Personal Health: The Empty-Diet-Claim Season

I don't need a calendar to know that a new year has begun. I can tell by the deluge of new diet books that arrive in the office mail — more than two dozen since mid-December. On a whim, I weighed them all: over 25 pounds of mostly bad advice, about as much as many readers hope to lose before they have to shed the concealing garb of winter.

Choices include a low-carb plan that promises a loss of "up to 15 pounds in two weeks" in "The New Atkins Made Easy," or the Paleo diet in "Cavewomen Don't Get Fat." One Dr. Mike Moreno recommends occasional fasting "to power boost your weight loss" in "The 17 Day Diet Breakthrough Edition."

Perhaps you're more interested in unearthing the secrets of the world's leanest people in "Burn the Fat, Feed the Muscle," or learning to identify and curb emotional eating as described in "Weight Loss for People Who Feel Too Much" and "Overcoming Binge Eating for Dummies." How about activating "your body's ability to burn fat and lose weight fast" via "The Blood Sugar Solution 10-Day Detox Diet"?

It goes on and on.

I know about the new year, too, from comments in the Y locker room: The holiday splurges are over, and the day of reckoning has arrived. Overheard on Jan. 1: "I'm going to work out every day. I've got to get rid of these pounds."

But neither the plethora of diet books nor annual resolutions are good predictors of permanent weight loss. First, if any of the scores of diet plans published in recent years had resulted in lasting weight loss for the growing legions of hopefuls, there would have been no need for yet another batch, including the ones that inevitably will arrive next December.

Second, as one middle-aged Y member, who has maintained a 20-pound weight loss for several years, responded to the locker room workout pledge: "Exercise by itself won't do it. To lose weight, you have to eat less."

She learned that, she said, at Weight Watchers after nearly wearing out her body by trying to lose weight through exercise alone. Not only does she now eat less, she also eats differently, having replaced many foods and snacks high in sugar and refined starches with more nutritious fare.

Another Weight Watchers success, a friend in his late 70s who shed 25 pounds, eats the same foods he always did but now eats less of them. He learned to recognize satiety — a feeling that he's had enough — and to rely on that instead of a feeling of being stuffed to signal the end of his meals.

Clearly, there is no one pathway to permanent weight loss that works for everyone. The latest guidelines for physicians, who are repeatedly exhorted to help overweight and obese patients lose pounds and keep them off, emphasize that a reduced-calorie diet should be based on individual dietary preferences and combined with "comprehensive lifestyle interventions" that would best include participation in a professionally led program for six months or longer.

Radical, abrupt dietary changes rarely stick. People soon tire of the restrictions and revert to their old dietary habits. Habits are not acquired overnight, and you should not expect to inculcate new ones overnight, either.

John P. Foreyt, director of the Behavioral Medicine Research Center at Baylor College of Medicine, advises would-be dieters to first become aware of their bad eating and exercise habits, and then to figure out ways to slowly change them into healthier new ones.

Small changes can end up making a big difference. One is to avoid skipping meals. Eat a nutritious breakfast every day and a wholesome snack or meal every few hours. I snack on nuts midmorning and have a digestive biscuit (70 calories) with café con leche midafternoon. The idea is to avoid becoming ravenous and losing control over your intake at the next meal.

Eat slowly — it takes 20 minutes for your brain to register satiety — and on smaller plates filled with one-fifth to one-third less food than usual. Fill most of the plate with foods like vegetables and salads that are rich in nutrients rather than calories.

Choose nutrient-dense carbohydrates like beans and whole grains over refined ones. If, however, you think a meal is not a meal without potatoes, rice, bread or (heaven forfend) dessert, by all means include them — but in controlled amounts.

Drink water or a calorie-free beverage with your meals. If you drink alcohol, limit yourself to one drink a day.

I crave something sweet after a meal, and fruit doesn't always cut it. My dessert favorites include a graham cracker (65 calories in two squares) and two dark chocolate Bahlsen Afrika biscuits (45 calories).

If, like me, you have an oral fixation, try chewing sugar-free gum. Or eat a fruit like an apricot or prunes with pits, then suck on the pits for the next hour or so.

Make physical exercise a daily activity. Decide each day what to do rather than whether to do it. The 4,200 members of the National Weight Control Registry (members have lost an average of 67 pounds and kept them off for six years) typically exercise for 60 to 90 minutes a day, often broken up into several smaller sessions; walking is their most popular activity.

Registry leaders report that those who have successfully maintained their weight loss typically eat a diet low in fat (25 percent of daily calories) and high in carbohydrates, with 56 percent of their calories from carbs like whole grains, beans and vegetables.

Perhaps most telling is that registry members weigh themselves regularly. Many (like me) get on a scale every day. A weekly weigh-in, as recommended by Weight Watchers, is probably best while losing weight. But to maintain weight, a daily check can provide an early warning to cut back a little when you gain a pound or two. Five extra pounds that make pants too tight are a lot harder to shed.

Registry members readily admit that, contrary to the claims of many diet books, effective weight loss and maintenance are not easy. Most, like me, became successful when they gave up "dieting" and adopted a sensible eating and exercise plan they could stay on comfortably for the rest of their lives.

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Well: The Empty Diet Claim Season

I don't need a calendar to know that a new year has begun. I can tell by the deluge of new diet books that arrive in the office mail — more than two dozen since mid-December. On a whim, I weighed them all: over 25 pounds of mostly bad advice, about as much as many readers hope to lose before they have to shed the concealing garb of winter.

Choices include a low-carb plan that promises a loss of "up to 15 pounds in two weeks" in "The New Atkins Made Easy," or the Paleo diet in "Cavewomen Don't Get Fat." One Dr. Mike Moreno recommends occasional fasting "to power boost your weight loss" in "The 17 Day Diet Breakthrough Edition."

Perhaps you're more interested in unearthing the secrets of the world's leanest people in "Burn the Fat, Feed the Muscle," or learning to identify and curb emotional eating as described in "Weight Loss for People Who Feel Too Much" and "Overcoming Binge Eating for Dummies." How about activating "your body's ability to burn fat and lose weight fast" via "The Blood Sugar Solution 10-Day Detox Diet"?

It goes on and on.

I know about the new year, too, from comments in the Y locker room: The holiday splurges are over, and the day of reckoning has arrived. Overheard on Jan. 1: "I'm going to work out every day. I've got to get rid of these pounds."

But neither the plethora of diet books nor annual resolutions are good predictors of permanent weight loss. First, if any of the scores of diet plans published in recent years had resulted in lasting weight loss for the growing legions of hopefuls, there would have been no need for yet another batch, including the ones that inevitably will arrive next December.

Second, as one middle-aged Y member, who has maintained a 20-pound weight loss for several years, responded to the locker room workout pledge: "Exercise by itself won't do it. To lose weight, you have to eat less."

She learned that, she said, at Weight Watchers after nearly wearing out her body by trying to lose weight through exercise alone. Not only does she now eat less, she also eats differently, having replaced many foods and snacks high in sugar and refined starches with more nutritious fare.

Another Weight Watchers success, a friend in his late 70s who shed 25 pounds, eats the same foods he always did but now eats less of them. He learned to recognize satiety — a feeling that he's had enough — and to rely on that instead of a feeling of being stuffed to signal the end of his meals.

Clearly, there is no one pathway to permanent weight loss that works for everyone. The latest guidelines for physicians, who are repeatedly exhorted to help overweight and obese patients lose pounds and keep them off, emphasize that a reduced-calorie diet should be based on individual dietary preferences and combined with "comprehensive lifestyle interventions" that would best include participation in a professionally led program for six months or longer.

Radical, abrupt dietary changes rarely stick. People soon tire of the restrictions and revert to their old dietary habits. Habits are not acquired overnight, and you should not expect to inculcate new ones overnight, either.

John P. Foreyt, director of the Behavioral Medicine Research Center at Baylor College of Medicine, advises would-be dieters to first become aware of their bad eating and exercise habits, and then to figure out ways to slowly change them into healthier new ones.

Small changes can end up making a big difference. One is to avoid skipping meals. Eat a nutritious breakfast every day and a wholesome snack or meal every few hours. I snack on nuts midmorning and have a digestive biscuit (70 calories) with café con leche midafternoon. The idea is to avoid becoming ravenous and losing control over your intake at the next meal.

Eat slowly — it takes 20 minutes for your brain to register satiety — and on smaller plates filled with one-fifth to one-third less food than usual. Fill most of the plate with foods like vegetables and salads that are rich in nutrients rather than calories.

Choose nutrient-dense carbohydrates like beans and whole grains over refined ones. If, however, you think a meal is not a meal without potatoes, rice, bread or (heaven forfend) dessert, by all means include them — but in controlled amounts.

Drink water or a calorie-free beverage with your meals. If you drink alcohol, limit yourself to one drink a day.

I crave something sweet after a meal, and fruit doesn't always cut it. My dessert favorites include a graham cracker (65 calories in two squares) and two dark chocolate Bahlsen Afrika biscuits (45 calories).

If, like me, you have an oral fixation, try chewing sugar-free gum. Or eat a fruit like an apricot or prunes with pits, then suck on the pits for the next hour or so.

Make physical exercise a daily activity. Decide each day what to do rather than whether to do it. The 4,200 members of the National Weight Control Registry (members have lost an average of 67 pounds and kept them off for six years) typically exercise for 60 to 90 minutes a day, often broken up into several smaller sessions; walking is their most popular activity.

Registry leaders report that those who have successfully maintained their weight loss typically eat a diet low in fat (25 percent of daily calories) and high in carbohydrates, with 56 percent of their calories from carbs like whole grains, beans and vegetables.

Perhaps most telling is that registry members weigh themselves regularly. Many (like me) get on a scale every day. A weekly weigh-in, as recommended by Weight Watchers, is probably best while losing weight. But to maintain weight, a daily check can provide an early warning to cut back a little when you gain a pound or two. Five extra pounds that make pants too tight are a lot harder to shed.

Registry members readily admit that, contrary to the claims of many diet books, effective weight loss and maintenance are not easy. Most, like me, became successful when they gave up "dieting" and adopted a sensible eating and exercise plan they could stay on comfortably for the rest of their lives.

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Well: The Well Smoking Quiz: Who Looks Older?

We know that smoking is bad for you — and that it ages you prematurely. Now a study provides photographic evidence for this claim.

Scientists gathered health and lifestyle information on 79 pairs of identical adult twins who fit into one of three groups: a pair in which one was a smoker and the other had never smoked; a pair in which both were smokers; or a pair in which both were smokers but with at least a 5-year difference in the duration of their smoking habit. They photographed them and had independent judges rate the pictures side-by-side for wrinkles, crow's feet, jowls, bags under the eyes, creases around the nose, lines around the lips and other evidence of aging skin.

The differences in some other factors that can age skin prematurely — alcohol consumption, sunscreen use and perceived stress at work — were statistically insignificant between twin pairs. But the judges' decisions on which twin looked older coincided almost perfectly with their smoking histories.

"The purpose of this study was to offer scientific evidence that smoking changes not only longevity, but also quality of appearance," said the senior author, Dr. Bahman Guyuron, chairman of the plastic surgery department at University Hospital, Case Medical Center in Cleveland. "It is harmful any way you look at it."

In the five twin pairs shown, click on the photo of the twin you think is the smoker or who smoked longer.

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Well: Ask Well: Is Jogging Bad for Older People?

A

Actually, much of the recent science about high-impact exercise by "older people" like me — I prefer the term "seasoned," by the way — reaches the opposite conclusion, suggesting that in many cases high-impact exercise can be beneficial for those middle aged and beyond. A seminal 2003 study of people aged 30 to past 70, for instance, found that while sedentary adults lost about 10 percent of their maximal endurance capacity every decade, young and middle-aged athletes who regularly engaged in intense and high-impact exercise, such as running intervals, experienced a much slower decline, losing only about 5 percent of their capacity per decade until age 70, when the loss of capacity accelerated for everyone.

There is also little evidence to support the widespread belief that high-impact exercise speeds the onset of arthritis. In a 2013 study, adult runners, including many aged 45 or older, had a lower incidence of knee osteoarthritis and hip replacement than age-matched walkers, with the adults who accumulated the most mileage over the course of seven years having the lowest risk, possibly, the study's author speculated, because running improved the health of joint cartilage and kept them lean as they aged. Similarly, a 2006 review of studies about jogging and joints concluded that "long-distance running does not increase the risk of osteoarthritis of the knees and hips for healthy people who have no other counter-indications for this kind of physical activity," and "might even have a protective effect against joint degeneration."

Running and similar high-impact activities likewise have a salutary effect on bone density, said Dr. Michael Joyner, an exercise physiologist at the Mayo Clinic in Rochester, Minn., and an expert on aging athletes, of whom he is one. Over all, he continued, he is "skeptical" of the idea that older people should avoid high-impact activities. "A lot of concerns about age-appropriate exercise modalities have turned out to be more speculative than real over the years," he said, adding that during his research and personal workouts, he's seen many seasoned adults pounding the pavement without ill effects.

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Well: The Workout: Speedskating With Eddy Alvarez

The Workout

An inside look at fitness routines, by Anahad O'Connor.

Being a successful short-track speedskater is no easy feat. Members of the United States team follow a grueling schedule that involves up to eight hours of training, six days a week.

They lift weights, they run and they cycle. And they practice racing around a rink at 40 miles an hour on two razor-sharp blades.

We asked Eddy Alvarez, who will be competing in his first Olympics in Sochi, Russia, in February, to take us through a speedskater's workout.

Nicknamed Eddy the Jet, Mr. Alvarez, 23, started roller-skating as a child while growing up in Miami, then transitioned to ice. He has won national and World Cup medals in speedskating. But his career was nearly derailed two years ago by devastating knee injuries, which required surgery that left him bedridden for a month. His doctor told him he might never skate again.

But Mr. Alvarez bounced back, and he is now considered a top prospect heading into the Olympics. Recently, we caught up with him at the Olympic Oval training facility in Salt Lake City to talk about how he trains six to eight hours a day to prepare for a 42-second race, how a "dino disc" helps prevent injuries and why he is superstitious about what he eats before a competition. Here is an edited version of our conversation.

Q.

How long have you been skating?

A.

I've been skating since I was 5; I used to speedskate on inline skates when I was little down in South Beach. I was kind of a side-street attraction. I was even sponsored by a skate shop in Miami. I would wear their logo and jump over boxes and skate around on the streets of South Beach.

Q.

How did you get into speedskating on ice?

A.

Ice was introduced to me at the age of 7. I still remember the first time I tried it. I can't tell you exactly where it was, but I remember the feeling. It was quite a rush for me as a 7-year-old, gliding and going fast.

Q.

What are some of the physical demands of the sport?

A.

The positions that we're in on the ice are, honestly, excruciating. We basically skate in a squat position, but what we try to do is become a compact ball. If you watch us skate, you'll that see our backs are curved. When people ask me how it feels, the best way I can describe it is to say go and do a wall-sit for 10 minutes and then stand up. That's how it feels.

Q.

What is a typical day like?

A.

I'm in two places every day. I'm either at the Oval training, or I'm at my house sleeping. I know it'll be worth it in the end, but I really hope I don't miss my fun years.

Q.

What are some of your greatest achievements in skating so far?

A.

It's been a very long road. But the biggest accomplishment that I've had would be coming back from my injury. It was the hardest thing I've ever had to face.

Q.

Can you tell us about your injury comeback?

A.

I always had knee issues growing up. We thought it was because I grew very fast, very late. But during the 2009-2010 season, it got to a point where I couldn't finish workouts. I would come home and cry. But I would tell myself to push through it because it was the Olympic season and I had nothing to lose. So I overdid it.

I fell short of the 2010 Games and didn't make the team, and then I finally went to get my knees checked. I got an ultrasound, and it turned out that I had torn the patella tendons in my knees. I had a total of 12 tears in both knees. The doctor was impressed that I was even able to be in skating condition, because my patella tendons were like strings – dangling strings, basically.

Q.

Can you tell us about the physical preparation that goes into the sport?

A.

We put in a lot of hours. We train six to eight hours a day to go race for 42 seconds. The reason we train this much is so our bodies can recover in between rounds of racing. In competitions, we usually skate six or eight rounds in a day, and it's usually 15 to 20 minutes of rest and then you're back at it again. It takes a toll on our bodies. Honestly, I always get sick after a competition. That's how much I put my body through. Unorthodox is the best word to describe our training and our sport.

Q.

Does it require some muscles more than others?

A.

Our sport is very lower-body dominant. The less weight you carry in your upper body, the easier it is. Unfortunately, I carry a little more than everyone else because I have a baseball background. The muscles in my upper body are a little different than the typical short tracker.

Q.

It sounds like injuries are a big concern.

A.

Injuries are huge for us. We are hitting speeds of roughly 40 miles per hour, and there's falls and crashes. The training takes a toll on our knees, our backs and our hamstrings. At the stage at which we compete, I don't think there's an athlete that's going to be 100 percent physically, with no injuries. We train our bodies every day, and it's just something that we have to accept.

Q.

Are there exercises you do to address these issues?

A.

We do extra training on the side to strengthen our weaknesses. I like to do exercises on something that we call a "dino disc." It's a little rubber disc that has air in it, and when you step on it, it's like a balance tool. I work a lot with that to strengthen all the little muscles that we don't have the opportunity to strengthen and activate while we skate. We also do a lot of rubber-band exercises at the beginning of the season to strengthen the knees and the muscles around them. Then we pray that it holds up throughout the season.

Q.

What are some of your favorite land exercises?

A.

We do a lot of jumping exercises, and we do things to develop our accuracy and our foot speed. We're trying to simulate what we do on the ice. So you'll find us doing exercises like "dry skating," which is basically just straight-away pushes on land to simulate the lactic acid that we build in our legs. And we do something called turn-belt exercises, where they strap a long belt around your waist that looks like a seatbelt, and then you have someone else holding the belt as you're simulating the lean that we have on the ice.

Q.

What about cardio?

A.

We do a lot of cycling and running. We run or bike for 45 minutes to an hour two to three days a week, and during the summer we do four-hour bike rides twice a week. We ride all the mountains out here in Salt Lake City.

Q.

What is your approach to diet?

A.

I try to cook and eat at home as much as possible so I can control the amount and type of oils I eat. One thing I like to use is coconut oil. I'm also a big fan of juicing vegetables. I absolutely hate eating them. So I stick them in a juicer with some fruit like an apple to sweeten it up and I chug it.

Some days, we just have to eat and eat and eat to be able to perform. We don't want to sell ourselves short by not eating enough. We slice through body fat, and we have to fuel our bodies. You're not going to find me at McDonald's or Wendy's. But I like to eat pasta and bread and carbs.

Q.

Are there certain foods you like to eat before a race or training?

A.

I have a superstition. I don't like to eat red meat before a competition. When I was little, I was always told that red meat is hard to process and sits in your stomach. So during competitions I only eat chicken. I have this thought that the red meat will just sit in my stomach and make me heavier. So I eat chicken during competitions, and some white rice and pasta.

Q.

What will it mean to you to compete in Sochi?

A.

I dream about standing on that podium, winning a medal. It would be such an accomplishment for me because of everything I had to go through. After my surgery, I went through depression. I wasn't on the ice for 24 months. It's been a long road for me, and it would mean a lot for my family. They've been there every step of the way. I owe it all to them, and if I succeed, the satisfaction of them being happy is the most important thing in the world to me.

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Contributing Op-Ed Writer: How Many Cheers for Cheerios?

Well, a major and venerable American brand has gone and announced that it contains no genetically modified organisms (G.M.O.'s). Cheerios is G.M.O.-free! And will soon be labeled "Not Made With Genetically Modified Ingredients."

Fred R. Conrad/The New York Times

Mark Bittman

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For Op-Ed, follow @nytopinion and to hear from the editorial page editor, Andrew Rosenthal, follow @andyrNYT.

Do we care? Should we? Is this a cynical marketing ploy or a huge deal or both? (It certainly isn't neither.)

Without question this could be the start of something big. That it has value to Cheerios and to anti-G.M.O. activists is also undoubtedly true; the question is whether it matters to the rest of us. It does; but that doesn't mean it's a good thing.

First, let's get this straight. Taking the G.M.O.'s out of Cheerios is only a little bit harder than taking them out of oatmeal: there are no G.M.O. oats, and Cheerios are, essentially, oats. (Well, hyper-processed oats.) They also contain small amounts of cornstarch and sugar, so its parent company, General Mills, has done little more than source non-G.M.O. cornstarch and cane rather than beet sugar to use in production. (There are G.M.O. beets, and almost all corn and soybeans grown in the United States use G.M.O. seeds, whose products find their way into most processed foods.) This is what they've done for years in most of Europe, where products with G.M.O.'s are almost universally labeled as such.

But it's not as if General Mills — which was among the funders of the opposition to G.M.O.-labeling efforts in California and Washington — has made a principled decision, or has suddenly seen some kind of light. (Other varieties of Cheerios, such as Apple Cinnamon and Multi Grain, will continue to be made with ingredients containing G.M.O.'s, including corn, corn syrup, beet sugar and others.) It could simply be that the company saw an opportunity to appease part of its market, and to test whether a minimal effort could lead to a labeling opportunity that would boost sales as would, say, a "high-fiber" or cholesterol-reduction notice.

But the label is only meaningless in terms of Cheerios' content. My guess is that General Mills is right: the G.M.O.-free label will appeal to consumers who, for whatever reasons — justified or not — would rather buy a G.M.O.-free product. Increased sales might come at the expense of other Cheerios products, but then again they might come at the expense of competitors' cereals that can't brag about their "purity." (Let's remember that few, if any, health-savvy breakfast-eating people would make Cheerios a frequent choice in any case— even if they are easy for toddlers to nibble on.)

All of this makes the announcement significant, because if it works, others will follow suit. And farmers could easily make the switch back to non-G.M.O. seeds (more are beginning to, as the benefits of G.M.O. seeds are increasingly outweighed by their costs), and processed food companies are — or at least should be — agnostic as to whether corn, for example, was grown with conventional or G.M.O. seeds.

Should we care? Yes. Much of the controversy over G.M.O.'s is being fought between those with a vested interest in their success and those who are willing to overstate the problems with the technology. Producing seeds containing G.M.O.'s is a valid scientific technique. The problem is that the benefits have accrued more to the seeds' producers than to farmers (who are spending many times more for seeds than they were previously) or consumers (who can't possibly tell the source of refined products in their processed foods) or to the environment. There's an argument that G.M.O. seeds increase yields and keep food costs down, but it's not a convincing one.

There are three real issues here, and none of them is about whether there are teeny tiny G.M.O. ingredients in our food. One is that G.M.O. seeds have arguably done more harm than good, by making traditional farming more expensive for farmers — not only here but internationally — and by retarding progress in combating weeds and bugs ecologically in industrial farming. Still, eliminating G.M.O.'s would not do much to remedy what's wrong with industrial agriculture; that's going to require a hard look at crop rotation, chemical applications and monoculture in general.

Another issue, and I've written about this before, is transparency. Increasingly, people want to know how and with what their food is being produced. (Over 90 percent of Americans are in favor of G.M.O. labeling.) Some of this may be for the wrong reason — fear of eating foods produced with G.M.O. seeds. (About half the population believes G.M.O.'s to be unsafe.) But the argument for labeling and transparency goes way beyond G.M.O.'s, and any labeling that provides more information should be seen as a victory for people who care about food quality.

This brings us to the third issue, one about which I'm not happy. If opportunistic marketers like those at General Mills can cash in by making insignificant changes in their products that lead to significant marketing benefits, what happens to people who've actually put work into making their products significantly cleaner — that is, organic? Once you have an "organic" label, you are forbidden to put "Not Made With Genetically Modified Ingredients" on your package — that's theoretically understood, as are more important benefits, like antibiotic- and pesticide-free. But thanks to the way-too-loud G.M.O. screaming match, my guess is that it's easier to market food using a meaningless "G.M.O.-free" label than an organic label. That's not a cheery thought.

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Pregnant, and Forced to Stay on Life Support

Rex C. Curry for The New York Times

Lynne Machado is the mother of Marlise Munoz, who is on life support in a Fort Worth hospital.

FORT WORTH — The diagnosis was crushing and irrevocable. At 33, Marlise Munoz was brain-dead after collapsing on her kitchen floor in November from what appeared to be a blood clot in her lungs.

But as her parents and her husband prepared to say their final goodbyes in the intensive care unit at John Peter Smith Hospital here and to honor her wish not to be left on life support, they were stunned when a doctor told them the hospital was not going to comply with their instructions. Mrs. Munoz was 14 weeks pregnant, the doctor said, and Texas is one of more than two dozen states that prohibit, with varying degrees of strictness, medical officials from cutting off life support to a pregnant patient.

More than a month later, Mrs. Munoz remains connected to life-support machines on the third floor of the I.C.U., where a medical team monitors the heartbeat of the fetus, now in its 20th week of development. Her case has become a strange collision of law, medicine, the ethics of end-of-life care and the issues swirling around abortion — when life begins and how it should be valued.

"It's not a matter of pro-choice and pro-life," said Mrs. Munoz's mother, Lynne Machado, 60. "It's about a matter of our daughter's wishes not being honored by the state of Texas."

Mrs. Munoz's father, Ernest Machado, 60, a former police officer and an Air Force veteran, put it even more bluntly. "All she is is a host for a fetus," he said on Tuesday. "I get angry with the state. What business did they have delving into these areas? Why are they practicing medicine up in Austin?"

Mrs. Munoz's parents said they wanted to see the law overturned, but they have not sought any legal action against the hospital, though they have not ruled it out either.

The hospital maintains that it is following the law, although several experts in medical ethics said they believed the hospital was misinterpreting it. A crucial issue is whether the law applies to pregnant patients who are brain-dead as opposed to those in a coma or a vegetative state. The law, first passed by the Texas Legislature in 1989 and amended in 1999, states that a person may not withdraw or withhold "life-sustaining treatment" from a pregnant patient.

Mr. and Mrs. Machado said the hospital had made it clear to them that their daughter was brain-dead, but hospital officials have declined to comment on Mrs. Munoz's care and condition, creating uncertainty over whether the hospital has formally declared her brain-dead.

A spokeswoman for the J.P.S. Health Network, the publicly financed hospital district in Tarrant County that runs the 537-bed John Peter Smith Hospital, defended the hospital's actions. "In all cases, J.P.S. will follow the law as it applies to health care in the state of Texas," the spokeswoman, Jill Labbe, said. "Every day, we have patients and families who must make difficult decisions. Our position remains the same. We follow the law."

Ms. Labbe said that neither she nor the doctors could answer questions about Mrs. Munoz's condition because her husband had not signed the paperwork allowing them to speak to the news media about his wife's care.

At least 31 states have adopted laws restricting the ability of doctors to end life support for terminally ill pregnant women, regardless of the wishes of the patient or the family, according to a 2012 report from the Center for Women Policy Studies in Washington. Texas is among 12 of those states with the most restrictive such laws, which require that life-support measures continue no matter how far along the pregnancy is.

Legal and ethical experts, meanwhile, said they were puzzled by the conflicting accounts of her condition. Brain death, an absence of neurological activity, can be readily determined, they said. It is legally death, even if other bodily functions can be maintained.

"If she is dead, I don't see how she can be a patient, and I don't see how we can be talking about treatment options for her," said Thomas W. Mayo, an expert on health care law and bioethics at the Southern Methodist University law school in Dallas.

Manny Fernandez reported from Fort Worth and Erik Eckholm from New York.

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Report Finds More Flaws in Digitizing Patient Files

Although the federal government is spending more than $22 billion to encourage hospitals and doctors to adopt electronic health records, it has failed to put safeguards in place to prevent the technology from being used for inflating costs and overbilling, according to a new report by a federal oversight agency.

The report, released on Wednesday by the Office of the Inspector General for the Health and Human Services Department, is the second in two months to warn about flaws in the oversight of the ambitious federal program aimed at converting patient records from paper to electronic. It comes as the Obama administration continues to face broad criticism over the troubled rollout of its health care law — especially the HealthCare.gov site.

Despite spending "considerable resources to promote widespread adoption of E.H.R.'s," or electronic health records, the government has "directed less attention to addressing potential fraud and abuse," according to the report. Medicare has not changed the way it tries to detect fraud and has provided its contractors "with limited guidance," the report said.

The report was especially critical of the lack of guidelines around the widely used copy-and-paste function, also known as cloning, available in many of the largest electronic health record systems. The technique, which allows information to be quickly copied from one document to another, can reduce the time a doctor spends inputting patient data. But it can also be used to indicate more extensive — and expensive — patient exams or treatment than actually occurred. The result, some critics say, is that hospitals and doctors are overcharging Medicare for the care they are providing. While the report did not estimate the amount of fraud that may be occurring, earlier government estimates have said it could run in the hundreds of millions of dollars. Although the amount is a fraction of the trillions of dollars spent annually on health care, the lack of safeguards at a time when the new technology is becoming pervasive could allow the fraud to balloon.

"As E.H.R. adoption has increased, so has its involvement in our cases," said Michael Cohen, an inspector at the oversight agency's investigations office, which is charged with investigating health care fraud in government programs.

In a separate analysis released last month, the inspector general's office found that three-quarters of the hospitals it surveyed had no formal policy surrounding the use of copy-and-paste for electronic health records. Its latest report faults Medicare for failing to provide guidance to the contractors who actually handle the payments on how to ferret out fraud stemming from the digital transformation. The office plans to make the scrutiny of cloning a priority for the coming year.

In a statement, Medicare officials called preventing fraud "a top priority" and said, "We are working to create strong standards for validating electronic health records to ensure that we allow beneficiaries to receive the care they need and at the same time protect taxpayers from fraud waste and abuse."

They also said they were developing better instructions for their contractors, but argued that the agency's specific recommendation about how contractors should detect fraud — by closely reviewing changes to specific patient documents — would not be appropriate for every situation. Hospitals say they are already carefully monitoring the use of electronic records.

"Hospitals already have strong safeguards," said Linda E. Fishman, a senior executive for public policy at the American Hospital Association. But, she said, they are also being pushed to adopt the new systems as quickly as possible. Federal officials "don't want providers to take their foot off their gas pedal," she said.

In addition, some experts say, doctors and hospitals are overloaded with demands to input electronic data and are copying some routine information from one file to another to save precious time.

"We're continuing to see the use of cut-and-paste in health care organizations because clinicians find it is one of the only ways they can manage the documentation process," said Michelle Dougherty, the senior director of research and development at the American Health Information Management Association, a group that focuses on improving the quality of health information. "But there is the potential that there is information being copied that is not relevant or even erroneous," she added.

Proponents of electronic records say the administration's goal of propelling more hospitals and doctors into the digital age has been successful and is critical to providing better, more coordinated patient care. The percentage of hospitals adopting a basic electronic system has nearly tripled since 2009 to 44 percent of all institutions.

Under a 2009 law, Congress enacted a program to provide billions of dollars in incentive payments for physicians and hospitals to install electronic health records. If they fail to meet the deadline, they will start to see reductions in their Medicare reimbursements by 2015.

But the rapid, vast metamorphosis in health care — like transformations of industries before — has been difficult, expensive and controversial. Hospitals have spent tens of billions of dollars buying systems that many have discovered are complicated to use, and critics have raised serious concerns about both patient privacy and safety. A study released last fall found that emergency-room physicians in a community hospital spent 43 percent of their time entering data, clicking up to 4,000 times during a 10-hour shift, compared with only 28 percent directly caring for patients.

As much as electronic records have the potential to provide better care, many are disappointed in the current technology. The boosters of electronic health records "spent a lot of years overhyping and overselling it," said Dr. Ashish K. Jha, professor of health policy at the Harvard School of Public Health.

One of the biggest questions around electronic health records is whether doctors and hospitals are using the technology to "upcode," or charge for services that were not provided. An analysis in September 2012 by The New York Times found a surge in Medicare spending on the most costly services at hospitals that had received money to put into place the new record systems. Hospitals said the increase reflected more accurate documentation of visits.

Administration officials and others then issued stern warnings against doctors and hospitals using digital records to overbill.

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Well: How Being Heavy or Lean Shapes Our View of Exercise

Phys Ed

Gretchen Reynolds on the science of fitness.

Overweight women's brains respond differently to images of exercise than do the brains of leaner women, a sophisticated new neurological study finds, suggesting that our attitudes toward physical activity may be more influenced by our body size than has previously been understood.

For the study, which was published last month in The International Journal of Obesity, scientists affiliated with the Key Laboratory of Cognition and Personality at Southwest University in Chongqing, China, recruited 13 healthy, young, normal-weight women and 13 who were overweight or obese.

The scientists asked their volunteers to complete two questionnaires, one of which probed the extent to which they considered exercise desirable; would they agree, for instance, that, "if I were to be healthy and active, it would help me make friends"? The other set of questions examined whether they expected exercise to be unpleasant; if they were to be physically active on most days, for example, would they expect to wind up feeling sore, or maybe even embarrassed by exercising in public?

The researchers next had each woman lie inside a functional magnetic resonance imaging machine, which scans blood flow to specific areas of the brain, indicating areas of increased activity. Then they started a slide show.

For some time, scientists have known that many overweight people's brains operate differently than the brains of thinner people when they look at images related to eating. In previous neurological studies, when heavier volunteers viewed pictures of food or food preparation, they typically developed increased activity in portions of the brain involved in reward processing, or an urge to like things, including in an area called the putamen. At the same time, their brains showed relatively blunted activity in areas that are thought to induce satiety, or the ability to know when you are full. These changes generally are reversed in the brains of thinner people shown the same images.

But no brain-scanning studies had examined whether being heavy might also affect people's brain responses — and presumably their attitudes — toward physical activity.

So, to address that gap, the researchers now flashed a series of photographs before their prone volunteers. Ninety of the images showed people being joyously active by running, dancing, leaping, playing tennis and such. The women were asked to vividly imagine themselves performing the same actions, using hand gestures and limited bodily contortions, to the extent possible within the confines of the scanner.

Ninety additional images featured relaxed, sedentary behaviors, including stretching out on a sofa and sitting in a desk chair. Again, the women were directed to imagine themselves similarly lounging. The various images of activity and quiet were interspersed with photographs of landscapes.

While the women viewed the pictures, the functional M.R.I. machine monitored their brain activity.

The resulting readouts revealed that overweight women's brains were put off by exercise. Shown images of people being active, these women developed little activation in the putamen region of the brain, suggesting that they did not enjoy what they were seeing. At the same time, a portion of the brain related to dealing with negative emotions lit up far more when they viewed images of moving than of sitting. Emotionally, the brain scans suggested, they anticipated disliking physical activity much more than they expected to disdain sitting.

Leaner women's brain activity, by and large, was the opposite, with the putamen lighting up when they watched others work out and envisaged doing the same themselves.

Such data might at first seem discouraging, underscoring the possibility that being obese or overweight is self-reinforcing, although it is impossible to know from this study whether a dislike of exercise contributed to or resulted from weight gain.

A final and unexpected finding from the study provides a basis for hope, though. The scans also showed that when overweight volunteers viewed images of exercise, a portion of their brain related to movement memory remained stubbornly silent. Their bodies were unfamiliar with how to be active, which might have contributed, the study's authors speculate, to the women's negative emotional response to activity. They didn't know how to exercise and anticipated not enjoying trying to learn.

Interestingly, these women had also said at the study's start, when answering the questionnaires, that they expected exercise to end in embarrassment (while also believing that if only they could exercise, they would be more popular).

The practical takeaways of the findings are obvious and almost poignant.

"Encourage people to pursue physical activities and exercise that they actually find pleasurable and might enjoy," said Todd Jackson, a professor of exercise science at Southwest University, who led the study. Hire a kind, nonjudgmental coach or personal trainer to lead you through a manageable exercise routine.

And if you continue to find yourself drawn to the couch instead of the gym, use that inclination strategically "as an incentive or reward for increasing exercise," Dr. Jackson said. Swim for 45 minutes and then allow yourself to surf the Internet, for instance, he suggests. Don't fight your brain's unenthusiastic attitude toward exercise, he said. Embrace it.

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Personal Health: Symptoms of Torn Artery Are Easy to Miss

Karin Satrom, a 35-year-old Brooklynite, had been feeling fine through 23 weeks of pregnancy when one night she said she became "very, very dizzy, as if I were drunk." Her husband suggested that she lie down, but even with her eyes closed, the room continued to spin.

Still extremely dizzy and seeing double in the morning, Ms. Satrom called her doctor, who sent her directly to New York Methodist Hospital. No pregnancy-related reason for her symptoms was found, but a neurologist suspected a tear in an artery in her neck that supplies blood to the back of the brain.

An M.R.I. confirmed the diagnosis, vertebral artery dissection, and showed that the transient ischemic attack, or mini-stroke, she had experienced as a result had left no lasting brain damage.

Ms. Satrom was immediately given an injection of Lovenox, an anticoagulant that she must continue to inject twice a day until the baby is born, sometime in March. Then a second scan will be done to see if the artery has healed.

Now six weeks later, Ms. Satrom has religiously followed her doctor's orders to "do nothing that involves turning my head — no swimming, no driving," and has remained symptom-free.

Dr. Wouter I. Schievink, a neurosurgeon at Cedars-Sinai Medical Center in Los Angeles and an expert on vertebral artery dissection, said Ms. Satrom was lucky to have seen astute physicians who zeroed in on the cause of her distress before it resulted in a full-blown stroke. Not everyone is as fortunate.

A dissection is not a hole in an artery, which would cause extensive bleeding. Rather, a tear occurs in one of the inner layers of the vessel, which results in a pooling of blood in the wall that partly or completely closes the flow of blood to the brain.

Rarely, a dissection can result in a bulge — an aneurysm — on the outer wall of the vessel that may or may not be painful.

Although vertebral artery dissection is one of the most common causes of stroke in young adults, it may produce no noticeable symptoms at first. And when they do occur, they are often nonspecific, like headache or neck pain. Symptoms may be ignored until it is too late or mistakenly attributed to a far less serious condition.

Ms. Satrom's dizziness, or vertigo, was the most commonly reported symptom in a review of 75 studies involving 1,972 patients by Dr. Rebecca F. Gottesman, a neurologist at the Johns Hopkins University School of Medicine, and co-authors. Vertigo afflicted 58 percent of those in the studies, headache (usually in the back of the head) 51 percent and neck pain 46 percent.

But nearly one-quarter of patients had no head or neck pain at the time of diagnosis.

Dizziness, headache and neck pain are extremely common and most often not related to a vertebral artery dissection. But when such a symptom occurs suddenly and seems out of the ordinary, emergency medical attention should be sought without delay, Dr. Gottesman said in an interview.

A prompt diagnosis is vital, she and her co-authors wrote, because the greatest risk of a stroke occurs in the first few weeks after an artery tears. Some tears — the percentage is unknown — never cause symptoms, however, and heal on their own without treatment, Dr. Gottesman said.

A vertebral artery dissection can result from a sports injury or a car accident. Minor traumas, including a forceful cough or sneeze, vomiting, extreme extension of the neck (as might happen in a beauty parlor, when painting a ceiling, or practicing yoga) or during chiropractic manipulation have been reported to cause dissections. The role of chiropractic manipulation is disputed, because people may seek chiropractic treatment for neck pain that is unknowingly the symptom of an existing dissection, not its cause. "If a neck pain comes on suddenly for no good reason or seems in any way unusual, people should think twice before going to a chiropractor," Dr. Gottesman said.

Fewer than half the patients in Dr. Gottesman's study reported a recognizable trauma that could have caused the tear, and less than 8 percent had a connective tissue disease like Ehlers-Danlos or Marfan syndrome that increases the risk of a dissection.

Other risk factors include high blood pressure, fibromuscular disease (causing abnormal cell growth in artery walls), migraine headaches, pregnancy (which loosens connective tissue throughout the body) and a recent respiratory tract infection.

The severity depends on whether the dissection occurs before or after the affected artery enters the skull. The latter causes a hemorrhage between the brain and skull in more than half of cases and has a much poorer prognosis.

An M.R.I., usually done using a contrast agent that highlights the arterial structures, is now the gold standard for diagnosing a vertebral artery dissection.

The main risk of a dissection is the formation of a clot, or series of clots, that can travel to the brain and cause a stroke. A transient ischemic attack is a warning sign of a possible stroke and should always be taken seriously.

Treatment with an anticoagulant, most often warfarin (also known by the brand name Coumadin), for several months or longer is needed to head off formation of a brain-damaging clot. There has been no controlled clinical trial to justify this approach, but experts attest to its logic. (Ms. Satrom was given Lovenox because it is much safer than warfarin during pregnancy.)

Although most dissections heal on their own, further intervention is occasionally needed, as when stroke-related symptoms persist after six months of anticoagulation. The damaged artery may then be treated by inserting a stent or coil.

If a dissected artery becomes completely blocked and continues to cause symptoms despite effective anticoagulation, Dr. Schievink said, a surgical bypass can be done to replace the damaged part of the artery

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