writing a series about the cost of health care, "Paying Till It Hurts."

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