When the seventh and posthumous – edition of Dr. Benjamin Spock’s “Baby and Child Care” was published recently, the guru’s endorsement of a vegetarian diet for kids over 2 caused many nutritionists and doctors to choke on their leafy greens.

Dr. T. Berry Brazelton, professor emeritus of pediatrics at Harvard Medical School, thinks it’s “absolutely hopeless” to try to get kids to eat enough vegetables to offset the loss of nutrients they would suffer from giving up meat and milk.

Dr. Ronald Kleinman, author of the kids’ nutrition guide, “Let Them Eat Cake!” and chief of pediatric gastroenterology and nutrition at Massachusetts General Hospital, calls it a “terrible recommendation for the population as a whole.”

Even Dr. Steven Parker, the Boston Medical Center pediatrician who co-authored Spock’s last edition, can’t stomach the elderly pediatrician’s “advocacy of what amounts to a vegan diet for kids – no meat, fish, dairy or eggs.”

“This was an area upon which we didn’t agree,” says Parker, noting there’s little data – for or against – a vegan diet for kids. So how did they resolve it? “Spock trumped Parker.”

But not everybody thinks it’s nuts to feed kids a diet limited to grains, legumes, seeds, veggies, and fruits. After all, that does leave peanut butter, pasta, bagels, and cereal.

And not everyone thinks it’s impossible to do in a culture where kids are bombarded by images of burgers and ice cream.

Dr. Neal Barnard, president of the Washington-based Physicians’ Committee for Responsible Medicine, an animal rights group, contends that a vegetarian diet for kids is a valuable way to reduce diet-associated diseases in later life because “childhood is a time when adult dietary patterns are set.”

The American Dietetic Association says “appropriately planned vegan” and vegetarian diets that include dairy products and eggs “satisfy nutrient needs of infants, children, and adolescents and promote normal growth.” The American Academy of Pediatrics adds that if meal planning is adequate, vegan children grow normally.

Reed Mangels, 41, a nutritionist and registered dietician in Amherst who has been feeding her kids a vegan diet for years, says it’s “quite doable.” They’re happy with bean burritos, soy milk on cereal, lots of p-b-and-j’s, veggie burgers, and veggie hot dogs. “We’re talking quick and easy,” she says.

But are we talking enough protein, minerals, and calories?

That depends.

A good vegan diet is “perfectly compatible with good health and is probably preferable to a diet of Coca-Cola, pizza, and MacDonald’s,” says Dr. Walter Willett, professor of nutrition and epidemiology at the Harvard School of Public Health.

If parents consult a registered dietician and use fortified cereals and plan meals well, a vegetarian diet that includes milk and eggs can be “a fine option” for kids,” says Johanna Dwyer, director of the Frances Stern Nutrition Center at Tufts and one of the few nutritionists who has studied the issue. “But I take a dim view of a strict vegan diet for kids” – one that excludes eggs and dairy products.

If, however, parents are haphazard about nutrition and ignore other health measures – such as routine immunizations – a vegetarian diet can contribute to poor growth and anemia.

Without any animal products, for instance, kids may become deficient in iron, calcium, some B vitamins, vitamin D, and zinc. In Northern climates like Boston’s, vitamin D deficiency can be a particular problem because the body makes the vitamin from precursors that are activated by sunshine.

And some kids who avoid animal products may become so deficient in vitamin B-12 they are at increased risk of seizures, adds Willett, who suggests that vegan kids take a multi-vitamin supplement daily.

Milk is a particular bone of contention.

Six years ago, Spock (who went on a nondairy, low fat, meatless diet in 1991, at age 88) triggered controversy when, with Barnard of the animal rights group, he proclaimed that neither adults nor kids should drink cow’s milk, contending that it “causes intestinal blood loss, allergies, indigestion and contributes to some cases of childhood diabetes.”

Milk may be “culturally normal” to Americans, though it’s not for much of the rest of the world, but it interferes with absorption of iron, Barnard contends.

Willett disagrees: Milk doesn’t interfere with iron absorption “in any major way” and is such a rich source of calcium that if a child is on a dairy-free diet, he should take a calcium supplement – 800 to 1,000 milligrams a day.

You can get enough calcium from vegetables, adds Kleinman of MGH, but it takes four cups of broccoli to equal a cup of milk.

And while a report in 1992 in the New England Journal of Medicine did suggest that cow’s milk may increase the risk of diabetes in genetically-susceptible children – perhaps by triggering production of antibodies that attack the pancreas – research since then has debunked that notion, Kleinman adds.

And what of the anti-milk argument that the fatty liquid leads to clogged arteries, even in kids?

Both the National Cholesterol Education Program, a government-sponsored committee of nutrition specialists, and the American Academy of Pediatrics say that fats should not be restricted in kids under two, but after that they should follow the same guidelines as adults – a diet of not more than 30 percent fat. In other words, kids should eat dairy products, but the low-fat kinds.

Getting enough protein is not a serious problem for children on vegan diets, provided the sources of plant protein are varied – not just carrots, celery, and lettuce, but beans and other legumes. While nutritionists once thought it was necessary to eat “complementary” proteins such as beans and grains at the same meal to get the full range of amino acids, many now think it’s fine just to balance proteins over 24 hours.

But getting enough calories on a veggie diet can be a problem. Granted, 30 percent of American kids are obese – they eat too many calories and expend too few in exercise. But kids on veggie diets, which are low in fat and high in fiber, may not provide enough energy for a growing child.

Very high fiber diets, says Dwyer of Tufts, means some kids “just can’t eat enough, especially when they are small and are being weaned from breast milk. They eat all the time.”

For Reed Mangels, the vegan mom, the bottom line is that even if parents don’t follow all of Spock’s recommendations, at least he’s made “people think a little bit about what kids eat.”

But Parker, Spock’s co-author, thinks a diet of all veggies is silly, especially since there’s little evidence that the eating habits you form in childhood stick with you for life.

“Personally,” he says, “I think a childhood without ice cream just isn’t worth it.”

Jesus thought fasting was good for the soul. So do Jews, who fast on Yom Kippur; Muslims, who fast by day during Ramadan; and Catholics, who fast on Ash Wednesday and Good Friday.

Ghandi fasted for political reasons – to liberate India in the 1920s and 1930s. IRA member Bobby Sands did, too, fasting in prison in 1981 – he died after 66 days – to protest being denied prisoner-of-war status.

And this month, Chuck Purcell, 52, a Virginia engineer at the Department of Energy, joined their ranks, taking nothing but water for 12 days. But like many other overfed folks in this land of plenty, he fasted not for spiritual or political reasons but for health: to try to lower his blood pressure and banish an itchy skin problem.

Fasting – the voluntary abstinence from food – is probably as old as the urge for self-control and spiritual purification, and whether it achieves those ends is a subjective judgment.

But proponents of fasting often claim it has medical benefits, too, like “detoxification,” healing auto-immune diseases, losing weight, and restoring bodily harmony. Does it?

With some important qualifiers, the mainstream answer is no.

“Fasting is not good for you medically,” says Dr. George Blackburn, a Harvard nutritionist. “There’s no such thing as a therapeutic fast.”

Fasting “sounds like it would cleanse you, but there’s really no science to it,” adds Elizabeth Ward, a registered dietician and spokeswoman for the American Dietetic Association.

“Fasting is basically bad news,” agrees physiologist Susan Roberts, head of the energy metabolism lab at Tufts University’s human nutrition research center.

The reason they are so emphatic is this: When you stop eating completely, even if you take in plenty of water, you start breaking down protein – muscles – almost immediately.

For the first 12 to 16 hours of total abstinence, there’s enough glycogen – stored sugar – in the liver to keep your brain, the chief consumer of energy, happy.

But during the next day and a half, the body makes glucose from amino acids stolen from muscle protein. At first, you lose protein from inside a muscle cell, which can be replaced. But soon, whole cells disappear, and they’re hard to replace.

After two days of abstinence, the body does begin burning fat for energy, but it takes 21 days before you adapt sufficiently to starvation that you stop losing protein. Granted, the body’s ability to switch from burning glucose to burning fat is a wonderful evolutionary adaptation that has undoubtedly aided survival when starvation, not obesity, was the chief threat.

But burning fat also produces ketone bodies, snippets of fatty acids, that can dehydrate you, give you bad breath and, some nutritionists think, have toxic metabolic effects.

It’s true you can live this way for more than 40 days, perhaps even 100, if you’re healthy and drink water. But ultimately, of course, if you don’t eat, you die.

That said, there may be some medical benefits to fasting, particularly modified fasting, for carefully selected patients.

There’s considerable evidence, for instance, that severe diabetes can be brought under control quickly on a modified fast in which the patient eats nothing but 9 to 12 ounces a day of protein (meat, fish or fowl), plus electrolyte supplements, and bicarbonate of soda, says Blackburn. Eating protein slows the wasting of muscle; and with no intake of carbohydrates, blood sugar stabilizes.

Modified fasting can also lower blood pressure. During his fast, Purcell’s pressure fell from 140 over 90 to 108 over 78.

Scandinavian data suggests that fasting also helps people with arthritis, says Dr. Joel Fuhrman, a guru in Belle Mead, N.J., who has overseen the fasts of thousands of patients, including Purcell, who paid $ 1,200 to live in Furhman’s home during his fast.

When no food is taken in, Furhman believes, the body’s inflammatory response to foreign substances may decrease, thus allowing the hyperactive immune system – the hallmark of auto-immune diseases like rheumatoid arthritis – to calm down.

Alternative medicine specialists, like Dr. Jay Glaser, medical director of the Maharishi Ayurveda Medical Center in Lancaster, believe modified fasting – a liquid diet (fruit and vegetable juices, broth and herb tea) one day a week – can also reset the “food-seeking thermostat” and “lighten the body.”

In ayurvedic medicine, which originated in ancient India, fasting is believed to increase “digestive fire” (agni), get rid of metabolic clutter (ama), and offset heaviness (kapha).

Western medicine scoffs at the notion that fasting is necessary to “detoxify” the body.

“People think there’s a whole bunch of junk floating around in their bodies,” says dietician Ward. That’s nonsense – the liver, kidneys, colon and sweat glands do a great job of waste control. If you want to do something extra, eat more fiber.

You’re also fooling yourself if you think fasting will jump start a weight-loss program. Fasting is a lousy way to lose weight – the metabolism slows down so much that when you start eating again, you’ll gain weight faster than before.

It is true that fasting may give you a sense of control, says New York psychologist Sandra Haber, who specializes in eating disorders. Many people complain that they can’t control their spouse, their work, their kids, or their feelings, and that the only thing they do have control over is food intake, she says.

But if control is the issue, “you’re better off going after it directly,” she says. In other words, “Let’s talk.”

It is also true that fasting may give you an emotional high. Part of this may come from the stress of early starvation, which triggers adrenalin. And part may be a sense of “doing penance” and being “spiritually clean,” says Larry Lindner, executive editor of the Tufts University Health & Nutrition Letter.

But fasting can also make you grumpy and weak. Reached on Day 10 of his fast, Purcell was in good spirits, but felt weak climbing stairs and admitted that Day 3, when he had dry heaves, had been “very difficult.” He was pleasantly surprised, though, that hunger was not a problem.

If, despite the shaky medical justification, you still want to fast for spiritual reasons, that’s fine, nutritionists say. Just don’t do it too often and don’t do it in two-day bursts, which would maximize muscle loss. The best bet is to keep fasts short – 12 hours – and to load up on carbohydrates beforehand.

While starving, Jews studied hunger

Most of the research data on human starvation comes from heroic studies by Jewish doctors and nurses in the Warsaw Ghetto during the Nazi occupation of Poland in the early 1940s.

As they themselves suffered, 28 doctors and perhaps 200 nurses kept track as the Nazis tried to starve the 250,000 Jews in the ghetto. It is “the only scientific study in which most of the investigators died at the end,” says Dr. Ronenn Roubenoff, a Tufts nutritionist. “It is truly a testament to the human spirit.”

Though a child needs 1,000 calories a day, a woman 2,000 and a man, 3,000, the Nazis allowed so little food into the ghetto that people were living on 800 calories a day or less – usually from thin soups and crusts of bread.

Meticulously, the researchers documented the effects: the loss of growth in children, the slowing of the eye’s response to light, the disappearance of the thymus gland (a key part of the immune system), the inability of the immune system to produce a normal response to tuberculosis skin tests and, of course, the loss of body fat and muscle.

Although it is contrary to Jewish law, the doctors also did autopsies on 492 people who had no other cause for death than what the researchers called “hunger disease.” (Overall, during the three years the Jews were confined to the ghetto, 98,165 died, 18,320 of hunger disease.) The researchers also found death came quickly once people lost 40 percent of lean body mass.

The researchers smuggled hundreds of pages of data out to a non-Jewish doctor at the University of Warsaw who buried the data in his backyard until the war was over. In 1945, one of the surviving ghetto doctors dug it up and wrote an 80-page summary, but before he could analyze the data fully, he died.

His widow sent the summary, written in French, to the United Nations, where, “like any great bureaucracy, they filed it,” says Roubenoff. It was not until 1966 that a Polish history student stumbled upon it while looking through UN archives. He then contacted a Columbia University nutrition professor and together, they tracked down the primary data, analyzed it and published it in 1979.

We’ve become a nation of water drinkers, so bitten by the bug to imbibe that we lug plastic bottles around all day, not just to stave off dehydration but to avoid just about every other ill from dry skin to constipation to fatigue, muscle weakness, and colds.

Are we really that desiccated? Or just deluded?

Obviously, since our bodies are two-thirds water, we need water to survive. Water is the nutrient “you can go without the shortest period of time,” says Dr. George Blackburn, a nutritionist at Beth Isreal Deaconess Medical Center.

True enough, but are most of us really getting too little?

Pop culture says so. Take last September’s Men’s Health magazine, which extolled the wonders of water to achieve miracles like this: “Lose fat – without pesky exercise!”

Then there’s Dr. Fereydoon Batmanghelidj, an Iranian-born physician (now in Virginia) who wrote “Your Body’s Many Cries for Water.” He says people “need to learn they’re not sick, only thirsty,” and that consuming water “cures many diseases like arthritis, angina, migraines, hypertension and asthma.

He says his insights – from reading, not research – are a “paradigm shift” and that he self-published his ideas lest they “be suppressed.”

On the other side, there’s Dr. Gary Curhan, who says that unless you have kidney stones, forcing yourself to drink water when you’re not thirsty is silly.

“There’s no evidence at all that drinking extra water is beneficial for an otherwise healthy person,” says Curhan, a kidney specialist at Brigham and Women’s and Massachusetts General hospitals.

Dr. Ronenn Roubenoff, a Tufts nutritionist, agrees: “A vitamin deficiency can be cured by vitamin treatment, but does taking more supplements than you need make you even better? The answer for water, just like vitamins, is probably no.”

In other words, if you eat regular meals and drink liquids as you eat, you’re probably fine, says physiologist Michael Sawka, chief of thermal and mountain medicine at the US Army Research Institute of Environmental Medicine in Natick.

Where all the experts, self-appointed and otherwise, agree is that actual dehydration can be deadly, not just for elderly folks who may lose a sense of thirst but for healthy, young jocks, too.

Last fall, three wrestlers, among them 21-year-old Jeff Reese of the University of Michigan, died trying to sweat themselves down to fighting weight. Reese died of a heart attack and kidney failure after trying to lose 12 pounds in one day by not eating or drinking and by working out – in a rubber suit – for two hours in a room at 92 degrees Fahrenheit.

Dehydration can cause muscle cramps, and “this person cramped his heart,” says Tufts exercise physiologist Ann McDermott. Body temperature soars, the concentration of minerals called electrolytes in the blood rises (which disrupts the ability of muscles to contract and relax properly), and heart rhythm abnormalities may develop.

But it’s a safe bet that most water guzzlers are less concerned with dehydration than with general health and beauty. So here are the facts – and myths – about water:

• How much do you need? On a sedentary day, to balance water lost through urination, breathing, and sweating, you should consume half an ounce of water for every two pounds of body weight. If you’re 120 pounds, that’s 7 1/2 eight-ounce cups.

• How can you get this much? Easily, and not just by drinking – there’s water in fruits, veggies, and other foods. If you’re still worried, keep water at your desk to sip.

• Do caffeinated beverages count? Sort of. Coffee, tea, and caffeinated sodas are mild diuretics, making you urinate more. But they’re basically water, so they help somewhat.

• What about sweet drinks and fruit juices? They count because they’re mostly water. But the sweetness can make you thirsty – and they’re fattening.

• OK, how about beer (or other alcoholic drinks)? Beer is mostly water, too, but because alcohol is dehydrating, you can’t count beer as hydration. That goes double for wine and liquor, which have so little volume they don’t contain much water.

• Does drinking lots of water make you lose weight faster? Not directly. But filling up on water, plus fiber, can make you feel full, with few calories.

• Does water flush fat cells out of the body? Nope, sorry.

• Does extra water moisturize skin from within? No. All you need for your skin – and other organs – is basic hydration, says Dr. Richard Johnson, a dermatologist at Beth Israel Deaconess.

• Does water fight constipation? Again, it’s basic hydration that keeps things normal. Drinking excess water won’t help. (If you have diarrhea, though, that’s when you do need extra water. Some people make the mistake of trying to stop diarrhea by not drinking.)

• Can water rid you of excess mucus in your nose or throat? Mucus is made from water, so you need to be adequately hydrated to make it. But you can’t make mucus thinner or a cough looser by drinking more, says Kenneth Lema pharmacist at the University of California San Francisco School of Pharmacy.

• Is bottled water better for you than tap water? No.

• What about water needs during exercise? That’s where you should take extra care, says the American College of Sports Medicine. When you exercise hard, especially in the heat, by the time you feel thirsty you’re already dehydrated.

• It’s sensible to drink some water before a long, vigorous workout. During exercise, if you sweat a lot, drink 8 ounces every 20 minutes. Afterwards, drink several glasses, even a quart.

• Do you need to replace electrolytes after a sweaty workout? Not if you eat a normal diet.

• So there’s no need for sports drinks like Gatorade? Probably not for workouts less than an hour. Gatorade and similar drinks can provide energy during longer workouts and can help replace sodium and potassium lost through sweating. But if you do drink them, get those with 8 percent or less carbohydrate. Carbohydrates slow stomach-emptying, which means it takes longer to get water into your system.

• Does drinking water during hard exercise reduce fatigue? It seems to. Physiologist Edmund Burke of the University of Colorado in Colorado Springs studied skiers who either drank water only at lunch or sipped all day from a CamelBak portable water system. The sippers felt stronger and less tired, he says.

• Is it possible to drink too much water? Yes. Too much water dilutes the concentration of sodium in your blood and causes seizures and impaired thinking. But for most of us, it would take 15 quarts a day to cause this.

So what’s the bottom line?

Do take dehydration seriously if you’re elderly or exercising very hard. Beyond that, don’t expect medical miracles from sipping all day. You probably don’t need to force yourself to drink water. You may be dehydrated if:

• You are elderly and fall a lot (especially if you take diuretics, which make you lose water) and take anti-hypertensive drugs.

• Your urine is dark (vitamin supplements and other substances can also this).

• You’re not urinating as often as usual.

• Your mouth is dry.

• You weigh a couple of pounds less one morning than the day before.

• You get a low-grade headache after working out.

About six years ago, Canadian researchers discovered quite by accident that people who sloshed down their high blood pressure medicine with a glass of grapefruit juice got an extra kick: The drug became much more effective, apparently because it was absorbed better by the body.

So much more effective, in fact, that some doctors now worry that people who usually use water to take certain calcium channel blockers may wind up lowering their blood pressure too steeply if they suddenly switch to grapefruit juice.

Then there’s the case of the young Michigan man who reportedly died of cardiac arrythmia soon after taking Seldane, the antihistamine/decongestant, with two glasses of grapefruit juice.

“The cause of his death is that he took Seldane with grapefruit juice,” says Dr. J. David Spence, one of the Canadian researchers and director of stroke prevention and atherosclerosis research at the Robarts Research Institute in London, Ontario.

But others, among them Dr. David Flockhart, associate director of the division of clinical pharmacology at Georgetown University Medical Center in Washington, D.C., say that after two studies on Seldane and grapefruit juice, the evidence remains inconclusive.

Nonetheless, Hoechst Marion Roussel, the manufacturer of Seldane, added a warning to package labels in May advising people not to take the pill with grapefruit.

Who’d-a-thunk it? Good old grapefruit, that mouth-zinging staple of many a breakfast table, cast in the role of nutritional bad guy!

Yet the “grapefruit effect” has been a source of concern for several years now, and two weeks ago University of Michigan researchers said they had discovered the reason why.

Unlike oranges and other citrus fruits, grapefruit — both in juice form and in wedges — contains two types of chemicals called furanocoumarins, says Dr. Paul B. Watkins, director of the University of Michigan General Clinical Research Center in Ann Arbor.

These substances trigger the drug-potentiating effect by interacting with an enzyme (called CYP3A4) in the intestinal walls. Normally, this enzyme breaks down some, though not all, drugs as they pass through the digestive system, says Watkins, adding that this is actually a problem for drug manufacturers because the enzyme makes it tough to get adequate quantities of some medications into the bloodstream.

But when grapefruit juice is present — and some researchers think its effects can linger for a day or more — the enzyme is knocked out of commission and absorption of certain drugs is dramatically increased, sometimes by as much as nine times.

With the immunosuppressant cyclosporin, for instance, grapefruit juice boosts absorption so much that some patients who take the drug to prevent rejection of a transplanted organ can get the same effect with less medication.

Dr. Ray Woosley, chairman of the pharmacology department and co-director of the Cardiovascular Institute at Georgetown, says that when his brother, a kidney transplant patient, began taking grapefruit juice along with cyclosporin, he was able to cut the cost of his medication from $12,000 a year to $6,000.

Donna Surratt, a 52-year-old liver transplant recipient from Forestville, Md., says that when she started taking grapefruit juice along with the immunosuppressant FK-506, the juice boosted the drug’s effect so much doctors became concerned about toxicity.

Some AIDS patients, too, use grapefruit juice to boost the absorption of drugs, notably saquinavir, a protease inhibitor.

But Dr. Greg Robbins, an infectious disease specialist at Massachusetts General Hospital, urges caution, warning that doctors don’t know enough about the interaction of grapefruit juice and AIDS drugs. A better-documented way to boost saquinavir’s effectiveness, he says, is to add a second protease inhibitor, ritonavir.

Dr. Jerome Groopman, an AIDS specialist and chief of experimental medicine at Beth Israel Deaconess Medical Center, adds that a just-released formulation of saquinavir is much better absorbed than its predecessor and that in general patients should not try to boost drug effects with grapefruit juice without checking with a doctor or druggist.

Flockhart of Georgetown agrees, noting that one of his patients “went close to psychotic” after taking grapefruit juice with a morphine-based painkiller called MS Contin.

Flockhart, who has compiled a list of drugs that may interact with grapefruit juice, also warns about mixing grapefruit with the sleeping pill Halcion or the sedative Xanax.

A number of calcium channel blockers, taken to lower blood pressure, also appear to interact with grapefruit juice, says Watkins of Michigan, though the degree of effect varies greatly. One such drug, Sular, now comes with a warning against taking it with grapefruit.

Cholesterol-lowering drugs such as lovastatin and simvastatin, as well as a drug called Propulsid for gastrointestinal reflux, may interact with grapefruit juice, too, although this is not as well studied.

So far, none of this constitutes a huge public health concern, says Watkins, because many drugs are designed to be safe even at high blood levels. This is especially true for drugs whose absorption rates vary.

Still, it gets tricky trying to figure out just how much grapefruit juice may affect drug metabolism in a given patient. Part of the difficulty is that the quantity of active ingredients in grapefruit varies considerably — between grapefruit products and even between different lots of the same brand of frozen concentrate.

Furthermore, people vary widely in how much of the intestinal enzyme they produce.

“If you have a lot of this enzyme,” says Watkins, “you won’t get much of certain drugs into your body. Therefore, taking grapefruit juice will have a big effect. If you have low amounts of this enzyme, you will already be absorbing higher amounts of drugs, and grapefruit juice will add little effect.” Unfortunately, there is no easy way consumers can gauge their enzyme levels.

Among those increasingly fascinated by the grapefruit effect are drug manufacturers, some of whom are now trying to incorporate the active ingredients into various pills, says Watkins, who consults with drug companies and is chairman of the scientific advisory board at AvMax, Inc. in Berkeley, Calif.

The ideal targets are pills that are poorly absorbed by the body in their current form, adds Jeff Silverman, an experimental pathologist at AvMax.

So what should you do until the scientists sort it all out?

The safest course is to not change what you’re doing. If you have been taking your pills with grapefruit juice for years and have had no problems, keep on doing so. If you haven’t, don’t start.

If you’re curious about a particular combination, ask your pharmacist to look up potential interactions.

And you can follow the rule of thumb some grapefruit researchers have come up with: If a drug carries a warning of possible adverse interaction with the antibiotic erythromycin, there’s a decent chance it interacts with grapefruit, too.

In other words, if you shouldn’t combine a particular medication with erythromycin, don’t take it with grapefruit juice, either.

 

As incidence of diabetes rises, a major effort is launched to head off costly and debilitating illness

Chances are, you think of diabetes as a problem of sheer bad luck — either you get it or you don’t.

But preliminary studies have suggested that, far from being inevitable, diabetes may actually be preventable, even if you’re among the 21 million Americans at higher-than-normal risk. 

Now, a major study under way at two hospitals in Boston and 23 others across the country is trying to determine whether an aggressive program of diet and exercise or drug therapy can prevent or at least delay diabetes in people most at risk.

And that’s not only a hypothesis. It’s also the fervent hope of people like Maureen Oliver, 32, of Norwood, who works at the Center for Blood Research in Boston and who became worried about her own health when her sister, 33, was diagnosed with Type II diabetes last year.

Oliver is among 4,000 people nationwide expected to participate in the five-year study, and so far, she says, the perks of being a human guinea pig are worth all the prodding and poking.

“They are watching your health so much more closely” than normal doctors do, Oliver says of researchers at the Joslin Diabetes Center. “My sister probably had this for a year without knowing it. . . I’d rather know right away” if diabetes develops.

Diabetes, which comes in two types, is one of the most debilitating of all medical problems.

Type I is an autoimmune disease that must be treated by daily injections of insulin and often strikes children and young adults; Type II, which constitutes 95 percent of all cases and can be treated with insulin, other drugs or diet and exercise, may have several causes and often begins later in life.

If diabetes really can be prevented much of the time, the payoff would be enormous, for individuals and the world.

In this country alone, diabetes is an epidemic affecting one of 10 adults, says Dr. David M. Nathan, director of the diabetes center at Massachusetts General Hospital and the leader of the national prevention study.

“Once it develops, it is difficult to treat, and it is the major cause of blindness, kidney failure and limb amputations. It also raises the risk of heart disease, stroke and peripheral blood vessel disease two- to seven-fold,” he says.

Worldwide, diabetes rates are also soaring, and the main reason is that people aren’t eating right or exercising enough, says Dr. Richard C. Eastman, who runs the diabetes program at the National Institute of Diabetes and Digestive and Kidney Diseases, sponsor of the study.

And the costs, both human and economic, are staggering.

Diabetes is now “the most expensive disease in the country,” says Dr. Gerald Bernstein, a New York City diabetes specialist and president-elect of the American Diabetes Association. With all its complications, it costs the nation $138 billion a year, 15 percent of the health care bill.

Yet while the government spends $5-$10 on research for every $100 spent on patient care for other major diseases, it invests only about 25 cents for every $100 spent on diabetes care, says Bernstein.

That low priority is hard to fathom, say diabetes specialists, given that there are an estimated 8 million diagnosed diabetics in America and another 8 million who are unaware they have the disease.

Those numbers are expected to rise as Americans continue packing on pounds — obesity is a risk factor — and as Baby Boomers age.

If you are genetically predisposed, “it may take only 10 to 15 pounds of weight gain” to become diabetic, says Dr. Om Ganda, a senior physician at the Joslin who is working on the prevention study with Dr. Edward S. Horton, the study’s lead researcher at the Joslin.

And the number of diabetics may also rise because diabetes specialists recently lowered the threshold score on the fasting blood sugar tests that are used to detect diabetes, from 140 milligrams per deciliter of blood to 126 mg. People with normal blood sugar usually score less than 110 if they have not eaten for eight hours.

The reason doctors are so concerned about diabetes is that it interferes at such a basic level with metabolism. In a healthy person, blood sugar is maintained at a relatively constant level because the body secretes insulin from the pancreas in the right amounts to make sure that sugar gets into muscle and other cells that need it for fuel.

But in Type I, which can be inherited and is caused by a misguided attack by the body’s own antibodies against the insulin-producing cells in the pancreas, a person winds up making little or no insulin.

In Type II diabetes, the pancreas still makes insulin, but over time, the body becomes “resistant” to its effects. Some people become resistant through genetic predisposition but others acquire the resistance as a result of being overweight. As resistance develops, the pancreas tries harder and harder to make enough insulin, but eventually it can’t keep up with the demand, and blood sugar rises to dangerous levels.

Diabetes can be “so big, so bad and so ugly” that if it is not detected early, says Nathan, damage to the eyes, kidneys and other organs can happen before treatment begins.

That is the logic behind the new study, “the first of its kind ever done at this magnitude,” says Ganda.

People who want to join the study are first screened for blood sugar levels. In the screening test, if your blood sugar is between 80 to 140, you are then given a “glucose tolerance” test — a sugary drink that, within two hours, may raise your blood sugar dramatically.

If your blood sugar soars to between 140 and 199, you have “impaired glucose tolerance,” which means that you, like 21 million other Americans, have roughly a 50 percent chance of developing diabetes over time.

Other risk factors include being overweight, being over 40, having a family history of diabetes, belonging to an ethnic group that is at higher risk (including African-Americans, Hispanic-Americans, Asian-Americans, Pacific Islanders and Native Americans) and having a history of diabetes during pregnancy.

Clinical symptoms such as feeling tired or sick, unusual thirst, weight loss, blurred vision, frequent infections or slow healing of sores may also be warning signs.

If you are accepted into the study, you are then randomly assigned to one of four groups. The first group gets an intensive diet and exercise program, with the goal of losing at least 7 percent of body weight by eating fewer calories than usual and burning up 700 calories a week more through exercise.

The other three groups all get one of three daily medication regimens, though neither participants nor doctors know who is getting placebo (a dummy drug), metformin (Glucophage, a drug that lowers blood sugar by decreasing the amount of sugar made in the liver), or troglitazone (Rezulin, a newer drug that improves the body’s sensitivity to insulin in people with Type II diabetes.

Those who participate in the study, of course, are most likely to reap the direct benefits of diabetes prevention.

But the very existence of the study, researchers hope, will also remind people who don’t participate that there may be a lot they can do to prevent diabetes, such as eating a good diet and exercising regularly.

This summer, the American Diabetes Association also recommended that everyone 45 and older get a baseline diabetes screening, with follow up tests every three years for people at normal risk, and every year for those at higher risk.

And for those, like Oliver, who do volunteer? The benefits of “really good health care” — free — as a participant in the study far outweigh the downside. “I’d recommend joining,” she says, if you are at all worried about getting diabetes.

SIDEBAR 1.

DIABETES IN AMERICA

PLEASE SEE MICROFILM FOR CHART DATA

GLOBE STAFF CHART

SIDEBAR 2.

To learn more

If you are interested in joining the diabetes prevention study, call:

– 1-800-339-6482, to join at either the Joslin Diabetes Center or Massachusetts General Hospital.

– 1-888-DPP-JOIN (1-888-377-5646), outside New England.

To read more about diabetes, try:

– “Diabetes — The Most Comprehensive, Up to Date Information Available to Help You,” by Dr. David M. Nathan with John F. Lauerman.

– “The Joslin Guide to Diabetes,” by Dr. Richard S. Beaser, with Joan V.C. Hill.

High-protein diets, America’s latest food fad, are like an overstuffed deli sandwich – some healthy nuggets here and there surrounded by a fair amount of unhealthful baloney.

That, at least, is the view of mainstream nutritionists, many of whom feel that Americans hooked on books like “The Zone,” by Barry Sears, “Protein Power,” by Drs. Michael and Mary Dan Eades, and “Dr. Atkins’ New Diet Revolution” are being fed a mixture of truths, half-truths and totally unproven assertions.

For years, nutritionists have urged us to eat less fat and more complex carbohydrates so that we’ll have fewer heart attacks and be generally more slim, healthy and vigorous.

That’s still a basically sound message. But somewhere along the line, it’s been twisted by some into a license to eat unlimited amounts of pasta and potatoes, with obvious results at the waistline.

But there’s a less obvious result of this love affair with carbo, too, a feeling on the part of many that “carbohydrates have failed them,” says Larry Lindner, executive editor of the monthly Tufts University Health & Nutrition Letter.

For that reason, he says, many people are hungry for any self-appointed guru who seems to have a better message.

The trouble is, switching from a carbo-heavy diet to one loaded with protein is not necessarily better. In fact, some parts of the high-protein message are not only unsupported by any scientific evidence but may even be dangerous.

To sort out what’s valid and what’s not, we consulted nine leading nutritionists, as well as the Harvard Health Letter of January 1997 and the Tufts nutrition letter of May 1996.

Their consensus is that at least some high-protein diets are based on a number of myths. Such as:

Myth No. 1. Americans do not eat enough protein.

This is unlikely, except for frail old people, poor people who do not get enough calories every day, and perhaps some elite athletes who put huge demands on their bodies.

Sears acknowledges that most Americans “probably consume adequate protein in the course of a day, but not at every meal.” But in the next breath he contends that because people have been told to shun fat, which often comes in the same foods as protein, many people on diets are protein-deficient.

A Swampscott biochemist, Sears runs a biotech company called Eicotech, Inc. He is not a nutritionist and complains that real nutritionists “have no command of the literature.” He recommends reducing carbohydrates to 40 percent of calories, boosting protein to 30 percent and keeping fat at the level of 30 percent or less that nutritionists suggest.

Men, he says, need 100 grams of protein a day, and women, 75, on average. To get that, you’d have to eat 14 ounces of steak or a 10-ounce steak plus three servings of milk, yogurt or cheese every day if you’re a man and 10 ounces of steak or a 6-ounce steak plus three dairy servings if you’re a woman.

By contrast, the US Department of Agriculture and the American Dietetic Association recommend diets that provide 15 percent of calories from protein, 55 to 60 percent from carbohydrate and up to 30 percent from fat.

This translates to about 75 grams a day of protein for men and 65 for women, says Dr. George Blackburn, medical director of the center for the study of nutrition and medicine at the Beth Israel Deaconess Medical Center. To get this, you’d need to eat 6 ounces of steak or the equivalent for a man, or 4 ounces of steak or the equivalent for a woman.  And unlike Sears, Blackburn and other nutritionists advocate getting lots of protein from grains and vegetables like beans and lentils.

The bottom line is that if you eat enough calories – 2,000 a day for women, 2,500 for men – you’re almost certainly getting plenty of protein because many foods contain a mix of all three basic macronutrients: fat, carbohydrate and protein.

Myth No. 2. Eating too many carbohydrates leads to hyperinsulinemia – chronically high levels of insulin.

This is one of those half-truths. The idea, according to the high-protein gurus, is that eating tons of carbo makes the body pump out too much insulin, the hormone that helps transport glucose from carbohydrate breakdown into cells for energy.

Because insulin does increase trigylcerides (the fat molecules that wind up as plaque on artery walls) and lowers HDL, or “good cholesterol,” the high-protein gurus contend that too much insulin is the cause of many health troubles.

This notion contains “just enough of a kernel of truth to mislead people,” says Dr. Dean Ornish, president of the Medical Research Institute in Sausalito, Calif., who adds that none of the high-protein advocates has “published a single study in any peer reviewed journal about anything, much less the benefits of their recommendations.”

Dr. Walter Willett, a nutritionist at the Harvard School of Public Health, agrees with Sears on some of the basic biochemistry.

“On that note, he is right. There has been this false idea perpetrated by nutritionists that you can load up on as many carbohydrates as you want and that it’s good for you. That’s not true,” Willett says.

But insulin does not, as protein gurus say, promote storage of glucose as fat, provided you burn more calories than you eat.

Nor is it true, as the “warning” on Sears’ book jacket says, that you should avoid fruits like bananas, cranberries and orange juice. While no one recommends a diet full of simple carbohydrates – sugar and pasta – nutritionists do advocate eating complex carbohydrates, including grains and fruits, in part because they provoke a nice, gradual secretion of insulin.

Dr. Gerald Reaven, emeritus professor of medicine at Stanford University School of Medicine, an insulin specialist, dismisses Sears point blank: “Nothing he says is right.”

In general, nutritionists say, you build up too much insulin if you are insulin-resistant – if your cells no longer respond to normal levels of insulin and your body makes more to compensate. But this condition affects only about 15 percent of the population and usually develops if you eat too many calories overall, not simply too many carbohydrates.

In short, insulin is not the monster hormone it’s portrayed to be, and without it you’d wind up with diabetes.

Myth No. 3. People are overweight because they are hyperinsulinemic.

Wrong. People are overweight because they eat too much and exercise too little, says dietician Chris Rosenbloom of the American Dietetic Association. There is no evidence that hyperinsulinemia causes people to be overweight and plenty of evidence that being overweight increases your risk of hyperinsulemia.

Myth No. 4. Carbohydrate is the enemy.

Not true, provided you don’t take in more calories than you expend. Among other things, carbohydrate is crucial for production of the brain chemical serotonin, which is necessary for mood maintenance and sleep.

Myth No. 5. Eating protein will not raise insulin.

Wrong. It’s true that carbohydrates raise insulin most dramatically, but protein can raise it, too. (Fat does not.) In reality, most foods are a mix of all three, so insulin goes up – as it should – after a meal.

Myth No. 6. Excess protein is not stored as fat.

Not true. Excess calories from any food are stored as fat.

Myth No. 7. A fat calorie is different from a protein calorie and from a carbohydrate calorie.

Wrong. A calorie is a calorie.

Myth No. 8. High-protein diets work because people change what they eat.

Not likely. If a high-protein diet works for you, it’s probably because you’re consuming fewer calories by passing up excess carbohydrates. On a high-protein diet, a woman may take in 1,300 calories a day and a man, 1,700 – far below what most people eat.

Myth No. 9. Ketosis is good for you.

Wrong. Ketosis is the state achieved if you are starving or eating almost no carbohydrate, but lots of protein and fat. The body then burns dietary fats and proteins for energy.

In their book, the Eades say ketosis is “not at all” dangerous unless you’re diabetic. In Dr. Robert Atkins’ book, he says ketosis as an “extremely desirable state to be in.”

This is misleading. Ketosis is a sign that the blood is becoming too acidic. To combat this, the body then takes calcium from the bones, which raises the risk of osteoporosis. In fact, the Nurses’ Health Study showed that women on higher protein diets had a higher risk of bone fractures. Ketosis can also damage the kidneys, cause bad breath and trigger irregular heart rhythms that can cause sudden death.

Myth No. 10. Don’t worry about fats, which often, as in a juicy steak, are present in foods that contain lots of protein.

This gets tricky. Nutritionists say we should get at most 30 percent of calories from fat, and Ornish pegs it at 10 percent. But the real issue is what kind of fat you eat, and you can eat a lot if it’s unsaturated stuff like olive or canola oil.

The basic problem is, if you want to reduce carbohydrates, you have to raise either fats or proteins, says Willet. “And I think it’s safer to raise fat, as long as it’s the right type.”

Instead of pushing protein up to 30 percent of calories, he says, you can allow unsaturated fats to comprise 40 percent of your diet. The result is the Mediterranean diet, one of the world’s most healthful, with 30 to 40 percent fat, 20 percent protein, and the rest carbohydrate.

There’s one final reason to take a dim view of some high-protein diets: They can get a little weird.

Although in conversation Sears insists he is just advocating the kind of balanced diet that everybody’s grandmother used to recommend, in his book, he suggests snacks like a half cup of Haagen-Dazs ice cream with four ounces of turkey as a chaser.

Did you ever know a grandmother to suggest a snack like that?

Sources for story

The following nutritionists were interviewed for this column:

• Dr. George Blackburn, medical director of the center for the study of nutrition and medicine at Beth Israel Deaconess Medical Center.

• Johanna Dwyer, director of the Frances Stern Nutrition Center at Tufts University.

• Alice Lichtenstein, nutritional biochemist, Tufts University.

• Larry Lindner, executive editor of the Tufts University Health & Nutrition Letter.

• Dr. Dean Ornish, president of the Preventive Medicine Institute in Sausalito, Calif.

• Dr. Gerald Reaven, professor of medicine (active emeritus) at Stanford University School of Medicine.

• Chris Rosenbloom, registered dietician, spokesperson for the American Dietetic Association.

• Dr. Walter Willett, professor of epidemiology and nutrition at the Harvard School of Public Health.

• Dr. Richard Wurtman, director of the clinical research center at the Massachusetts Institute of Technology.

Weight loss center pinning hopes for fat profits on diet drugs – and doctors hired to prescribe them on demand.

So. You’re determined to lose those 20 pounds this year. Okay, maybe a little more. Really. Once and for all.

You go to your friendly family doctor, who’s been badgering you for years to gets those pounds off with diet and exercise.

You explain that you’ve tried. And tried. And tried. You beg for some of those trendy prescription diet pills like the recently-approved Redux or the two-drug combo “fen/phen.”

To your dismay, your doctor says no, you’re not that fat – you don’t have a body mass index, or BMI, of 30 or more.

Not fat enough? With 300,000 Americans dying every year from obesity and you on your way to joining them? With everyone from your once-favorite doctor to your nearest and dearest begging you to slim down lest you face some medical disaster?

Vowing to get your pills elsewhere, you march straight to the nearest Jenny Craig, Diet Workshop, or Nutri/System center.

The question is, should you?

Weeeellll, maybe. But there are a few things that you, or any other frustrated, well-padded American, should know about the commercial weight loss industry before you plunk down your hard-earned bucks – usually hundreds of them. Such as:

The desperation factor – theirs, not yours. The commercial weight loss industry has been struggling for years because of public discouragement about dieting and consumer resistance to the high price of programs, says industry analyst John LaRosa, director of Marketdata Enterprises, Inc. in Tampa.

And that means that the big chains are extremely eager – caveat emptor – to woo customers back. And, like you, they are pinning many of their hopes on diet pills.

So far, Weight Watchers International, Inc., the industry leader, has resisted jumping on the pill mill bandwagon because, as spokeswoman Linda Carilli puts it, “We are not a medical organization. Our primary focus is on behavior modification and it will continue to be that.”

But the other big chains have no such qualms. Jenny Craig, Nutri/System and Diet Workshop have recently added diet pills to their programs and hired doctors to dispense them. Locally, centers like Doctors Weightloss Program and Medical Weight Loss Center have also sprung up to meet the consumer demand for the newly respectable weight loss drugs.

Misleading ads. The Federal Trade Commission doesn’t believe ads that say or imply you can lose lots of weight fast and keep it off – with or without pills – and neither should you. That goes double for ads that make you think that pills alone – without exercise and better eating habits – will work.

A case in point: One ad for the Medical Weight Loss Center in Chestnut Hill, which runs regularly in the Globe, touts “Hot New Diet Pills! Fen/Phen & Redux. Lose 20 lbs in 4 weeks.”

“There is absolutely no evidence in the medical literature that people can lose 20 pounds of body fat in four weeks safely on these drugs,” says Dr. George Blackburn, medical director of the center for the study of nutrition and medicine at Beth Israel Deaconess Medical Center. You might lose 20 pounds if you were severely obese, he says, but it would be water, not fat.

In recent years, the FTC has cracked down on misleading advertising, forcing Diet Workshop, Nutri/System and Physicians Weight Loss Centers, among others, to change some ads. Complaints are still pending against Weight Watchers and Jenny Craig, says FTC spokeswoman Mary Haley.

So if the ads tempt you, keep in mind this reasonable expectation: If you take the pills and stick to a behavior modification and exercise program, you’ll probably lose about 10 percent of your body weight, then level off.

There certainly are medical benefits to be had from losing even just 5 percent of body weight, Blackburn notes, but it is “rare indeed” for people to lose more than 10 percent, and many regain weight when they stop the pills. Although Redux is approved for long-term use, there are no data on its safety for more than one year.

Pre-signed prescriptions. You might think you could assure yourself decent medical care if you picked a weight loss center with a medical-sounding name, and there are plenty to choose from, including Medical Weight Loss Center, Doctors Weight Loss Program and Physicians Weight Care Associates.

But that is not necessarily the case. In fact, a major problem occurred in just such a center, Medical Weight Loss Center in Chestnut Hill.

Last fall, WBZ-TV 4’s Liz Walker caught Dr. Richard Cohen of that center using pre-signed prescriptions for diet pills, which nurse-practitioners then handed out to patients. The center also prescribed diet drugs for a WBZ producer who had been told by Blackburn that she did not need them.

It is against federal Drug Enforcement Administration guidelines to pre-sign prescriptions. In a recent interview, Cohen said, “I did it because I didn’t know you weren’t supposed to.”

He added that he was “just trying to do the best for people. What I did was technically not proper, but it had nothing to do with their care.” Cohen added that he no longer pre-signs prescriptions and tries to individualize care. But he remains under investigation by the Board of Registration in Medicine.

Outside the commercial diet centers, many doctors acknowledge that patient demand for pills is growing – and hard to resist.

Dr. William Dietz, director of clinical nutrition at Boston Floating Hospital at the New England Medical Center, worries about the ease with which patients get pills at some centers.

“It certainly is a bad idea,” he says, for doctors to prescribe diet pills “without a review of whether a patient needs it or whether a patient needs to lose only five pounds.”

Dr. Carl Aselton, a general practitioner in rural Maine, echoes that, but he acknowledges that some patients “get mad” when he refuses to write diet pill prescriptions. “My wife, my secretary and my nurse all bring up the question, too.”

Some doctors in commercial weight loss centers insist they do screen patients and prescribe pills only when they are medically necessary, that is, when a person has a body mass index of 30 or more or has obesity-related medical problems and a BMI of 27.

One of those is Dr. Robert Nierman, medical director of the Doctors Weightloss Program in Lexington. He insists that some centers are not truly “physician-based,” but his is.

“Ninety-five of people on medications are seen by me each time,” he says. “This is a legitimate medical practice with a large volume. It’s not a business, it’s a practice.”

Still, the mere idea of being hired by a commercial weight loss center to prescribe diet pills is anathema to many doctors.

Dr. Richard Levy,, an internist and emergency medicine physician at the Boston Veterans Administration Medical Center in Jamaica Plain, was recruited recently by a representative for Jenny Craig. He declined.

“I think in the hearts of most physicians, we don’t enter the profession to act as hired guns to write prescriptions for diet pills,” says Levy. “I think if somebody is hired specifically to promote prescriptions for a particular medication, they are already compromising themselves.”

1. AS SALES SOAR, SO DO THE COMPLAINTS

Keith Van Gasken, 45, a Lynn man who works in a health management company, swears by fen/phen. He says it has helped him trim down to 195 pounds, from 270 a year ago.

The pills, which contain two drugs called fenfluramine and phentermine, are “an absolute godsend,” he says, because they curb his hunger so he can stick to his diet without much agony.

A different drug, Redux, gets raves from a 35-year-old Medford woman who requested anonymity because she is “very, very overweight.” She has lost 20 pounds in three months and hopes “to finally get the weight off and keep it off.”

Americans are in love, once again, with diet drugs – not the old addictive amphetamines that gave diet pills a bad name, but the current crop of non-addictive appetite suppressants.

Compared to their precedessors, these drugs, which also act on the brain and are considered controlled substances, are relatively safe. But as the popularity of diet pills soars, so do reports of side effects, some minor, some not.

Electronic chatters on American Online, for instance, trade worries about “phen brain,” or short-term memory loss.

“My first experience with this side effect was horrible,” complained one dieter. “It happened at about the five-week period on meds. I couldn’t find my accordion file that held my checkbook and billing statements, which I am usually extremely organized with. By the time I located it, the bills were all past due.”

Others complain of unusually vivid dreams, hair loss, heavy menstrual periods and mood changes, such as becoming, as one writer put it, “incredibly depressed and crabby.”

Redux, too, gets its share of complaints, including dry mouth, mild drowsiness and diarrhea. Except for dry mouth, these usually subside in a few days.

But both Redux and fen/phen also raise the risk of a more serious side effect, pulmonary hypertension, which can be fatal.

In August, European researchers reported in the New England Journal of Medicine that dexfenfluramine (a molecule in both Redux and fen/phen) increases the risk of this condition, in which blood vessels to the lungs become thickened and scarred.

The risk is 23 times higher in patients using diet drugs for three months or more. But because pulmonary hypertension is rare, even this means only 28 of every million people taking dexfenfluramine will get the lung problems every year.

Even so, some people on diet drugs get so worried they rush to the emergency room when they needn’t, says Dr. George Blackburn, medical director of the center for the study of nutrition and medicine at Beth Israel Deaconess Medical Center.

Their fears could hardly have been helped by the credibility problem that developed when it turned out that two authors of an editorial in the New England Journal of Medicine, which was favorable to diet drugs, had been paid consultants to companies that stood to gain from robust sales. The Journal apologized for the mess in October.

Still, worries about side effects haven’t dampened sales. Just seven months after its approval by the Food and Drug Administration, Redux has captured 11 percent of the market with 2.4 million prescriptions to date, though sales have leveled off recently, says Bill Noonan, a spokesman for IMS America, a firm that tracks pharmaceutical sales.

Fenfluramine and phentermine, which have been on the market separately for decades but are not FDA-approved for combination use, are doing well, too, boosted by a 1992 study showing the potency of the pairing. Two generic versions of phentermine alone accounted for 11 million prescriptions last year.

That’s because the pills really work, at least for the first six months. After that, weight loss mysteriously tapers off.

Both Redux and fen/phen work by acting in the brain to reduce carbohydrate craving, says Judith Wurtman,, a cognitive scientist at the Massachusetts Institute of Technology and co-inventor of Redux.

Specifically, dexfenfluramine boosts the activity of a brain chemical called serotonin, she notes, adding that a serotonin deficiency underlies both carbohydrate craving and depression.

In fact, researchers have wondered whether anti-depressant drugs like Prozac, called SSRIs or selective serotonin reuptake inhibitors, might also help people lose weight. But they don’t – and the FDA warns ary control with helping him lose 75 pounds, agrees.

Diet pills “can be powerful tools but only if you do the behavioral stuff, too,” he says. “If you don’t, I’d recommend that you don’t even start.”

People who need to lose 55 to 90 pounds who are interested in participating in a free, 12-month study on Redux at MIT may call 617-253-3437.

1. Body mass index

To learn your body mass index click HERE to visit the National Institute of Health web site. Just follow the directions and enter your height and weight, then click the Conpute BMI button.

1. Are you overweight?

There are various ways to gauge whether you are overweight, but one of the best is the body mass index, which uses a formula that takes into account both height and weight.

In general, if you are 35 or older, you are considered obese if you have a BMI of 27 or more. If you are younger, a BMI of 25 or more indicates obesity. To qualify for Redux or fen/phen you should have a BMI of 30 or more, or a BMI of 27 along with health problems like diabetes or high blood pressure.

These rules of thumb are not absolute. If you are a body builder with lots of muscle and no fat, you can have a high BMI and still be healthy. On the other hand, a BMI as low as 25 can elevate your risk of diabetes or heart disease, notes Dr. William Dietz, a nutritionist at New England Medical Center.

If your BMI is high, do something about it, but take comfort in the fact that you are not alone. Based on a BMI of 25, half the country is overweight; based on a BMI of 27, one third is.

Some doctors and commercial weight loss centers also use body fat analysis to gauge who should qualify for weight loss drugs. According to the National Institutes of Health, women are considered obese if they have more than 30 percent body fat, and men, more than 25 percent fat.

But it can be difficult to measure body fat accurately, so beware of any center that tells you your BMI is okay but that you qualify for drugs only on the basis of body fat analysis.

 

 

Is your toddler is getting pudgy? Is your preschooler shorter than the other kids? Are your kids’ teeth sprouting white spots or brown stains?

If so, the culprit may be the juice craze that’s sweeping the nation, as well-meaning parents stuff lunchboxes and backpacks with juice boxes and kids guzzle the stuff all day.

Last week, a study published in the journal Pediatrics found that kids who drank more than 12 ounces of fruit juice a day were more likely to be short or fat, though not both, than kids who drank less than 12 ounces.

The American Academy of Pediatrics quickly chimed in with a different warning — that too much juice with a type of sugar called sorbitol, found in pear and apple juice, can cause diarrhea, abdominal pain or bloating.

And last year, the American Dental Association published yet another study that showed that drinking too much fruit juice, which often contains fluoride, can trigger a process called fluorosis that leaves white or dark brown spots on kids’ teeth.

Health researchers have long been appalled at America’s worsening dietary habits, in part because 22 percent of kids and teen-agers are now overweight, up 47 percent from 30 years ago.

But while fast foods, take out meals and the usual no-nos like potato chips and cookies get most of the blame in the public mind, researchers are increasingly recognizing that what kids drink — from the obviously non-nutritious soda pop to the seemingly innocuous fruit juices — can contribute, too.

Last fall, a study by researchers at New York Hospital-Cornell Medical Center’s Nutrition Information Center concluded that “liquid nutrition,” including high-calorie fruit juices and soft drinks consumed by kids and teen-agers, may play a key role in the growing problem of childhood obesity.

It’s not just that juices have lots of calories — 155 of them in an 8-ounce box of grape juice, for instance — but that juices may be “replacing other more important nutrients,” says Dr. William Dietz, director of clinical nutrition at the Floating Hospital for Children at New England Medical Center.

“Consumption of juice and soda has increased and milk has decreased,” says Dietz, who is a consultant to the Milk Processors Education Program and its “milk mustache” campaign. “I don’t think there is any reason why children should drink more than one glass of juice a day, about eight ounces.”

In fact, the emerging consensus from those concerned about kids’ health is that many children would be better off drinking a little less juice and a little — or even a lot — more skim or lowfat milk and plain old water. Not to mention eating more real fruit, which has fiber and other goodies, too.

But before you dump the fruit juice out with the bathwater, consider the finer points of all this.

Last week’s study in Pediatrics, conducted by Dr. Barbara Dennison, a pediatrician at Bassett Hospital in Cooperstown, N.Y., is somewhat less scary than it sounds at first.

Dennison’s team studied 168 healthy kids — 94 two-year olds and 74 five-year olds, recording weight, height and dietary habits, including how much juice they drank. The researchers counted only the real stuff — 100 percent fruit juice, including mixed juices like Juicy Juice — not juice-flavored drinks.

Only 19 kids (11 percent of the study group) drank 12 ounces of juice a day or more, a tiny number on which to make weighty dietary recommendations. But of these 19, eight (or 42 percent) were short. Of those who drank less than 12 ounces a day — the rest of the kids in the study — only 14 percent were short.

The team also found that those few kids who drank 12 ounces of juice a day or more were tubby. About half of them — that’s 10 kids — were in the 75th percentile for body mass index, a commonly used measure that includes both height and weight. By contrast, among those who drank less juice — all the other kids — 32 percent were overweight.

Dennison has several hypotheses to explain her results. Perhaps, she says, kids who drink lots of juice don’t get other nutrients they need: “That would explain why they are short.”

Other kids may gain weight because they drink juice on top of everything else they normally consume, she says, thus consuming more calories per kilogram of body weight than other kids. Although kids who dranks lots of juice and those who didn’t consumed roughly the same amount of calories, the high juice drinkers gained weight because they took in more calories than their metabolisms needed.

Few of the kids in Dennison’s study drank soda pop, she adds, because they were so young and because “a lot of parents go out of their way to get 100 percent juice.” Because preschoolers need two servings of fruit a day, she says, it’s fine for one to be a glass of juice, but the other should be real fruit.

Needless to say, the National Food Processors Association is less than thrilled by Dennison’s findings. Rhona Applebaum, the group’s executive vice president for scientific and regulatory affairs, notes that this was only an observational study and could not establish cause and effect. Applebaum also objects to calling “excessive” anything over 12 ounces of juice a day: “That is arbitrary.”

If Dennison’s study were the only concern, this might be just a tempest in a juice box. But it’s not.

It’s long been known, for instance, that if you put a baby to bed with a bottle of juice (or even milk), the result can be rampant tooth decay. Sugars in the drink cause bacteria in the mouth to release toxins that break down tooth enamel, a process that is accelerated because saliva that would normally wash away the sugars is decreased during sleep.

And then there’s all that fluoride.

A team of dentists, led by researchers at the University of Iowa, last year contacted manufacturers of 532 ready-to-drink juices, frozen-juice concentrates and juice-flavored drinks to see how much fluoride was in their products. More than half of products contained too much fluoride, they found, although parents would never know this because package labels say nothing about fluoride concentrations.

In the right amounts — 0.3 to 0.6 parts per million — fluoride prevents tooth decay, according to the Academy of General Dentistry. That’s why many towns add fluoride to drinking water, why toothpaste makers put fluoride in their products and why dentists give kids fluoride treatments.

But with fluoride, “sometimes you could have too much of a good thing,” says Dr. William Chase, a dentist in Adrian, Mich., and a spokesperson for the dental academy. If juice drinks are manufactured in communities where the water supply has high fluoride levels, the result can be an excess of fluoride — and white or brown spots on the teeth.

The dental study found that 43 percent of juice products had fluoride concentrations above the recommended maximum (0.6 parts per million) and 19 percent were above 1.0 part per million.

White grape juice, the researchers found, had the highest fluoride concentrations, probably because the skins from grapes contained fluoride from pesticides. Grape juices made after skins were removed had no detectable fluoride.

Tea and prune, cranberry, pear, red grape, cherry and apple-grape juices all had mean fluoride concentrations greater than 0.6 parts per million, the researchers found. The mean fluoride level in straight apple juice was just under 0.6 parts per million. Orange juices, lemonades, fruit nectars and pineapple juices usually had less.

Because excess fluoride can be harmful, especially for 6-to-9-year-old kids whose permanent teeth are still forming, parents should say no to fluoride treatments at the dentist’s office if their children drink a lot of juice, says Chase. Another thing you can do, he says, is join forces with dentists to get manufacturers to list fluoride content on juice labels.

But this doesn’t mean kids should switch to soda. Even sugar-free soda can be harmful because the carbonation attacks tooth enamel.

The bottom line, say the New York nutrition researchers, is to get kids and teen-agers to cut their overall consumption of high-calorie fruit juices and soft drinks.

You can get there by diluting juices 3 to 1 with water, putting kids’ favorite cups near a water cooler and putting water bottles in kids lunch boxes at least several times a week.

And when your child gets thirsty, offer water. “That’s what the body wants,” says Dietz. “There’s no need to accompany water with calories.”

 

Dr. Dean Ornish, the California guru whose radical approach to diet has been shown to reverse heart disease, settles in at the corner table at the Ritz cafe, facing Temptation.

Temptation, his luncheon partner one recent winter day, points to the lobster bisque, the special Ritz cheeseburger with aged cheddar, the Boston cream pie.

“They sound good, but I think I’ll try something different,” says Ornish, 42, whose tastes — and recommendations — run to fruits, vegetables, grains, beans, nonfat dairy products, egg whites and not a whole lot more.

With no added oils of any sort, this amounts to a diet that is 10 percent fat, with almost no cholesterol.

As the maitre d’ hovers, Ornish, clearly unconstrained by conventional expectations or printed menus, begins the serious negotiations.

“Can you make me a cup of minestrone with no cream and no butter? Can you make up just some pasta, angel hair pasta, and can you make a marinara sauce without any oil, not even olive oil? And grill up some vegetables?”

(Temptation orders the penne with portobello mushrooms and cepes, swimming in olive oil.)

Ornish settles back, takes a hefty swallow of water and launches into a plug for his latest book, “Everyday Cooking with Dr. Dean Ornish,” and his new program at Beth Israel Hospital, where for $7,000 or so each — some insurers cover it — about 100 people this year will try Ornish’s approach to reversing heart disease.

Just as Ornish is warming to his tale of healthy hearts, legumes and yoga, the waiter swoops over. Would it be all right to add just the tiniest bit of oil to cook the onions for the marinara sauce?

It would not.

“Why not just leave the onions out?” suggests Ornish. Heads nod: Of course.

Eating the way he does, says Ornish, who is 6 feet tall, weighs 170 (he’s gained 15 pounds pumping iron) and has a total cholesterol level of 130, is ”not a moral issue.”

“This is just a choice I prefer. Once you start categorizing food as good or bad, soon you’re a good or bad person,” he says, noting that he grew up eating meat five times a day in Texas but now loves his plant-based, meat-free diet.

Once you get used to it, he says, food tastes better, you feel better fast, and you even come to prefer healthful things like skim milk. Besides, he contends, making big, radical changes in lifestyle and diet is easier and more effective than chipping away at the problem with small, incremental changes.

Over the years, Ornish’s approach has been controversial. At first, other doctors doubted that clogged arteries and chest pain could be reversed by something as low-tech as diet and behavior modification. Lately, critics have worried that his program is just too tough for the average person to stomach.

But it seems to work. Several years ago, Ornish published a study of 48 people that showed that blockage of coronary arteries was significantly reversed in 82 percent of patients after one year on the diet and a behavior modification program.

Last fall, he published a five-year followup on the same people. Using scans that measure blood flow to the heart, he found that 99 percent of patients were able to halt or reverse progression of heart disease.

Nationwide, about 1,000 patients so far have enrolled in Ornish programs at eight hospitals, and many, he says, have been able to avoid expensive bypass surgery or angioplasty to open their arteries. In fact, Mutual of Omaha insurance company, which has followed more than 40 Ornish patients, has saved $5.55 for every dollar it spent on the program, he says.

The heart of the regimen, says Ornish, who is director of the Preventive Medicine Research Institute in Sausalito, Calif., is its multidisciplinary approach.

At Beth Israel, for instance, patients exercise — that is, walk — a minimum of half an hour a day, or one hour three times a week. They also spend an hour a day doing yoga, relaxation exercises and meditation, and have regular cardiac checkups and group counseling.

Richard Murphy, a 54-year-old plumber from Hanover who has been in Beth Israel’s pilot program since September, attests to both the rigor of the program, and its results.

After a heart attack seven years ago, Murphy says, he stuck to a healthful diet and exercise program for a few years, but gradually slipped back. Last year, he began having angina, the chest pains that are a hallmark of clogged coronary arteries.

When his insurer, John Hancock Co., offered to foot 90 percent of the bill for the Ornish program, Murphy jumped at the chance. Since September, he has lost 15 pounds, feels “excellent” and says he has “a bounce to my step I didn’t have before.” And his angina is gone.

Back at the Ritz, lunch arrives, and Ornish is thrilled.

“Doesn’t that look good,” he says. “You did a very nice job. My compliments to the chef.”

His plate is filled with grilled vegetables that glow with health and color atop a pile of pasta. There is not a droplet of oil.

“You can go out to eat and order this,” says Ornish, relishing every bite. People hesitate to ask restaurants for what they want, he says, because ”they don’t want to look weird or different — but my plate looks better than yours.”

It does.

“And if you eat low-fat all the time, you begin to prefer it,” he says.

Temptation eyes the oil at the bottom of her plate.

Finally, the dessert menus arrive. “Tiramisu?” asks the maitre d’.

At first, Ornish hangs tough. “What kind of sorbet do you have?” Then, saying he’d “rather eat chocolate if I’m going to eat fat,” he caves: “Do you have any chocolate desserts?”

Invited to split a chocolate mousse, he agrees to have a taste.

It’s OK, he says, because he knows he’s free of heart disease. Besides, the real reason to stick to a healthful diet, says the guru, is that “you’ll feel better. It’s the joy of living, not the fear of dying, that sustains you.”

The mousse arrives. It’s gorgeous. Ornish slips his fork into it, puts a tiny bit into his mouth. Conversation stops. It is the moment of truth.

He closes his eyes to savor it. No wonder. It’s the only bite he takes.