Warmed-Over Atkins? Don’t Tell the French

PIERRE DUKAN has been called the French Dr. Atkins. Millions of Frenchmen are said to have tried his program, a method that promises— like dozens of diets before and since— no hunger, no calorie counting, instant weight loss and lifelong weight maintenance. The original Dukandietbook sold 3.5 million copies in French and has been translated into 14 languages. Three Dukan books were among the top five best sellers in France last year. Hundreds of online blogs and forums serve as the diet’s virtual support system, not unlike Weight Watchers’ weekly meetings.

Few Americans have even heard of the diet that made the 69-year-old Dr. Dukan famous, but that is about to change.

Next month, the diet will make its American debut when a division of Crown Publishing rolls out the North American edition of“The Dukan Diet,” its cover featuring a plate with two Eiffel Towers and the words,“The Real Reason the French Stay Thin.”

Dr. Dukan, who says he was paid a $1.3 million advance for the North American rights, will attempt to woo American audiences with his well-rehearsed, rapid-fire pitch, which he seasons with medical jargon and wraps in charmingly imperfect English. The diet will be heavily promoted with a national print, television and radio campaign, and outreach viaFacebookandTwitter, all part of the publicity machine that propels diet books— one of the largest revenue generators in publishing— into general consciousness.

The doctor comes across as a missionary.“My dear friends, today I am reaching out to you with the certainty that I can help you put an end to the inevitability of weight problems in North America,” he wrote in the preface of the new edition.“Now let this mutual journey begin!”

The diet has become so central to French culture that almost any public figure who has lost a lot of weight is labeled by the media as a Dukanniste:Jean-Marie Le Pen, until recently the leader of the far-right National Front party; François Hollande, a longtime Socialist Party politician, former party leader and presidential hopeful; David Douillet, a judo gold medalist (who reported losing more than 75 pounds in six months). In Britain, the press has Carole Middleton, mother of future princess Kate, going on the diet in preparation for the royal wedding next month.

For years, critics have dismissed the Dukan diet as a warmed-over version of early Atkins: a simple protein-centric method that divides foods into good and bad categories and relies on the claims of a medical doctor who is long on enthusiasm and short on scientific research.

Asked about Atkins, Dr. Dukan acknowledged that it was a source of inspiration.“I am built on the shoulders of Weight Watchers and Atkins diets,” he said. But he criticized Weight Watchers for its emphasis on quantity sizes and calorie counting, and Atkins for allowing unlimited consumption of fat.“I have a lot of respect for Atkins,” Dr. Dukan said.“He was a legend in his time.” But now, he added,“Atkins is dead.”

His own diet’s high-protein, low-fat approach is organized into four phases: attack, cruise, consolidation and stabilization. The first encourages dieters to eat as much as they want of nonfatty, protein rich foods, including oat bran (a key component) washed down with oceans of water. The second stage introduces vegetables, but no fruit; the third brings with it two slices of bread, a serving of cheese and fruit and two servings ofcarbohydratesa day, with two weekly“celebration” meals with wine and dessert (the diet is French, after all); and the final stage six days a week of“anything goes” and one day of reversion to strict protein-only stage one— for the rest of your life.

The only must-do daily physical exercises are a 20-minute walk and total elevator avoidance, fine in a city like Paris where five-story buildings are common.

Even before its American introduction, the diet is under attack.“This is just another one of those diets invented by a charismatic individual who makes a lot of promises and has loads of testimonials but is not based on any scientific data whatsoever,” said Frank Sacks, professor in the Department of Nutrition atHarvard University’s School of Public Health and chairman of theAmerican Heart AssociationNutrition Committee.

France’s governmental National Agency for Food, Environmental and Work Health Safety has identified it as one of 15 imbalanced and potentially risky diets. The British Dietetic Association, the country’s organization of professional dietitians, branded it one of the five worst diets of 2011.“We call it the‘Do-can’t’ diet,” said Sian Porter, a dietitian and spokeswoman for the British Dietetic Association.“Even if you can survive it for the first few days, it’s hard to stick with it. It’s hard on your kidneys. And it’s expensive.”

Michèle Fitoussi, a columnist for Elle magazine, commented simply that“of course you lose weight at the beginning.”

“You are so bored eating nothing but sliced turkey and fake crab that you lose the desire to eat.”

The diet was an accidental creation, and Dr. Dukan will tell you the story of its inspiration, whether you ask or not. It began in the 1970s with four words:“Let me eat meat.” Dr. Dukan, then a Paris neurologist, was treating an asthmatic and seriously overweight longtime patient, a poetry editor. The patient had tried every sort of diet. They all had failed him. He was determined to try again, but on one condition: he wanted meat.

Dr. Dukan told him to eat nothing but protein, to drink lots of water and to come back in five days. When the man returned, he had lost 11 pounds.

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Pain, Persistence, Family - Sickle Cell Disease

Sickle cell anemia is an inherited disease that causes red blood cells to have a distinctive crescentlike, or sickle, shape. These cells are unable to properly carry oxygen throughout the body, and they tend to clump together, blocking blood flow, damaging organs and causing severe pain.

Affecting about 72,000 people in the United States, sickle cell anemia is most common among people of African or South American descent, but the genetic trait is also routinely found in people with ancestry from Central America, India, Saudi Arabia and Mediterranean countries. One in every 500 African-American births results in a child with sickle cell disease,according to the Sickle Cell Disease Association of America.

The challenges of living with sickle cell anemia are great, but with diligent care, the disease can be managed. Here, three people speak about the impact sickle cell anemia has had on their lives and families. Hear more:Patient Voices: Sickle Cell Anemia. 

Andre Hinckson, 38

Queens

“With a sickle cell crisis, there’s a lot of pain, unbelievable pain. It’s like a jackhammer on your back, basically. Imagine that kind of pain throughout your whole body. Sometimes there’s pain in your joints, in the abdominal area, in your head, in your chest. Sometimes it’s all over at one time.

I wish people in the medical field would take the disease more seriously. I’ve had experiences where they’ve called me‘drug seeker.’ It’s as if we’re going to the emergency room once a month or once a week for our drug fix. They treat us atrociously, and I’m just tired of the whole situation.

Some people, they smile— that’s how they deal with their pain. Me? I’m very serious, and I know people look at my face and they wonder why I’m so serious or so sad. Maybe its just because of what I’ve experienced, you know?”

Shanoah Moore, 8

Cincinnati

“Every time I have a pain episode, I either get a heating pad or they take my temperature. If it’s over 101, that means I have to go to the hospital.

I know when I’m getting sick because my head starts getting warm, and my mom knows because my eyes kind of turn yellow. It feels like someone is just squeezing my legs or arms. Sometimes it’s very, very painful.

Normally in the middle of the night, I just go and get the heating pad and go back to my bed, but when I wake up and it feels worse, then I just go to my mom or dad.“I don’t like getting sick. I still want to be in school, so I can be there and not be absent a lot.”

Tiffany Dews, 33

Richmond, Va.

“When I first got pregnant, my intention was not to be a stay-at-home mom. My intention was to work and finish school, but of course, plans change.

Both my husband and I have the trait for sickle cell disease, and combined we have two children, Tracy and Riley, with the disease. There’s a one in four chance each time we decide to have kids that we would pass on the disease.

Years ago, {children with sickle cell disease} were not making it past the age of 20 or 21. So my hope is that they will have kids, and hopefully not have kids with the disease.”

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Radiation Exposure Could Curtail Efforts of Workers

The workers are performing what have been described as heroic tasks, like using fire equipment to pump seawater into the three failing reactors to keep the nuclear fuel from melting down and fighting the fire at a fourth reactor.

 They are operating in places that have been contaminated by radioactive isotopes from all four reactors. Technicians who have not been evacuated face an escalating exposure, and will have to be replaced if the fight is to go on.

“If they exceed a certain amount, they can’t go back in for a day or a week or longer,” said Dr. Lew Pepper, a professor at the Boston University School of Public Health who has studied the effects of radiation on nuclear weapons workers. And the pool of available replacements is finite, he said:“What do you do? You don’t have a lot of people who can do this work.”

The nuclear plants’ operator, Tokyo Electric Power Company, has declined to provide details about the workers— who they are, how many there are and how they are being assigned to do the most hazardous work.

 But Arnold Gundersen, a consultant who worked in American plants nearly identical to the stricken Japanese ones, said it was likely that the company was calling in retirees and workers from unaffected plants for help. And perhaps for sacrifice, as well.“They may also be asking for people to volunteer to receive additional exposure,” he said.

 People who are working close to the reactor— pumping water, or operating valves inside the secondary containment structure— would almost certainly be wearing full bodysuits and air packs, Mr. Gundersen said. But some forms of radiation can penetrate any gear.

Gamma rays and other penetrating radiation can cause cancers and other long-term illnesses or, in high amounts, near-term illness or death.

Health physicists should gauge the radiation level in the work area, and the workers would normally be told how long they can remain.“There may be a health physicist who will say, You only have an hour or two to do this job,” Mr. Gundersen said. Each worker would carry a dosimeter, which measures radiation exposure,“and they’ll be looking at it,” he added.“When it hits a certain number, they should leave.”

Suits and air packs are meant to keep radioactive particles off the skin and out of the lungs until the workers return to a safer area.

Workers are trained to remove the gear in a specific way to avoid leaving any particles on their skin that would result in continuing exposure.

While regulations may differ somewhat in Japan, in the United States the usual radiation exposure limit for nuclear power plant workers is 50 millisieverts, or 5 rem, per year (compared with the 0.3 rem that the Environmental Protection Agency says most people get from normal background radiation). When there is an emergency, the limit can be raised to 25 rem, which is still far below the level at which people would show symptoms or get sick.

The explosion at Fukushima’s Reactor No. 2 on Tuesday morning sent radiation levels spiking, to 8,217 microsieverts an hour from 1,941 about 40 minutes earlier.

 During the Chernobyl accident in Ukraine in 1986, when the reactor caught fire, operators and firefighters received high doses of radiation, sometimes within minutes and without being made aware of the dangers. More than two dozen of them died of acute radiation illness.“People in Chernobyl were just over overexposed,” Dr. Pepper said.“The outcome for those folks was death.”

Determining allowable exposure is usually based on three principles: distance, time and shielding. In the Japanese plants, extensive contamination would mean that distance and shielding are not really factors, so the controlling variable is time.

Mr. Gundersen said that when he worked at the Vermont Yankee plant, which is nearly identical to some of the crippled Japanese reactors, he had one maintenance task where the“stay time,” in which workers would be exposed to their yearly limit, was three minutes. He hired local farmers, trained them on a mock-up for two weeks, and then sent them in for their brief stint.“Then I’d send them home for a year,” he said.

In Japan, the plant operators do not have the luxury of time for training.“You need somebody who is familiar with the plant, because you need somebody to do it now,” Mr. Gundersen said.

 Japanese workers might be so committed that they might be willing to exceed accepted levels of exposure. But that might not extend to extremely high radiation.

 “I don’t think anyone is going to take 50 rems,” he said.“But if it’s a difference between 5 and 7, they might say:‘I’ll take it. It’s worth the risk.’”

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Stair-Climbing Workouts and Staircase Races

Still, I enjoy climbing stairs. And at work, at The New York Times building, I climb nine flights, typically three times a day, for a total of 609 steps, up but not down.

The brief treks are back-loosening, head-clearing aerobic jolts— and they may be contributing more to my health than I suspect, according to exercise experts. Stairs, it seems, are a neglected asset in the fitness crusade.

“There’s good scientific evidence that the activity itself is quite beneficial,” said Paul M. Juris, a kinesiologist and executive director ofthe Cybex Institute for Exercise Science, in Medway, Mass., the research arm of the maker of Cybex exercise equipment.

Mr. Juris, a former researcher atBeth Israel Medical Centerin Manhattan and a past consultant to professional sports teams, including the Dallas Mavericks of theN.B.A., pointed to stair-climbing scholarship. It concludes that a few brisk climbs a day, like my modest regimen, can increase aerobic capacity and reducecholesterol.

Most any stair-climbing routine, experts say, is a healthy step, literally, toward achievingthe recommended level of physical activityfor adults, according to the American College of Sports Medicine and theAmerican Heart Association. (The goal: moderate aerobic activity— think purposeful walking— for 30 minutes five or more days a week, or vigorous activity like jogging for 20 minutes or more at least three times a week.)

“It’s not all or nothing,” saidCarla Sottovia, an exercise physiologist at the Cooper Fitness Center in Dallas.“Short bouts of exercise, like climbing stairs, certainly help. It all adds up.”

For real athletes, there are staircase races. Once regarded as oddball curiosities, the races have increased in number and stature. Last year there were more than 160 staircase races in the world, on five continents, chronicled and celebrated on Web sites liketowerrunning.com. One of the earliest races, the 86-floor ascent of theEmpire State Building, begun in 1978, was run for the 34th time on Feb. 1, attracting competitors from around the world.

Serious stair runners seem to be mostly marathoners and triathletes, who find stairs a related but novel challenge.

For Emily Kindlon, 30, a runner and triathlete, gaining access to high-rise buildings for training is an obstacle. Frustrated by her eight-story apartment building in Brooklyn, she asks friends in loftier homes for stair privileges. Yet building managers, she said, are reluctant to open their stairs to outsiders, and one asked her to sign a legal wavier.

“In case I fell and broke my neck,” she explained.

“I’ve honestly considered moving to a high-rise in Manhattan for the stairs,” Ms. Kindlon said.

To James Miller, 52, who runs up to 60 miles a week, stair climbing is a kind of cross-training, as if they were vertical wind sprints.“It really expands the lungs— that has to help the running,” he said.

Like Ms. Kindlon, Mr. Miller participated in the Empire State Building race this year. His training was done at home, by repeatedly scaling the 17 flights of his Central Park West apartment building. The training, he said, got him thinking about the neglected stairs.

“It’s not ingrained in our brains to take the stairs,” Mr. Miller observed.“But we live in New York City, and we have this great resource here— so many buildings with so many stairs.”

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Wheat Berries With Winter Squash and Chickpeas - Recipes for Health

3 tablespoons extra virgin olive oil

1 large onion, chopped

2 large garlic cloves, minced

1 teaspoon ground allspice

1/4 to 1/2 teaspoon cayenne (to taste)

1 cup wheat berries

2 tablespoons tomato paste

5 cups water

Salt to taste

1/2 cup chopped fresh parsley

1/4 cup chopped fresh dill or mint

1 pound winter squash, peeled, seeded and cut in large dice

1 can chickpeas, drained

1.Heat the oil in a large heavy soup pot or Dutch oven over medium heat. Add the onion. Cook, stirring, until tender, about five minutes. Stir in the garlic, ground allspice and cayenne. Stir together for about one minute, then add the wheat berries, tomato paste and 4 cups of water. Bring to a boil, and add salt to taste. Reduce the heat, cover and simmer 30 minutes. Add 2 tablespoons each of the parsley and dill or mint, and stir in the winter squash and chickpeas. Bring back to a boil, reduce the heat and simmer for another 45 minutes to an hour until the beans and wheat berries are tender and the squash is beginning to fall apart.

2.Uncover the pot, and turn the heat to high so that the liquid returns to a boil. Boil until the liquid is reduced to a syrupy consistency. Remove from the heat, and stir in the remaining herbs. Taste and adjust salt. Serve hot or warm in wide soup bowls.

Yield:Serves six.

Advance preparation:You can make this a few days ahead through Step 1. Reheat and reduce liquid (which will already be thicker if you’ve made it ahead) on the day you are serving.

Nutritional information per serving:264calories; 1 gramsaturated fat; 2 grams polyunsaturated fat; 5 grams monounsaturated fat; 0 milligramscholesterol; 44 gramscarbohydrates; 9 gramsdietary fiber; 211 milligrams sodium (does not include salt to taste); 9 grams protein

Martha Rose Shulmanis the author of"The Very Best of Recipes for Health."

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Cabbage With Tomatoes, Bulgur and Chickpeas - Recipes for Health

1/4 cup extra virgin olive oil

1 onion, finely chopped

Salt to taste

1 tablespoon sweet paprika

1 medium head green or red cabbage, finely shredded

1 14-ounce can choppedtomatoeswith juice

2 teaspoons sugar

2 teaspoons red wine vinegar, cider vinegar or sherry vinegar

1/4 cup chopped fresh dill

2 cups water

1 cup coarse bulgur

1 15-ounce can chickpeas, drained and rinsed

1.Heat the olive oil over medium heat in a large, heavy lidded skillet or Dutch oven. Add the onion, and cook, stirring often, until tender, about five minutes. Stir in a pinch of salt and the paprika. Cook, stirring, until the onion is thoroughly tender and infused with paprika, three to four minutes.

2.Add the cabbage, and cook, stirring, for three minutes or until it begins to wilt. Stir in the tomatoes, sugar and vinegar, and add salt to taste. Bring to a simmer, lower the heat, cover and simmer 15 minutes until the cabbage is thoroughly tender.

3.Stir in the dill and the water, and bring a to a boil. Add the bulgur and chickpeas. Stir to combine. When the water comes back to a boil, reduce the heat to low and cover. Simmer 10 minutes or until all of the water has been absorbed. Remove from the heat, taste and adjust seasonings, and serve hot or at room temperature.

Yield:Serves six.

Advance preparation:Since this is good served at room temperature, you can make it several hours ahead. Reheat if desired. It will keep for three or four days in the refrigerator.

Nutritional information per serving:281calories; 1 gramsaturated fat; 2 grams polyunsaturated fat; 7 grams monounsaturated fat; 0 milligramscholesterol; 42 gramscarbohydrates; 12 gramsdietary fiber; 311 milligrams sodium (does not include salt to taste); 9 grams protein

Martha Rose Shulmanis the author of"The Very Best of Recipes for Health."

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When Optimism is Unrealistic

One of the patients was a woman in her late 30s, a mother of three. Known for her cheery disposition— she reminded the doctors and nurses of a brunette Cathy Rigby— she hadmelanomathat had spread through her body despite efforts to halt its growth. By the time I met her, she was already the veteran of two clinical trials at the center. Hertumorhad responded slightly during one of those studies, but slowing the pace of its growth had come at a significant price. She had endured countless hospitalizations, serious bloating, a punctured lung, overwhelming fatigue and two nearly intractable infections.

Nonetheless, when hercancerbegan growing again, she eagerly applied for a third study. This time she would participate in one of the earliest studies of a brand-new drug, a Phase I clinical trial, and would have to undergo major surgery before taking the experimental drug.

On the evening before her operation, she joked with the surgical team and shook her head when we asked if she had any more questions.“Haven’t we talked about this enough?” she said smiling and nodding gamely as the head surgeon explained once more that because this was an early-phase trial, it would benefit research but was not likely to be of any therapeutic help to her. Like other such trials, it would test only for toxicity and the maximum safe doses of the experimental drug; generally fewer than 5 percent of patients ever benefit from such early trials.

The woman nodded and waved her hand for the consent form.“I’ve been through this before,” she said to us as she signed the papers.“I know what I am getting into.”

Then, voice lowered, she added:“I’m a mother. I would do anything for a little extra time with my children.”

We all fell silent when she said those words. She seemed to understand the study, and it was hard not to be in awe of her courage and selflessness. But we were also hesitant to probe any further. None of us wanted to deflate her sense of hope. And knowing what we did about the extent of her disease, it was hard not to convince ourselves that optimism, even if based on somewhat false hopes, had to be helpful for someone in her position.

I remembered her words a little over a year later when I heard she had died. Her tumor never responded to the experimental treatment.

Foralmost four decades, researchers and patient advocates have debated the ethicsof informed consent in early-phase clinical trials, studies that test only toxicity and dosing and offer little, if any, therapeutic benefit to those enrolled. A major part of the debate has focused on the motivations of patients who participate. Some research on patient motivations has had disturbing ethical implications, indicating thatpatients may never fully understand the purpose of trials, despite explanations by the researchers. Others have been more reassuring, noting thatpatients are driven by a sense of altruism and a desireto help others who may one day suffer from the same disease.

More recently, a few studies have offered what appears to be the happiest of hypotheses. Patients maysimply be optimistic and have strong needs to express hope. And because optimism has long been considered an effective coping mechanism for patients with terminal diseases, other researchers have also then assumed that optimism in this context poses few ethical issues.

Nowone group of ethicists has just published a study challenging that assumption. It turns out that when it comes to being hopeful, not all optimism is created equal.

The ethicists surveyed 70 patients enrolled in several early-phase cancer trials and asked them about their expectations and understanding of their respective trials. A solid majority understood that the trials’ purpose was to advance research, not to treat them. But despite clearly understanding the purpose, and limits, of early-phase trials, the patients were also blinded by what researchers called an“unrealistic optimism,” or an optimistic bias, when it came to applying that knowledge to their own particular situations. A majority of patients assumed that the experimental drugs would controltheircancer and thattheywould experience benefits but not complications.

In essence, they believed they would fare better than the average patient enrolled in the same trial.

“It’s the Lake Wobegon effect,” said Dr. Daniel P. Sulmasy, senior author and a professor of medicine and ethics at theUniversity of Chicago.“If you have more than 50 percent of patients saying their chances are better than average of avoiding some harm or obtaining some benefit, they are being unrealistically optimistic because you can’t say that most people are above average.”

Such unrealistic optimism differs from so-called dispositional optimism, or a general optimistic outlook.“This is not about trying to quash hope in dying patients,” said Lynn A. Jansen, lead author and an associate director at the Center for Ethics in Health Care at Oregon Health and Science University in Portland.“It’s about distinguishing between the different kinds of optimism.”

Socialpsychologistspoint to smokers who underestimate their chances of getting cancer or gamblers who believe they will beat the odds as classic examples of unrealistic optimism. But unrealistic optimism can be present in anyone, regardless of whether they have a generally optimistic outlook.“No one is immune to this kind of bias,” Dr. Jansen said.“Optimistic biases are part of humanpsychology.”

But placed in the context of early-phase clinical cancer trials, unrealistic optimism results in a perfect ethical storm.“You have oncology, a field of medicine that is strongly evidence-based and research-intensive, and you have a population of patients who are experiencing an immediate threat to their lives,” said Dr. Neal J. Meropol, a researcher who has done extensive work on the ethics of early-phase cancer trials and chief of the division of hematology and oncology at UniversityHospitalsCase Medical Center and Case Western Reserve University in Cleveland.“Patients almost invariably take part in early-phase clinical trials because they believe they will personally benefit.”

While the study represents a breakthrough in understanding how different types of optimism affect the informed consent process, doing something about these biases presents a whole different issue. Unrealistic optimism is notoriously difficult to recognize because most individuals are completely unaware that it even exists.“We would probably be able to walk away from these types of biases,” Dr. Jansen said,“if we realized when we were operating under them.”

Dr. Jansen and her colleagues are hoping next to delineate the factors involved in evoking this biased response in patients. By gaining a deeper appreciation of how unrealistic optimism develops, they believe they may be able to help patients and cancer researchers more easily recognize those optimistic biases that impair a patient’s autonomy and compromise the ethics of clinical trials.

“We all need to care about this kind of research,” Dr. Jansen said.“It’s how we advance knowledge and cure disease.”

She added:“We just need to realize that not all optimism is ethically benign.”

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